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Inspection visit

Inspection

SERENITY ESTATES OF LINCOLNSHIRECMS #14602825 citations on this visit
25 citations recorded

Citations

25 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0363GeneralS&S Epotential for harm

    Install corridor and hallway doors that block smoke.

  • 0920GeneralS&S Epotential for harm

    F920 - Dining and Resident Activities

    Ensure proper usage of power strips and extension cords.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0692GeneralS&S Dpotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0015GeneralS&S Fpotential for harm

    Address subsistence needs for staff and patients.

  • 0022GeneralS&S Fpotential for harm

    Establish policies and procedures for sheltering.

  • 0026GeneralS&S Fpotential for harm

    Establish roles under a Waiver declared by secretary.

  • 0034GeneralS&S Fpotential for harm

    Provide a means of sharing information on occupancy/needs.

  • 0035GeneralS&S Fpotential for harm

    Provide family notifications of emergency plan.

  • 0037GeneralS&S Fpotential for harm

    Establish staff and initial training requirements.

  • 0133GeneralS&S Epotential for harm

    Install a two-hour-resistant firewall separation.

  • 0211GeneralS&S Epotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0281GeneralS&S Epotential for harm

    Install proper backup exit lighting.

  • 0293GeneralS&S Epotential for harm

    Have properly located and lighted "Exit" signs.

  • 0321GeneralS&S Epotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324GeneralS&S Epotential for harm

    Provide properly protected cooking facilities.

  • 0341GeneralS&S Fpotential for harm

    Install a fire alarm system that can be heard throughout the facility.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0712GeneralS&S Cno actual harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0919GeneralS&S Epotential for harm

    F919 - Resident Call System

    Meet requirements for the use of electrical equipment.

  • 0926GeneralS&S Epotential for harm

    F926 - Establish policies, in accordance with applicable Federal, State, and

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

FAQ · About this visit

Common questions about this visit

What happened during the April 24, 2025 survey of SERENITY ESTATES OF LINCOLNSHIRE?

This was a inspection survey of SERENITY ESTATES OF LINCOLNSHIRE on April 24, 2025. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SERENITY ESTATES OF LINCOLNSHIRE on April 24, 2025?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.