Serenity Estates Of Lincolnshire
SERENITY ESTATES OF LINCOLNSHIRE in LINCOLNSHIRE, IL — inspection on April 29, 2026.
Found 2 citations. 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
The survey team reviewed the revised abatement plan and was unable to accept the plan to remove the immediacy.
The abatement plan was returned to the facility for revisions.
The facility presented a revised abatement plan on 4/29/26 at 11:34 AM.
The survey team reviewed the revised abatement plan and was unable to accept the plan to remove the immediacy.
The abatement plan was returned to the facility for revisions.
The facility presented a revised abatement plan on 4/29/26 at 11:59 AM.
The survey team reviewed the revised abatement plan and was unable to accept the plan to remove the immediacy.
The abatement plan was returned to the facility for revisions.
The facility presented a revised abatement plan on 4/29/26 at 12:20 PM, and the survey team accepted the abatement plan on 4/29/26 at 12:20 PM.The Immediate Jeopardy that began on 4/19/26 was removed on 4/28/26 when the facility took the following actions to remove the immediacy:All resident elopement assessments reviewed and up to date as of 4/20/26, and reviewed again on 4/28/26.
All residents identified as a high risk for elopement had care plans reviewed for accuracy by 4/20/26, and reviewed again on 4/28/26.
Elopement binder reviewed and up to date to reflect high risk residents by 4/20/26 and reviewed again on 4/28/26. An emergency QAPI was held to review policies/procedures, and final investigation notes, on 4/20/26.
Daily door alarm audits completed beginning 4/20/26. An in-service education process was initiate on April 19, 2026.
The Administrator is responsible for providing education and expectations to all managers and supervisors. In collaboration, the Administrator, managers, and supervisors will ensure re-education on the elopement policy is provided to all department staff as they return to work to verify understanding and ongoing compliance with facility policies and procedures. R1 provided with 1:1 staff and/or increased supervision as needed effective 4/19/2026.Ensure a dedicated staff is scheduled on each unit.
The HR (Human Resources) director will ensure there will be a dedicated staff on each unit.
The administrator or DON (Director of Nursing) will audit compliance.
146028 04/29/2026
Serenity Estates of Lincolnshire 150 Jamestown Lane Lincolnshire, IL 60069
nurse in charge on each shift.
units were attended during the overnight shift.
This has the potential to effect all 128 residents
there are 128 residents residing in the facility as of 4/27/26.
Facility provided nursing schedule from 2/27/26 to 4/27/26 shows the facility staffs the overnight shift with three nurses and six certified nursing assistants (CNAs) to cover seven units.
Facility nursing schedule from 4/18/26 shows the 700 unit had a census of 23, the 100 unit had a census of 11, and the 200 unit had census of 16. V3 (Licensed Practical Nurse- LPN) was scheduled to cover the 700 unit, the 100 unit, and half of the 200 unit totaling 42 residents.
This is a nurse to resident ratio of one to 42.Facility nursing schedule from 4/18/26 shows the 300 unit had a census of 20, the 400 unit had a census of 13, and the 200 unit had census of 16. V10 (Registered Nurse- RN) was scheduled to cover the 300 unit, the 400 unit, and half of the 200 unit totaling 41 residents.
This is a nurse to resident ratio of one to 41.Facility nursing schedule from 4/18/26 shows the 500 unit had a census of 21 and the 600 unit had census of 16. V11 (RN) was scheduled to cover the 500 and 600 units totaling 44 residents.
This is a nurse to resident ratio of one to 44.Facility nursing schedule from 4/18/26 shows the 100 unit had a census of 11, the 200 unit had a census of 16, the 300 unit had a census of 20, and the 400 unit had a census of 13.
The schedule shows three CNAs are scheduled to cover those four units, providing each CNA with a staff to resident ratio of approximately one to 20.
Facility nursing schedule from 4/18/26 shows the 500, 600, and 700 units each have their own scheduled CNA with unit census of 20 or more on each unit.
On 4/27/26 at 12:58 PM, V13 (CNA) said it is normal to split the four units with only three CNAs and they try and split it so each CNA has 20 residents each. V13 said it would be better to have one CNA per unit because there is a lot of distance between some of the units.
When you are on one unit, you can't see what's going on with the other unit.On 4/28/26 at 11:10 AM, V15 (Human Resources Director) said the current staffing pattern is the same staffing pattern the facility has followed for a while. V15 did say the 400 unit could use a full time nurse on all shifts, seven days a week, but it's not V15's decision to make.
The Facility Assessment updated 4/1/26 states, The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Use this assessment to make decisions about your direct care staff needs (including those who provide services under contract and volunteers), as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement.
Using evidence-based, data driven methods focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.
The assessment also shows direct care staffing ratios for licensed staff should not exceed a ratio of one staff member to 30 residents for the overnight shift and it shows for certified staff the ratio should not exceed a ratio of one staff member to 18 residents for the overnight shift.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.