Serenity Estates at Morris

In the surveyor’s words

From the most serious findings on record at Serenity Estates at Morris, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 19, 2026

  Based on interview and record review, the facility failed to ensure that a resident's transfer status was reevaluated according to resident's condition to ensure safety during transfer. This failure resulted in the resident sustaining an acute mildly displaced and slightly angulated distal femoral fracture.This applies to 1 of 1 resident (R2) reviewed for injury of unknown origin in the sample of 7. The findings include:Face sheet showed that R2 was 87 years-old who had multiple medical diagnoses including Alzheimer's disease, chronic kidney disease, presence of right artificial hip joint, poly-osteoarthritis, disorders of bone density and structure, vitamin D deficiency, and vitamin B12 deficiency anemia. […]

• Actual harm, isolatedF689Jul 11, 2026

  Based on interviews and record reviews, the facility failed to ensure a resident was properly secured in their wheelchair while being transported by facility staff in the facility's van. This failure resulted in R2 falling from his wheelchair and sustaining a subdural hematoma (brain bleed) and fracture. This applies to 1 of 3 residents (R2) reviewed for supervision and accidents. The findings include: R2's electronic medical records show he is an [AGE] year-old male with diagnoses including chronic congestive heart failure, chronic kidney disease, chronic peripheral venous insufficiency, metabolic encephalopathy, anxiety disorder, and need for assistance with personal care and was admitted to the facility 7/23/2025. […]

• Actual harm, isolatedF689Oct 26, 2024

  Based on interview and record review, the facility failed to provide safe transfer assistance. This applies to 1 resident (R1) of three reviewed for safe transfers. This failure resulted in R1 incurring a acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. Findings include: 1. R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old, with diagnoses to include Aphasia, Hemiplegia and Hemiparesis following a Cerebral Infarction. The Final Report to Illinois Department of Public Health, dated 10/17/2/2024, documents, On 10/11/2024, The resident was lowered to the ground after becoming weak during a transfer from her electric wheelchair to her bed via pivot transfer. […]

• Actual harm, isolatedF689Dec 1, 2021

  Based on observation, interview, and record review, the facility failed to ensure the safety of a resident who is known to wander. This failure resulted in the resident falling down a stairwell with her wheelchair and sustaining fractures to her clavicle and ribs. This applies to 1 of 3 residents (R1) reviewed for fall with significant injury. The findings include: R1's Electronic Medical Record (EMR) shows diagnoses of [CONDITION(S)] with behaviors, generalized anxiety disorder, and repeated falls. R1's September 7, 2021 Minimum Data Set (MDS) shows R1 has severe cognitive impairment and requires one staff physical assistance for locomotion on the unit. […]

• No harm, potential for more than minimal, widespreadF802Oct 11, 2024

  Based on interview and record review, the facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Services, including meal preparation. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 10/8/24, documents the total census was 90 residents. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. […]