Serenity Estates of Lincolnshire

In the surveyor’s words

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

• Immediate jeopardy, widespreadF600May 15, 2023

  Based on interview and record review the facility neglected to have licensed nursing staff to assess and monitor a resident with low blood oxygen levels, neglected to have licensed nursing staff to assess, monitor, and provide medications, and neglected to assist with safe discharge planning. This failure resulted in R13 being sent out of the facility by emergency personnel related to no licensed nursing staff to monitor or assess R13. This failure resulted in no licensed nursing staff in the facility for approximately 2 hours to assess, monitor, and provide morning medications as ordered by a physician. This failure also resulted in R1 and R8 leaving the facility with no physician orders or medications. This applies to all 108 residents residing in the facility. […]

• Immediate jeopardy, widespreadF725May 15, 2023

  Based on interview, and record review, the facility failed to ensure the facility had licensed nursing staff present in the facility after a change of ownership. This failure has the potential to affect 108 residents residing within the facility. This failure resulted in R13 being transferred to the hospital for low oxygen saturation, residents being removed from the facility by family due to lack of staff, and residents not receiving their prescribed medications as ordered. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 1, 2023 during a change of ownership. V1 Administrator was notified of the Immediate Jeopardy on May 8, 2023 at 3:26PM by the surveyor. […]

• Immediate jeopardy, widespreadF835May 15, 2023

  Based on observations, interview, and record review the administration failed to ensure key personnel were hired prior to taking ownership of the facility, and failed to ensure nursing staff were hired to meet the needs of the residents. These failures have the potential to affect all 108 currently residing within the facility. The Immediate Jeopardy began on 5/1/2023 during a change of ownership when the administration failed to ensure a safe living environment for residents by not having licensed nursing staff present. V1 Administrator was notified of the Immediate Jeopardy on 5/8/2023 at 3:26 PM. […]

• Immediate jeopardy, isolatedF689Apr 29, 2026

  Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident with a known history of elopement while at home did not elope from the facility for 1 of 3 residents (R1). This failure resulted in R1 exiting a secured unit and the facility unsupervised, walking approximately 1,000 feet and crossing a four-lane road in the dark until found by staff approximately 45 minutes later. The Immediate Jeopardy began on 4/19/26 at approximately 3:30 AM, when R1 exited from a secured unit, walked to a different unattended unit and past a nurse's station, down a hallway, and exited the facility unsupervised through a fire exit door. […]

• Immediate jeopardy, isolatedF689Feb 11, 2026

  Based on interview and record review the facility failed to ensure a resident with cognitive impairment did not elope the facility and failed to ensure all residents were accounted for one of three residents (R1) reviewed for safety/supervision in the sample of seven.The Immediate Jeopardy began on February 4, 2026, at 5:43 AM when R1 was found sitting outside in the cold in her wheelchair by herself, a block away from the facility and was transferred to the local hospital for cold exposure. V1 Administrator was notified of the Immediate Jeopardy on February 9, 2026, at 3:45 PM. […]