Serenity Estates Of Lena
Serenity Estates of Lena in LENA, IL — inspection on November 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
in my mind as to what [V5] was doing (when she grabbed R1's nose).
She was trying to get him to be quiet through twisting and pulling his nose.
When she did that he squealed. V4 said after the physical abuse she separated R1 from V5, reported the incident, and then V5 was escorted from the building. On 11/18/25 at 10:21 AM, V5 CNA stated R1 .cussed me out V5 stated she is used to racial slurs, and it does not affect her ability to provide care. V5 denied the incident and stated the facility is lying. On 11/18/25 at 11:52 PM, V10 CNA Supervisor stated, I've never had a problem (with V4).
She is respectful and quiet.
She has never made an allegation against another staff member that I know of. V10 said V5 has very poor customer service. V10 said her demeanor and speech came off as lacking compassion; she would talk to them (residents) like children.I did hear her tell a resident that they should not be using their call light constantly because she had things to do. I pulled her aside and told her that we need to encourage the residents to use the call lights for safety and she cannot say that to the residents.She said she felt like she was going to get fired and she was fired from her previous job.
She actually told me that. V10 stated V5 told her at her previous facility herself and other CNAs would turn off the call light system when residents would continue to use the call light. V10 said that 11/8/25 was V5's first day off training. V10 said it is known by the staff that R1 does not like to be repositioned and he moans during care. V10 said V4 reported to her that V5 had told R1 to shut the h*ll up and that V5 pinched and pulled his nose. V10 said R1 and V5 were separated then V5 was escorted from the building. V10 said R1 was upset and riled up following the incident; however, by the time supper was over he was at his baseline. V10 said she did not see any facial trauma on R1.On 11/18/25 at 12:10 PM, V11 Registered Nurse (RN) stated she escorted V5 from the facility on 11/8/25. V11 stated she had not worked with V5. V11 stated, .[V4] is a sweet girl.
She does her job. V11 stated R1 does moan and groan during care due to his catheter. V11 stated R1 is receiving an ointment for his catheter discomfort. V11 stated she assessed R1 after the incident and he was aggravated. On 11/18/25 at 9:41 AM, V6 R1's Power of Attorney/R1's Daughter stated she did not see R1 until the following Wednesday. (11/8/25 was a Saturday). V6 stated, her brother, R1's Son, was in the facility shortly after the incident and R1 reported to him there had been a ruckus. V6 stated she did not see any injuries to R1's face. V6 said if this incident had occurred to R1 and he was cognitively intact, he would have been upset; however, there would not have been any lasting consequences to his behavior or mood. V6 said R1 has been experiencing a recent decline in cognition and health. On 11/18/25 at 9:59 AM, V7 R1's Son stated he saw R1 on Monday, 11/10/25. V7 stated, R1 reported there had been a ruckus but could not provide any further details. V7 stated R1 had no injuries to his face, and he would have shrugged off an incident like this if he was cognitively intact. V7 stated R1 has started to experience a recent decline in his health and cognition. On 11/18/25 at 8:33 AM, V1 Administrator stated V4 was a trusted and valued staff member. V1 stated he believed V4's statement and substantiated the abuse. On 11/18/25 at 12:10 PM, V2 Director of Nursing stated V4 .is one of our best. R1's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, psychosis, and pain. R1's 9/2/25 Quarterly Minimum Data Set showed, during the assessment period, he had moderate cognitive impairment.
The facility's Abuse policy (Dated 2/17/2020) showed, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.It included verbal abuse, sexual abuse, physical abuse and [NAME] abuse.
The policy continued, Employees are required to report all incidents of possible abuse, mistreatment or neglect of any resident.
The policy showed accused staff should be removed from the facility and suspended.
Facility ID:
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LENA, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Serenity Estates of Lena or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.