Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Serenity Estates of Lena

LENA, IL · 92 certified beds · Last Life Safety survey March 27, 2025

CMS Certification Number 146114 · first certified July 2007

Ownership

Operated by SERENITY ESTATES · For profit - Individual

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within IL

42 citations — more than 94% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 21 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (February 2026 to May 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

18 of the 42 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 42 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	42
Median facility in IL	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
May 25, 2023	9
April 12, 2024	12
March 27, 2025	21

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2025-03-27
E-0015	Address subsistence needs for staff and patients.	3	2025-03-27
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2025-03-27
E-0035	Provide family notifications of emergency plan.	2	2025-03-27
K-0712	Have simulated fire drills held at unexpected times.	2	2025-03-27
K-0363	Install corridor and hallway doors that block smoke.	2	2025-03-27
E-0039	Conduct testing and exercise requirements.	2	2025-03-27
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2024-04-12

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 18
Smoke Deficiencies 11
Egress Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 4
Other 4

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	18
Smoke Deficiencies	11
Egress Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	4
Miscellaneous Deficiencies	4

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 27, 2025 — 21 citations

Citations issued on March 27, 2025
Tag	What the surveyor checks	Status
E-0001	Establish an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (May 9, 2025)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (May 9, 2025)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (May 9, 2025)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (May 9, 2025)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (May 9, 2025)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (May 9, 2025)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (May 9, 2025)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (May 9, 2025)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (May 9, 2025)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (May 9, 2025)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (May 9, 2025)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (May 9, 2025)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (May 9, 2025)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (May 9, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (May 9, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (May 9, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (May 9, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (May 9, 2025)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (May 9, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (May 9, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (May 9, 2025)

April 12, 2024 — 12 citations

Citations issued on April 12, 2024
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (May 30, 2024)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (May 30, 2024)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (May 24, 2024)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (May 30, 2024)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (May 24, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (May 24, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 6, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (May 28, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (May 24, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (June 30, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (May 24, 2024)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (May 24, 2024)

May 25, 2023 — 9 citations

Citations issued on May 25, 2023
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (July 5, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (July 12, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (July 12, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (June 30, 2023)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (July 12, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 12, 2023)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (July 12, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (June 30, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (June 30, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.