Inspection·June 24, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents that require staff assistance for incontinence care and/or toileting for 2 of 5 residents (R2, R5) reviewed for ADLs in the sample of 7. Residents Affected - Few The findings include: 1. R2's care plan dated 5/20/25 showed R2 required substantial assistance from staff to complete personal hygiene and toileting ADLs. R2's resident assessment dated [DATE] showed R2 was incontinent of urine and stool. On 6/23/25 at 8:31 AM, R2's call light was on and flashing. On 6/23/25 at 8:42 AM, R2's call light remained on. R2 stated, This is a joke. I have had my call light on since 7 AM. I am soaked. My bed is wet and I need to be changed. R2 stated his incontinence brief was last changed around 10 PM on 6/22/25. On 6/23/25, from 8:42 AM-9:18 AM, R2's call light remained on and flashing. At 9:18 AM, V3 Certified Nursing Assistant (CNA) entered R2's room to deliver his breakfast tray. V3 spoke with R2, delivered R2's tray, turned off the call light, and then exited R2's room. V3 CNA stated, He (R2) needs to be changed but I have to pass all of the breakfast trays before I can change him. On 6/23/25 at 9:39 AM, R2 stated, I still haven't been changed. (V3 CNA) said she would be back to do it after breakfast. On 6/23/25 at 9:57 AM, V5 CNA provided to incontinence care to R2. R2's incontinence brief, bedding, and mattress were saturated with urine. 2. R5's current care plan showed R5 was cognitively impaired due to her diagnosis of dementia. R5 required substantial assistance from staff to complete personal hygiene and toileting ADLs. R5's resident assessment dated [DATE] showed R5 was incontinent of urine and stool. On 6/23/25, from 8:31 AM-10:03 AM, R5 was seated in a wheelchair in a dining room of the facility. At 10:03 AM, V4 Registered Nurse stated, She (R5) has been up (in the wheelchair) all morning. Not sure when she was last changed. We don't put her in bed during the day because she will try to get up and fall. She is (V6 CNA) patient today. He is on the other unit. He was assigned residents over (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 9 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 06/24/2025 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)