Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SERENITY ESTATES OF LINCOLNSHIRE
LINCOLNSHIRE, IL · 144 certified beds · Last Life Safety survey April 24, 2025
CMS Certification Number 146028 · first certified May 2002
Ownership
Operated by SERENITY ESTATES · For profit - Limited Liability company
- Ownership changed September 1, 2024 (change of ownership)from WEALSHIRE REHAB, LLC
Position within IL
40 citations — more than 92% 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
The latest survey found 19 citations; the earlier surveys in the window averaged 7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to June 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was April 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
Get an email about SERENITY ESTATES OF LINCOLNSHIRE
One email when it happens. No account; stop it any time with one click.
4 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
8 of the 40 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)
14 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 40 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 40 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 22, 2023 | 4 |
| October 31, 2023 | 4 |
| January 31, 2024 | 13 |
| April 24, 2025 | 19 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-04-24 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 3 | 2025-04-24 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 2 | 2025-04-24 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-04-24 |
| E-0015 | Address subsistence needs for staff and patients. | 2 | 2025-04-24 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-04-24 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-04-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-04-24 |
What the citations cover
- Smoke Deficiencies 12
- Emergency Preparedness Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 7
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Emergency Preparedness Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 7 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 24, 2025 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 6, 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 (June 6, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 20, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 6, 2025) |
January 31, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (May 1, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (May 1, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 13, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 1, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (February 13, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (December 3, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 10, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 1, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (August 14, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 1, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 13, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (February 13, 2024) |
October 31, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 9, 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 (November 9, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 9, 2023) |
March 22, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 29, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (April 11, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 23, 2023) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (March 23, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.