Latest reports, citations, and penalties from CMS data
R3 carries diagnoses of unspecified dementia, cognitive communication deficit, major depressive disorder, and essential hypertension....
Inspectors who visited the facility on November 18, 2025, reviewed nursing schedules, resident census data, and staff interviews covering a two-week window....
Federal inspectors were there to see it....
No entry appeared in the resident's progress notes....
The incident happened on November 8, 2025, at Serenity Estates of Lena, a nursing facility in this small town in the far northwestern corner of Illinois....
The sequence was documented in a November 2025 federal inspection triggered by a complaint....
The director of nursing found out about it after the resident was already gone....
That's what federal inspectors found when they examined the records at Southfield Wellness Community, a nursing home at 2416 Des Moines Street in Webster City....
Elopement is not the same as wandering....
The resident had not asked to be discharged....
The citation covered not just the two residents who were attacked, but every resident in the immediate area of the secured unit at the time....
The resident, identified in inspection records only as R1, was admitted to Thrive of Lisle with moderate dementia....
A normal blood sugar runs between roughly 70 and 140....
The deficiency was tagged at a level indicating minimal harm or potential for actual harm, affecting a small number of residents....
The facility's own policy, revised in 2016, lays out the sequence clearly....
The doctor's documentation uploaded automatically to a miscellaneous tab inside each resident's electronic chart....
The right lower leg had four separate skin tears, each roughly 2 centimeters long, sealed with Dermabond, a medical-grade skin adhesive....
LPN-B cleansed the wound with a skin prep wipe, applied bacitracin ointment, and put on a new foam dressing....
The medication at the center of it, lorazepam, is a schedule IV controlled substance....
The resident, identified in inspection records only as R1, was transported to the hospital....