Health inspection·December 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify and assess a resident with a change of condition and requiring medical intervention. This applies to 1 of 3 residents (R1) reviewed for change of condition in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with diagnoses including Esophageal Cancer, Lung Cancer with Brain metastasis, Anxiety, Chronic Obstructive Pulmonary Disease and Dyspnea. R1's Progress Notes dated 12/18/25 states, Resident called 911 and had himself taken to (Local) Hospital. In stable condition at time of departure .The 911 Ambulance Run Report states, (Ambulance) dispatched to the location for the person with trouble breathing. Upon arrival crew found pt in his nursing home bed A&O x3 with a GCS (Glasgow Coma Scale) of 15 (Fully Alert) in obvious respiratory distress. T53(?) had arrived PTOA(?) and started care. Pt stated that he had been attempting to contact the nurses at the nursing home for the past 45 minutes with no success. To which he called 911. Pt had no complaints of chest pain, dizziness, weakness, or N/V (Nausea/vomiting). Crew noted that the pt was struggling to speak between breaths. Crew also noted that the pt's abdomen was distended and rigid upon palpation. Vitals obtained as noted. 12-lead acquired and read as noted. Oxygen administered as noted. After placing the pt on a NRM (Non-rebreather mask), the pt's respiratory effort improved drastically. (Local hospital) contacted with no further orders. IV established enroute as noted. Secondary assessmentrevealed that the pt's SPO2 was WNL and the pt appeared to be in less distress . This same report shows R1's vital signs as: B/P-152/112, Pulse 126, Respirations 22 (labored), Oxygen Saturation 88% on room air at 5:17AM upon initial assessment.On 12/26/25 at 9:49AM V10 (Paramedic) stated, When we arrived at the front of the building we were met by the Police. We entered the building, and the police had gone to the right and said they couldn't find any staff and we went to the left. We found this guy in a roped off area by himself, no computers or anything at the nurse's station. No staff anywhere around. The Police went off to start looking for staff. It took about 10 minutes for a nurse to show up. (R1) said he had been calling for 45 minutes. His O2 saturation was 84%. We gave him O2 and brought him up to the low 90's. He was very alert and oriented and when he saw the nurse he started screaming at her and I told him he needed to calm down. I could not see any other residents around the area. We were in the building at least 10 minutes before we saw any staff. We had him loaded on the cot and ready to go before we ever saw her. On 12/26/25 at 11:50AM V5 (Registered Nurse) stated, It was around 4:00AM - that is a very busy time, we are passing medications, and the CNAs are busy with patient care. There are a lot of call lights around that time. I think I went in to assess (R1) around 4:15AM - 4:30AM and he was sleeping. We do rounds and assess residents every 1-2 hours. He was breathing ok all night. I was on the [NAME] Unit when the paramedics arrived- 200 wing. I didn't hear anyone yelling or looking for staff. I would have responded if I knew they were looking for me. When I got to R1's room (400 wing) he was stable and he was talking to the 911 team. He was not really Residents Affected - Few (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 2 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 12/26/2025 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)