Inspection visit
Inspection
31 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 31 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to perform interdisciplinary care plan conferences for 1 of 1
residents (R44) reviewed for care plans in the sample of 26.
The findings include:
R44's electronic face sheet printed on 3/26/25 showed R44 has diagnoses including but not limited to
cerebral infarction, hemiplegia & hemiparesis affecting left dominant side, dementia with anxiety, and
dementia with behaviors.
R44's facility assessment dated [DATE] showed R44 has severe cognitive impairment.
On 3/25/25 at 10:10AM, V13 (R44's power of attorney) stated, I have been leaving voicemails for about 3
weeks at the facility to figure out (R44's) finances and I am getting very angry because you can never reach
anyone. When they call me, I answer or call back. A few weeks ago, I went to see (R44), and I wanted to be
able to sit down with someone and ask questions about his care. I have never heard of a care plan meeting,
and we have never had one.
R44's care plan attendance records showed, 6/18/24 no family attendance, 9/11/24 no family attendance,
and 12/18/24 no family attendance.
On 3/26/25 at 1:33PM, V12 (Social Service Director) stated, (R44) is a tough situation because he was kind
of just dropped off here, so he didn't have a lot of family involvement but now his (family) have been coming
around more to see him, so they'll begin to be invited to care plan meetings.
R44's nursing progress notes showed the facility has contacted the family 6 times since R44's admission to
the facility on 5/20/24 and have never invited R44's family to a care plan meeting.
On 3/26/25 at 2:05PM, V12 stated, (R44's) power of attorney is (V13). She became his power of attorney in
December 2024. Invitations for care plan meetings are not documented, we just call families. There is a lot
of family drama with (R44), but someone should still be invited to the meetings. (R44) is due for a care plan
meeting by the end of the month but I have not reached out to his family yet to invite them. I typically reach
out at least a week prior to when the meeting is scheduled. (Only 5 days are left in the month)
The facility was unable to provide a policy regarding family/healthcare power of attorney attendance at care
plan meetings or documentation of invitations to care plan meetings.
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 12
Event ID:
146114
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
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 perform incontinence care and activities of
daily living care for 1 of 1 residents (R35) reviewed for activities of daily living in the sample of 26.
Residents Affected - Few
The findings include:
R35's electronic face sheet printed on 3/27/25 showed R35 has diagnoses including but not limited to need
for personal care, muscle wasting and atrophy, morbid obesity, and edema.
R35's facility assessment dated [DATE] showed R35 has mild cognitive impairment and requires
partial/moderate assistance with toileting hygiene.
R35's care plan dated 7/27/22 showed, I have an ADL (activities of daily living) self-care performance
deficit related to activity intolerance, limited mobility .personal hygiene: limited assist x 1 at times.
On 3/25/25 at 10:46AM, R35 was walking down the hallway and had wet marks on the back of his pants.
V14 (Certified Nursing Assistant) took R35 to his bathroom and removed his wet pants and incontinence
brief. V14 confirmed R35's incontinence brief was wet with urine. V14 applied a clean incontinence brief
and pants onto R35 without performing incontinence care. After V14 left R35's room, V14 stated, He will
usually ask for incontinence care but since he didn't then I didn't provide it. I guess I could have offered to
him, but he probably would have said no. Sometimes he doesn't like us to help him.
On 3/26/25 at 11:10AM and 3/27/25 at 9:42AM, R35 continued to wear the same shirt and pants that he
was wearing on 3/25/25.
R35's nursing progress notes were reviewed and showed no documentation that R35 refused to change his
clothes or receive incontinence care on 3/25, 3/26, or 3/27.
On 3/27/25 at 11:29AM, V2 (Director of Nursing) stated, (R35) needs assistance with personal care. When
a resident has a brief that is wet with urine it should be removed and followed up with incontinence care to
prevent skin breakdown and provide cleanliness. Staff should be offering and trying to do incontinence care
and asking him to change his clothes and if he refuses, it should be documented.
The facility's policy titled, Incontinent Care-with or without a catheter dated 1/1/23 showed, It is the policy of
this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity
and ensures no cross contamination .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 2 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 facilty failed to ensure a healed pressure injury did not reopen
for 1 (R40) of 6 residents reviewed for pressure injury in the sample of 26.
Residents Affected - Few
The findings include:
R40's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including
congestive heart failure, and need for assistance with personal care. His 2/18/25 resident assessment and
care screening documents moderate cognitive impairment. The same assessment documents he requires
partial to moderate assistance with rolling side to side, sitting to stand, and transfers. He is occasionally
incontinent of urine, and he was admitted with a Stage 3 pressure wound.
R40's Wound evaluation and management summary of 2/24/25 documents a Stage 3 pressure wound to
the left upper medial buttock was resolved.
The 3/10/25 wound evaluation and management summary documents the same Stage 3 wound re-opened
and the initial measurements were 2.2 cm (centimeters) (length) x 1.4 cm (width) x 0.2 cm (depth).
On 3/26/25 at 12:51 PM, V3 RN (Registered Nurse) stood R40 up with a walker, and pulled down his
incontinence brief. At the top of his left inner buttock was an open irregular shaped wound with a white
paste covering. V3 said the wound originally was 2 open areas that became one. She said R40 was
incontinent of urine, mostly at night, during the day he will ask for assistance with the bathroom.
On 3/27/25 at 11:51 AM, V2 DON (Director of Nursing) said the nurses do weekly skin checks, and the
aides should be doing skin checks for redness and open areas when providing care. After consulting with
V8 Wound nurse, V2 said the current wound is a re-opening of the prior Stage 3, and it should have been
noted and reported prior to becoming open again at that size.
The facility's 1/2025 policy for pressure ulcers documents 3. The facility will ensure that all residents at risk
for pressure ulcers are identified to be at risk and given care to prevent the development of pressure ulcers.
4. The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to
promote healing, prevent infection and prevent new sores from developing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 3 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure fall prevention measures were in place
for 1 of 3 residents (R19) reviewed for safety and supervision in the sample of 26.
The findings include:
R19's electronic face sheet printed on 3/27/25 showed R19 has diagnoses including but not limited to femur
fracture, dysphagia, osteoarthritis, dementia with behaviors, and major depressive disorder.
R19's facility assessment dated [DATE] showed R19 has severe cognitive impairment and utilizes a bed
and chair alarm daily.
R19's physician's orders dated 3/25/25 showed, Ensure bed/chair alarm in place & functioning at all times.
R19's care plan dated 9/22/23 showed, I had an actual fall 2/17/25 .utilize bed/chair alarms, bolstered
mattress, (non-slip pad) when up in wheelchair.
R19's care plan dated 10/16/23 showed, I require bed/chair alarm related to I have a history of falls with
attempted independent transfers and ambulation.
On 3/25/25 at 9:18AM, R19 was laying in her bed with her bed alarm cord laying in a basin. The alarm box
was sitting out in plain view with no cord attached to it and no blinking light showing any function on the
alarm.
On 3/25/25 at 9:32AM, V10 (Licensed Practical Nurse) stated, (R19's) orders do not show that she needs a
bed alarm, so I don't think she uses one. If it's in her room, I would think she uses it though and it should be
plugged in. If it is not plugged in, then it is not on and will not alert us if she tries to get up on her own.
On 3/25/25 at 10:59AM, V11 (Certified Nursing Assistant) stated R19 uses a bed alarm and is unsure of
why it was not plugged in.
On 3/27/25 at 11:29AM, V2 (Director of Nursing) stated, (R19) uses a bed and chair alarm and they should
be plugged in at all times. We re-instated her alarms after her fall last month because we weren't sure if she
slid out of her chair or was trying to get up.
The facility's policy titled, Fall Management-Evaluation dated 1/1/23 showed, It is the policy of this center to
evaluate residents for their fall risk and develop interventions for prevention .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 4 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review the facility failed to show a resident was assessed for a psychotropic
gradual dose reduction. This applies to 1 of 5 (R33) residents in the sample of 26.
The findings include:
R33's admission Record (Face Sheet) showed an admission date of 5/14/22.
R33's Physician Orders showed, as of 3/27/25, she was taking quetiapine (antipsychotic medication) and
sertraline (antidepressant). The diagnosis for quetiapine was anxiety and major depression with psychotic
symptoms. The diagnosis for sertraline was major depression with psychotic symptoms.
R33's Order Listing Report for quetiapine showed she had been taking quetiapine since her admission.
R33's Order History showed she had been taking 25 milligrams twice daily since 8/3/23.
On 3/26/25 at 2:50 PM, R33's most recent gradual dose reduction (GDR, a lowering of a resident's
psychotropic medication) attempt or decline documentation was requested from V2 Director of Nursing.
On 3/27/25 at 8:21 AM, V2 Director of Nursing stated V7 Psychiatrist would like to speak over the phone
regarding R33's quetiapine GDR. (The facility had not yet produced GDR documentation.) V7 stated, it was
his understanding, that if a GDR was attempted for one psychotropic medication and the resident failed the
GDR, GDRs for all other psychotropics did not need to be attempted or the reason for the declination did
not need to be documented. V7 stated R33 had a failed sertraline GDR in September 2024, which would
cover R33's quetiapine GDR attempt.
R33's 3/10/25 Psychiatry note showed a list of GDR(s). The last documented GDR for quetiapine was
7/10/23 (20 months ago) when the dose was lowered to 12.5 milligrams twice a day. The document showed
she failed the GDR.
The facility's Drug Regimen-Gradual Dose Reduction policy (revision 1/2025) showed, For any resident
who is receiving an antipsychotic drug to treat a psychiatric disorder other than behavioral symptoms
related to dementia, the GDR may be considered contraindicated if: a) The continued use is in accordance
with relevant current standards of practice and the physician has documented the clinical rationale for why
any attempted dose reduction would be likely to impair the resident's function or cause psychiatric
instability by exacerbating an underlying psychiatric disorder; or b) The resident's target symptoms returned
or worsened after the most recent attempt at a GDR within the facility and the physician has documented
the clinical rationale for why any additional attempted dose reduction at that time would likely impair the
resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric
disorder.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 5 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review the facility failed to follow manufacturer instructions regarding the
expiration date of in use insulin. This applies to 2 of 2 residents (R47, R27) reviewed for insulin in the
sample of 26.
The findings include:
1. On [DATE] at 10:00 AM, R47's insulin glargine (long-acting insulin) was in the E hall cart. The insulin vial
had a label which showed an open date of [DATE] and a discard date of [DATE]. The cart had no other
opened insulin glargine for R47.
R47's [DATE] Medication Administration Record (MAR) showed he was to receive 8 units of insulin glargine
at bedtime. The MAR showed the insulin glargine was documented as being given on [DATE].
The manufacturer's instructions Learn How to Inject [insulin glargine] showed, The [insulin] vials you are
using should be thrown away after 28 days, even if it still has insulin in it.
On [DATE] at 12:32 PM, V2 (Director of Nursing) stated the facility follows manufacturer instructions
regarding the storage and use of insulin. V2 said R47 should not have been given the insulin from the
expired vial on [DATE]. V2 said the purpose of disposal after 28 days in use is due to a risk of
contamination after prolonged use of the insulin vial as well as decreased potency of the insulin.
The facility's Insulin Administration policy (dated [DATE]) showed, Procedure: .5. Check expiration date, if
drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial
(follow manufacturer recommendations for expiration after opening.)
2. On [DATE] at 10:00 AM, R27's insulin aspart (fast-acting insulin) pen was in the E hall cart. The pen had
a facility applied yellow oval label with two spaces for a date opened and a discard date. The label said
discard 28 days after opening. The sticker was blank; no dates had been documented. The insulin pen
showed approximately half the insulin had been used.
On [DATE] at 12:32 PM, V2 (Director of Nursing) stated insulin pens should be dated once they are
removed from the refrigerator. V2 said the purpose of labeling the pen is to keep track of when the pen
needs to be discarded.
The facility's Insulin Administration policy (dated [DATE]) showed, Procedure: .5. Check expiration date, if
drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial
(follow manufacturer recommendations for expiration after opening.)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 6 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to ensure cooked foods were cooled in
a manner to limit the growth of potentially dangerous pathogens. The failure has the potential to affect all
residents in the facility.
The findings include:
The CMS 671, dated 3/25/25, showed 52 residents reside in the facility.
On 3/25/25 at 9:05 AM, the facility's reach-in freezer had several left-over food items to include but not
limited to: 1.) Spaghetti Sauce prepared on 3/18/25 and use by date of 4/18/25 2.) Taco meat prepared on
3/3/25 and use by date of 4/3/25 3.) Beef Barley soup prepared on 3/25/25 and use by date of 3/27/25 4.)
Meat Balls prepared on 3/19/25 and use by date of 4/19/25. The facility's reach-in refrigerator had leftover
chicken noodle soup with a prepared date of 3/24/25.
On 3/27/25 at 11:35 AM, V9 (Dietary Manager) stated the facility does serve leftover foods to the residents.
V9 said the leftover chicken noodle soup in the refrigerator and the leftovers in the freezer are for all the
residents. V9 said the soups are on the alternative menu and served to the residents per their request. V9
said the leftovers, like the pasta sauce and taco meat, will be used the next time that food item is on the
menu.
On 3/26/25 at 8:59 AM, V9 Dietary Manager stated the cooling logs for the leftover items in the freezer
should be posted on the reach-ins. (V9 pointed to the doors of the reach-ins in the kitchen.) V9 said, We
don't have any cooling logs for the leftovers. V9 said the leftovers must be cooled quickly enough so the
food does not linger in the danger zone, which is a temperature range where pathogens will grow more
rapidly.
The facility's General HACCP (Hazard Analysis and Critical Control Points) Guidelines for Food Safety
policy showed, .Limit the time that food is in the temperature danger zone. The policy showed the danger
zone is 135 degrees Fahrenheit (F) to 41 F. The policy showed cooked food should be cooled from 135 F to
70 F in 2 hours then from 70 F to 41 F within 4 hours. The policy showed if these times and temperatures
were not met, then the food should be reheated to 165 F and the process restarted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 7 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0880
Provide and implement an infection prevention and control program.
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 perform glove changes and hand hygiene
during incontinence care for 1 of 8 residents (R5) reviewed for infection control in the sample of 26.
Residents Affected - Few
The findings include:
R5's electronic face sheet printed on 3/27/25 showed R5 has diagnoses including but not limited to chronic
kidney disease stage 4, urinary tract infection, and anxiety disorder.
R5's facility assessment dated [DATE] showed R5 has moderate cognitive impairment and is dependent on
staff for personal hygiene.
On 3/25/25 at 12:07PM, V5 and V14 (Certified Nursing Assistants) provided incontinence care to R5. V14
cleansed feces off R5's buttocks with toilet paper, handed the toilet paper to V14 to throw away. This
occurred 4 times between V5 and V14 throughout R5's incontinence care. V5 and V14 then applied a clean
incontinence brief, touched the mechanical lift remote, R5's bed controls, and R5's wheelchair without
removing their soiled gloves. V14 stated gloves are not removed until all care is completed with a resident.
V5 and V14 were unable to verbalized when gloves should be changed, and hand hygiene performed
during incontinence care.
On 3/27/25 at 11:29AM, V2 (Director of Nursing) stated, Whenever the aides are going from a dirty to clean
task they should remove their gloves, perform hand hygiene, and apply new gloves to prevent
contamination and the spread of infection. These are taught in classes and observed during competencies,
so all aides know the correct procedure. This is not a new procedure and staff should know this.
The facility's policy titled, Incontinent Care- with or without catheter dated 1/1/23 showed, If is the policy of
this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity
and ensures no cross contamination .re-glove prior to touching clean linens/adult brief .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 8 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to offer a resident the flu vaccine for the 2024/2025
flu season. This applies to 1 of 5 residents (R7) reviewed for vaccinations in the sample of 26.
Residents Affected - Few
The findings include:
R7's admission Record (Face Sheet) showed an original admission date of 2/8/24 with diagnoses to include
dementia without behavioral disturbance, influenza, and covid-19.
R7's Immunization History (as of 3/27/25) showed she did not receive the 2024/2025 flu vaccine.
On 3/26/25 at 1:46 PM, V2 (Director of Nursing/DON) stated R7's Power of Attorney was in the Intensive
Care Unit the end of October 2024, and he was not reachable. V2 said R7's (family) was not willing to make
decisions for R7. V2 said R7 was not given the flu shot and R7 did have flu early in 2025.
On 3/26/25 at 2:50 PM, V2 said if a resident has a diagnosis of dementia, they do not allow the resident to
sign consents, only the power of attorney.
On 3/26/25 at 3:17 PM, R7 was oriented to date, city, and her medical history. R7 said, Early this year I was
sick with both flu and covid; I had the double decker. I was not feeling well. R7 said, I always get the flu shot
.I would like to make my own decision about my vaccines.
R7's 2/12/24, 10/24/24, and 2/23/25 Minimum Data Sets (MDSs) showed she was cognitively intact with a
brief interview for mental status (BIMS) score of 15 out of 15.
R7's 10/3/24 Nurse Practitioner note showed, Orientation: Yes alert, awake and oriented x3 (oriented to
person, place, and time)
R7's 11/11/24 Psychiatry Note showed, .No evidence of psychosis such as mania, paranoia, or delusional
thoughts .Insight: Fair, Judgement: Fair .
R7's 12/4/24 Fall Risk Evaluation showed she was alert and oriented to person, place and time.
On 3/27/25 at 8:39 AM, V2 said, If they are diagnosed with dementia the POA (Power of Attorney) is
activated. If someone has dementia, we go to the POA to sign their consents. That's what I've always done.
It is possible that a resident can have a diagnosis of dementia and they are alert, oriented, they know their
health history, and are aware of their health status. If a resident has dementia, we don't have anything in
place to assess a resident's cognition at the time of singing their paperwork. V2 stated her concern with
dementia resident's signing consents is, The resident could come back at a later time and say they didn't
sign that paperwork. V2 said R7 was not hospitalized when she had the flu and covid; and she made a full
recovery.
R7's Power of Attorney paperwork (signed by R7 on 4/18/23) showed, I authorize my agent to: Make
decisions for me starting now and continuing after I am no longer able to make them for myself. While I am
still able to make my own decisions, I can still do so if I want to.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 9 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/27/25 at 9:49 AM, V6 (Ombudsman) stated he is well acquainted with resident rights. V6 stated,
regarding not allowing dementia residents to sign consents, I've heard a few facilities say that, but my
response to that is dementia is not one thing it is a spectrum. Someone can be mildly forgetful or be very
advanced. In one case they may be perfectly capable of making decisions and signing consents and the
other resident may not be able to sign. Both those people would have the same dementia diagnosis. (R7's
POA statement above was read to V6 verbatim.) I understand that statement to mean that, if she is able to
make her own decisions, she can still do so if she wants to.
On 3/26/25 at 4:14 PM, V2 stated the facility did not have a specific flu vaccination policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 10 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0887
Level of Harm - Minimal harm
or potential for actual harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
Based on interview and record review the facility failed to offer a resident the covid vaccine for the
2024/2025 covid season. This applies to 1 of 5 residents (R7) reviewed for vaccinations in the sample of 26.
Residents Affected - Few
The findings include:
R7's admission Record (Face Sheet) showed an original admission date of 2/8/24 with diagnoses to include
dementia without behavioral disturbance, influenza, and covid-19.
R7's Immunization History (as of 3/27/25) showed she did not receive the 2024/2025 covid booster.
On 3/26/25 at 1:46 PM, V2 (Director of Nursing) stated R7's Power of Attorney was in the Intensive Care
Unit the end of October 2024, and he was not reachable. V2 said R7's (family) was not willing to make
decisions for R7. V2 said R7 was not given the covid booster and R7 did have covid early in 2025.
On 3/26/25 at 2:50 PM, V2 said if a resident has a diagnosis of dementia, they do not allow the resident to
sign consents, only the power of attorney.
On 3/26/25 at 3:17 PM, R7 was oriented to date, city, and her medical history. R7 said, Early this year I was
sick with both flu and covid; I had the double decker. I was not feeling well. R7 said, .I should probably get
the covid vaccine. I would like to make my own decision about my vaccines.
R7's 2/12/24, 10/24/24, and 2/23/25 Minimum Data Sets (MDSs) showed she was cognitively intact with a
brief interview for mental status (BIMS) score of 15 out of 15.
R7's 10/3/24 Nurse Practitioner note showed, Orientation: Yes alert, awake and oriented x3 (oriented to
person, place, and time)
R7's 11/11/24 Psychiatry Note showed, .No evidence of psychosis such as mania, paranoia, or delusional
thoughts .Insight: Fair, Judgement: Fair .
R7's 12/4/24 Fall Risk Evaluation showed she was alert and oriented to person, place and time.
On 3/27/25 at 8:39 AM, V2 said, If they are diagnosed with dementia the POA (Power of Attorney) is
activated. If someone has dementia, we go to the POA to sign their consents. That's what I've always done.
It is possible that a resident can have a diagnosis of dementia and they are alert, oriented, they know their
health history, and are aware of their health status. If a resident has dementia, we don't have anything in
place to assess a resident's cognition at the time of singing their paperwork. V2 stated her concern with
dementia resident's signing consents is, The resident could come back at a later time and say they didn't
sign that paperwork. V2 said R7 was not hospitalized when she had the flu and covid; and she made a full
recovery.
R7's Power of Attorney paperwork (signed by R7 on 4/18/23) showed, I authorize my agent to: Make
decisions for me starting now and continuing after I am no longer able to make them for myself. While
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 11 of 12
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
146114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lena Living Center
1010 South Logan Street
Lena, IL 61048
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)
F 0887
I am still able to make my own decisions, I can still do so if I want to.
Level of Harm - Minimal harm
or potential for actual harm
On 3/27/25 at 9:49 AM, V6 (Ombudsman) stated he is well acquainted with resident rights. V6 stated,
regarding not allowing dementia residents to sign consents, I've heard a few facilities say that, but my
response to that is dementia is not one thing it is a spectrum. Someone can be mildly forgetful or be very
advanced. In one case they may be perfectly capable of making decisions and signing consents and the
other resident may not be able to sign. Both those people would have the same dementia diagnosis. (R7's
POA statement above was read to V6 verbatim.) I understand that statement to mean that, if she is able to
make her own decisions, she can still do so if she wants to.
Residents Affected - Few
On 3/26/25 at 4:14 PM, V2 stated the facility did not have a specific covid vaccination policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146114
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
31 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.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 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.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
- 0001GeneralS&S Fpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0281GeneralS&S Fpotential for harm
Install proper backup exit lighting.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the March 27, 2025 survey of Serenity Estates of Lena?
This was a inspection survey of Serenity Estates of Lena on March 27, 2025. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Serenity Estates of Lena on March 27, 2025?
Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."
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.
SourceView on CMS Care Compare
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.