Inspection·May 27, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure dressing changes and/or intravenous (IV) tubing changes were completed to decrease the potential for infection for 2 of 2 residents (R1 and R2) in the sample of 2 with central lines. Residents Affected - Few The findings include: On 5/27/25 at 9:38 AM, R1's PICC (peripherally inserted central catheter) insertion site to his right upper arm was dressed, but it was not labeled with a date or time. R1 had antibiotics infusing and the tubing was not labeled with a date or time. R1 said the staff do not change his PICC dressing every week as is required. On 5/27/25 at 10:25 AM, R2 had antibiotics infusing via his PICC line. The tubing was not labeled with the date or time. R2 said staff had not changed his PICC dressing for almost two weeks and the IV medication tubing is supposed to be changed every 24 hours, but it is four days old. On 5/27/25 at 10:34 AM, V6, RN, said they can use the same IV tubing for 72 hours, but he changes the tubing every day, so he does not date/time the tubing. V6 said PICC dressing changes are every week. V6 said the PICC dressing changes are documented on the EMAR/ETAR (electronic medication administration record/electronic treatment administration record) when they are done. V6 said if it is not signed off, then it has not been done. On 5/27/25 at 11:49 AM, V5, Registered Nurse (RN), said the PICC line dressing is supposed to be changed by an RN weekly and the dressing is dated, timed, and initialed and documented on the TAR. V5 said the IV tubing needs to be changed every 24 hours for each medication being administered. On 5/27/25 at 12:25 PM, V4, Licensed Practical Nurse (LPN) said the PICC dressing is supposed to be changed every seven days and the IV tubing needs to be changed every three days. V4 said the IV tubing is supposed to be dated with the date it was changed. On 5/27/25 at 1:07 PM, V2, Director of Nursing (DON), said she does not know how long a set of IV tubing can be used before needing to be changed, but the tubing should be dated when it is changed. V2 said she does not know if PICC line dressings should be dated. V2 said PICC dressings are changed once a week and documented on the TAR. V2 said if a medication or treatment is not documented, it has not been done. On 5/27/25 at 2:43 PM, V3, Assistant DON/Infection Prevention nurse, said IV tubing for intermittent medications should be changed every 48 hours to prevent the contamination of the IVs when they are not being used. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 146028 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Estates of Lincolnshire 150 Jamestown Lane Lincolnshire, IL 60069 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)