Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenity Estates Of Lena during CMS and state inspections, most recent first.
A facility failed to ensure access to petty cash for 4 residents whose funds were being managed by the facility. The BOM stated she was new to the role, did not know how residents received money from their accounts, and had no petty cash or access to the resident accounts, despite the facility policy allowing resident personal funds to be maintained in a petty cash fund.
A facility failed to provide quarterly statements for resident funds managed by the facility. Four residents with accounts on the trial balance had no statements sent to them or their POAs, and interviews showed the residents or responsible parties were unaware of the accounts or had not been informed. The BOM stated she was new, had not been trained, and did not send statements because she did not know she was required to.
A facility failed to ensure that the POAs of two deceased residents were reimbursed money held in resident funds accounts. Trial balance records showed one resident had $648.54 and the other had $28.00 still in facility-managed accounts after both had expired and been discharged. The BOM stated she was new and noticed during the survey that the funds needed to be reimbursed. The facility policy required conveyance of resident funds and a final accounting within 30 days of discharge or death.
A facility failed to provide enough CNA staffing and did not address repeated Resident Council concerns about staffing and call light delays. Residents reported long waits for care, unanswered call lights, and reduced assistance after staffing cuts, while staff confirmed longer response times and less time to provide care. The record also showed missed pressure reduction interventions for a resident with a pressure ulcer, an unreported significant weight change, and a CNA not following posted PPE guidance during ADL care.
Failure to Complete GDR for Psychotropic Medications: A resident with dementia, depression, and anxiety was found to have missed GDRs for escitalopram and mirtazapine after a pharmacy review identified both psychotropic meds were due for dose reduction. Psychiatry notes and the MAR continued to show the resident on the same doses for months, and the DON confirmed the GDR had been missed.
A resident with a sacral pressure wound and a recurring right posterior thigh pressure wound was assessed as high risk for pressure ulcers, but the ordered wheelchair cushion for wound prevention was not positioned at the edge of the bariatric wheelchair. A CNA observed only a small padded cushion in the middle of the seat, and the wound nurse stated the resident needed a cushion covering the front edge of the wheelchair because the thigh wound was caused by pressure from the chair edge.
A facility failed to ensure safe hot water temperatures in an activity area sink used by residents for handwashing and cleanup after activities. Staff stated the sink was connected to the kitchen water supply, and the measured water temperature was 129.6 degrees Fahrenheit. The facility did not provide a policy or guidelines for protecting residents from hot water burns.
Failure to Notify Provider of Significant Weight Loss: A resident with influenza, acute respiratory failure, and protein-calorie malnutrition had significant unplanned wt loss with meal intake mostly 0-25% and breakfast left untouched during observation. The chart showed repeated 5% wt-loss warnings, but there was no documentation that the provider or RD was notified; the RD noted the wt loss and suggested an appetite stimulant, and staff interviews confirmed the provider was not documented as being informed.
A resident with a very loose front tooth reported trouble eating and said he could only manage soft foods, but no urgent dental visit was arranged and his regular diet order remained in place. Nursing staff knew about the problem, yet the RN did not notify the provider and instead relied on the resident’s wife to find a dentist. The chart contained only limited documentation of the loose tooth, despite the facility policy requiring assistance with emergency dental care, physician notification for acute dental conditions, and diet changes when needed.
Failure to serve diet texture as ordered. A resident with an active order for a regular texture diet with chopped meats was observed eating lunch with a whole pork chop served instead of chopped meat. The meal ticket indicated chopped meats were required, and a dietary aide later confirmed the resident should have received a chopped pork chop rather than a full pork chop.
Failure to use PPE during EBP care. A resident with pressure wounds was on EBP, and a sign on the door directed staff to wear a gown and gloves for high-contact care such as transferring and hygiene. A CNA entered the room without a gown, assisted the resident to the toilet, provided perineal care, and helped her back to her wheelchair.
Failure to monitor prophylactic antibiotic use: A resident with progressive MS and a UTI diagnosis had an order for daily Trimethoprim for UTI prophylaxis, but the IP Nurse/ADON stated she did not know any resident was on prophylactic antibiotics and confirmed the resident’s antibiotic use had not been evaluated. The facility’s Antibiotic Stewardship plan states the IP monitors antibiotic stewardship activities and tracks antibiotic use.
A resident with dementia and a right arm amputation was found to have dark purple bruising near the left eye and additional bruising on the left upper arm, with no witnesses and the resident unable to explain the injuries. An LPN documented the bruises as an injury of unknown origin and notified the DON, who completed a risk management report but deemed the bruising explainable, suggesting it was plausibly caused by the resident pulling on a door handle, despite no documented or witnessed behavior confirming this. Social services staff reported the resident sometimes held a door handle and flailed arms when redirected but had never seen the resident hit himself. The administrator later acknowledged that unexplained eye bruising without a known cause should have triggered an injury-of-unknown-origin abuse investigation, which was not done, contrary to the facility’s abuse policy requiring investigation and reporting of suspicious injuries of unknown origin such as an unexplained black eye.
An agency LPN administered a full set of medications prescribed for one resident to a different resident after failing to verify the resident’s identity and insisting the pills were correct despite the resident’s objections. The medications included multiple cardiac, supplement, and antipsychotic agents that were not ordered for the recipient. The facility’s error report cited inexperienced staff and an outdated resident photo as contributing factors, and leadership confirmed that required verification steps under the six rights of medication administration were not followed.
Failure to prevent staff abuse during resident care. A resident with dementia, psychosis, pain, and moderate cognitive impairment was being assisted by two CNAs when one CNA became frustrated with the resident’s resistance to care, pulled off his bedding aggressively, used profanity, and grabbed and twisted his nose while telling him to be quiet. The other CNA witnessed the conduct and reported it, and the facility substantiated the allegation.
The facility failed to properly cool cooked foods, risking pathogen growth. Leftover items like spaghetti sauce and taco meat were stored without cooling logs, contrary to HACCP guidelines. The Dietary Manager confirmed these leftovers were served to residents, highlighting a lapse in food safety protocols.
A facility failed to conduct interdisciplinary care plan conferences for a resident with severe cognitive impairment and multiple diagnoses. The resident's power of attorney was not informed or invited to care plan meetings, despite expressing frustration over the lack of communication. The facility did not document invitations to these meetings, and no family attendance was recorded, highlighting a deficiency in involving family in the care planning process.
A resident with mild cognitive impairment and multiple diagnoses requiring assistance with ADLs was observed with wet clothing, indicating a need for incontinence care. A CNA changed the resident's brief and pants without performing necessary incontinence care. The resident continued to wear the same clothes for two days without documented refusal to change. The DON confirmed the need for assistance and adherence to facility policy for incontinence care.
A resident with a history of a Stage 3 pressure wound experienced a reopening of the wound due to inadequate monitoring and reporting by the facility staff. Despite the facility's policy to prevent pressure ulcers, the wound was not identified and reported in a timely manner, leading to its reopening and enlargement.
A resident with severe cognitive impairment and a history of falls was found without a functioning bed alarm, despite care plans and physician's orders requiring it. Staff were confused about the alarm's necessity, and the DON confirmed it should be in place. The facility's fall management policy was not followed.
The facility did not follow manufacturer instructions for insulin expiration, affecting two residents. One resident received expired insulin glargine, while another's insulin aspart pen lacked proper labeling to track expiration. The DON confirmed the importance of adhering to expiration guidelines to prevent contamination and potency issues.
A facility failed to follow infection control protocols during incontinence care for a resident with chronic kidney disease and a UTI. CNAs did not change gloves or perform hand hygiene after cleaning feces and before touching clean items. The CNAs were unable to state when glove changes and hand hygiene should occur, despite facility policies and training.
A resident, diagnosed with dementia but cognitively intact, was not offered the flu vaccine for the 2024/2025 season due to the facility's policy of requiring POA consent for dementia patients. The POA was unavailable, and the facility lacked a specific flu vaccination policy, leading to the resident contracting flu and COVID-19.
A facility failed to offer a COVID-19 vaccine to a resident with dementia who was cognitively intact and expressed a desire to make her own vaccination decisions. The facility's practice was to defer to the POA for consent, and the resident's POA was unavailable. The resident, who had a BIMS score of 15, was not offered the vaccine and later contracted COVID-19 and influenza. The facility lacked a specific COVID-19 vaccination policy.
The facility failed to ensure staff wore the required PPE when entering the rooms of three residents on droplet/contact isolation for influenza. Staff were observed not using full PPE, such as gowns, masks, eye protection, and gloves, despite signage indicating these requirements. The Director of Nursing confirmed the deficiency in PPE usage.
A resident's call light was removed by a CNA due to frequent activation, leaving it out of reach and violating the resident's rights. The resident, with conditions including cellulitis and COPD, expressed concern about not being able to call for help. The incident was confirmed by staff and the DON, highlighting a failure to adhere to the facility's policy on dignity and resident rights.
A significant medication error occurred when a nurse, distracted by giving a shift report, administered 40 units of unnecessary sliding scale insulin to a resident with a blood glucose level of 103. The resident, with a history of diabetes, congestive heart failure, and hypertension, appeared tired and vomited once the following day. The error was reported to the physician and Power of Attorney.
A resident with severe cognitive impairment and requiring two-person assistance for bed mobility was injured when a CNA attempted to provide care alone. The resident fell from a raised bed during a bed bath, resulting in a nasal bone fracture, femoral neck fracture, and a forehead laceration requiring sutures. The CNA did not seek help despite knowing the resident's needs and the availability of other aides.
The facility failed to ensure that the Director of Nursing (DON) and the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The review of attendance sheets confirmed that the Infection Preventionist attended only two meetings, and the DON attended only one meeting out of four. This deficiency impacts the facility's adherence to its QAPI policy.
The facility failed to prevent a resident from falling from a broken beauty shop chair and did not implement fall prevention interventions for four residents. One resident fell due to a faulty chair, another lacked a required non-slip pad, and two others were without necessary bed and chair alarms.
The facility failed to obtain physician's orders for a resident on CPAP therapy and did not store nebulizer and CPAP masks in a sanitary manner for four residents. One resident had a CPAP machine without any physician's orders or documented settings, and three other residents had their nebulizer masks left uncovered and exposed to air on their bedside tables, contrary to facility policy.
The facility failed to reassess and update the dietary preferences and nutritional needs of a resident after readmission with a diet change to a full liquid diet. The care plan was not updated, and the dietary card did not include prescribed supplements. The Dietary Manager admitted to not reassessing the resident's needs, and the cook confirmed limited dietary options were provided.
The facility failed to ensure that two residents were assessed by a physician within the first 30 days after admission. Both residents were only seen by a Nurse Practitioner, and the facility staff misinformed one resident that a Nurse Practitioner is a doctor. The Clinical Coordinator confirmed the lack of physician assessments, which is against the facility's policy.
A resident with severe cognitive impairment and anxiety disorder did not receive 18 doses of Alprazolam over six days due to issues with medication availability and delays in receiving a new prescription. Despite multiple attempts by nursing staff to resolve the issue, the medication was not delivered in a timely manner.
The facility failed to ensure that vegetables served to residents were palatable and properly cooked. The vegetables were overcooked to a mushy texture and lacked flavor due to the omission of salt. Two residents expressed dissatisfaction, leading to uneaten portions on their trays.
A facility failed to ensure proper PPE was worn by a nurse while providing care to a resident in contact isolation for a MRSA infection. The nurse entered the room without a gown, despite clear signage and policy requirements, and performed tasks that involved contact with the resident's bedding.
Resident Funds Not Accessible as Petty Cash
Penalty
Summary
The facility failed to ensure residents had access to petty cash for 4 of 4 residents reviewed for resident funds (R29, R32, R41, and R46) in a sample of 15. The facility’s current trial balance of resident funds showed that these residents had money in accounts managed by the facility. During interview, the Business Office Manager stated she was new to the position, was not sure how residents received their money from their accounts, and did not have any petty cash or access to the residents’ accounts. The facility’s Resident Personal Funds policy states that residents have the right to manage their financial affairs and that the facility will maintain resident personal funds not exceeding $100 in a non-interest bearing account, interest bearing account, or petty cash fund.
Failure to Provide Quarterly Statements for Resident Funds
Penalty
Summary
The facility failed to ensure that residents and/or their POAs received quarterly statements for personal funds managed by the facility. A review of the resident funds trial balance showed that R29, R32, R41, and R46 each had money in an account managed by the facility, but interviews confirmed that none of the residents or their responsible parties had received statements for those accounts. The facility’s Business Office Manager stated she had only been in the role for a couple of months, was still learning, had not received training on what to do, and did not send out any statements to residents or families because she was not aware she needed to. R29’s sister/POA stated she knew about the account from the previous owners but had not received any statements; R29 had diagnoses of dementia and moderate intellectual disability, and his current balance was $2,744.77. R32, who had progressive multiple sclerosis, cognitive communication deficit, and altered mental status, was not aware she had money in an account at the facility, and her sister/ პასუხისმგible party also stated she had not received statements; R32’s balance was $88.49. R41’s daughter/POA stated she was not aware of any account and had not received statements; R41 had vascular dementia and a balance of $991.91. R46’s son/POA stated he received bills from the facility but never a statement for any money in an account and was not aware of the account; R46 had bipolar disorder and hallucinations and a balance of $2,572.37.
Failure to Reimburse Deceased Residents’ Funds
Penalty
Summary
The facility failed to ensure that the Power of Attorney representatives of two deceased residents were reimbursed money from resident funds accounts managed by the facility. The current trial balance of resident funds showed that R56 had $648.54 in an account at the facility and had expired 54 days earlier, and R57 had $28.00 in an account at the facility and had expired 78 days earlier. Both residents had been discharged from the facility, and the Business Office Manager stated she was new to the position, was still learning, and noticed during the survey that R56 and R57 had money in accounts that needed to be reimbursed. The facility’s Resident Personal Funds policy stated that upon discharge, eviction, or death, the facility would convey the resident’s funds and a final accounting within 30 days to the resident or, in the case of death, to the individual or probate jurisdiction administering the estate.
Insufficient Staffing and Unaddressed Resident Council Concerns
Penalty
Summary
The facility failed to provide sufficient staffing and did not address staffing concerns raised by the Resident Council for multiple residents. Residents reported long waits for care and call lights, with one resident stating they waited a long time for care, had dirtied and wet themselves, and that meals were not hot half the time. Another resident reported that call lights were not being answered and that staffing had been cut, while two other residents described having to wait a long time for CNA assistance, including at night when one resident said a planned every-2-hour CNA check did not occur and staff tried to place a diaper on them instead of providing the requested care. Staff also acknowledged that staffing had been reduced after new ownership and that longer call light times were occurring. The Resident Council minutes from February and March 2026 documented repeated concerns about staffing and call light response times, but there were no documents showing the Administrator addressed those concerns. Staff interviews confirmed the concerns were discussed with the Administrator, and multiple staff members stated that the staffing changes left them with less time to provide care beyond baseline tasks. In addition, one resident with a current pressure ulcer did not receive the physician-ordered pressure reduction interventions in the wheelchair, another resident’s significant weight change was not identified or reported to the physician, and a CNA failed to don PPE according to the resident’s posted infection control guidance during ADL care.
Failure to Complete GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was completed for a resident with diagnoses including dementia, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder. The resident was observed in the room, in bed, and in a wheelchair, and was not cognitively intact and unable to answer questions. A consultant pharmacist’s medication regimen review identified that escitalopram 20 mg daily and mirtazapine 15 mg daily were due for GDR to ensure the lowest possible effective dose. Psychiatry documentation noted that escitalopram had been decreased to 15 mg and stated that a GDR for mirtazapine was contraindicated due to increased risk of depressive symptoms, but the psychiatry notes from August 2025 through March 2026 continued to show the resident taking escitalopram 20 mg daily and mirtazapine 15 mg daily and did not address the original pharmacy request for both medications. The MAR showed escitalopram 20 mg daily and mirtazapine 15 mg daily remained in place until March 2026, and the DON confirmed the GDR for both medications had been missed and that the psychiatry notes indicated it had been done when it had not.
Pressure ulcer prevention intervention not in place for resident with existing wounds
Penalty
Summary
The facility failed to ensure pressure ulcer prevention interventions were in place for a resident at risk for pressure ulcers. R33 had a pressure wound to the sacrum and a pressure wound to the right posterior thigh, and her Braden assessment showed she was at high risk for developing pressure ulcers. Her Physician's Order Sheet included an order dated 11/13/24 for a cushion at the edge of the seat for wound prevention. On 4/27/26, a CNA assisted R33 to the toilet and observed that she stood up from her bariatric-sized wheelchair with a small padded cushion positioned in the middle of the seat rather than at the edge of the chair, and there was no other padding on the edge. The wound nurse later stated that R33's posterior thigh pressure ulcer was facility acquired and recurring, and that she should have a cushion covering the front edge of the wheelchair because the wound was caused by her thighs pressing on the edge of the chair. The wound nurse also stated the wrong type of cushion had been on the wheelchair and had been replaced with the appropriate sized one.
Unsafe Hot Water Temperature in Activity Area Sink
Penalty
Summary
The facility failed to ensure safe hot water temperatures in a resident care area for 1 of 25 residents reviewed for safety and supervision. Surveyors observed the sink in the activity area, which residents use to wash their hands and clean up after messy activities, and measured the water temperature at 129.6 degrees Fahrenheit. Maintenance staff stated that the sink in the activity area is connected to the kitchen water supply and that the kitchen hot water needs to be at a higher temperature. The Maintenance Director said residents have different opinions about water temperature and stated that hot water should not go over 110 degrees Fahrenheit. The facility did not provide a policy or guidelines for protecting residents from hot water burns.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
The facility failed to ensure a resident with significant unplanned weight loss was identified and that the physician was notified. The resident was admitted with diagnoses including influenza, acute respiratory failure, and unspecified protein-calorie malnutrition. On observation, the resident was in bed, not dressed for the day, with breakfast untouched on the bedside table and stated being tired and not hungry. The resident’s weight record showed a 7.2 lb, 5.88% unplanned weight loss over about 8 days, with multiple weights triggering a 5% loss warning and meal intake documented mostly at 0-25%. Record review showed no nurse, provider, or dietician progress notes documenting that the provider or RD was notified of the significant weight loss. The RD documented the resident twice and noted a -5.0% weight loss with a recommendation for an appetite stimulant if medically appropriate, but the note did not indicate provider notification. Staff interviews showed the dietary aide tracked intake and notified nurses, while an LPN stated a provider should be notified of significant weight change and was unsure who monitored nutritional intake. The DON stated the resident’s weight loss had been discussed and reviewed by the care team, including a provider, but the medical record did not reflect this. The facility policy required comparison of weights, identification of a 5% change as significant, and notification of the physician and consultation with the RD.
Failure to Provide Timely Dental Care and Diet Modification for a Resident With a Loose Tooth
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident with a loose front tooth, failed to modify the resident’s diet for chewing difficulty related to the dental problem, and failed to notify the physician about the dental concern. R12 was observed in the dining room with a very loose top front right tooth that appeared barely attached to the gums. He stated the tooth had been loose for a couple of days, that it was almost falling out, and that he was having trouble eating because of it. He also said he could only eat softer foods and no meat. Staff interviews showed the concern was known to nursing staff, but no urgent dental evaluation was arranged and no physician notification was documented. A CNA said she reported the loose tooth to the nurse, and the RN said she told R12’s wife about it and was waiting for the wife to find a dentist because no dentist had been available since the new company took over in November 2025. The RN also said she did not report the tooth problem to anyone else. The DON stated that if a resident had an urgent dental problem, the nurse would tell the provider and the resident would be evaluated, and that if a resident had trouble eating or could choke on a loose tooth, staff would want to make sure the resident was safe. Record review showed R12’s MDS did not indicate chewing difficulty or loose dentures, and his order summary showed a regular texture diet despite his report that he could only eat soft foods. The only documentation in the chart noted the tooth was very loose, that the nurse tried to wiggle it out but the resident did not want it pulled, and that the wife would look into a dental appointment. R12’s diagnoses included atrial fibrillation and he was receiving apixaban twice daily. The facility policy stated it would assist residents with routine and emergency dental care, notify the physician for acute dental conditions, modify diet consistency, and document all actions and delays related to dental services, but no additional documentation was found regarding the tooth concern.
Failure to Serve Diet Texture as Ordered
Penalty
Summary
The facility failed to serve a resident chopped meat as ordered for R33, who had an active physician order for a regular texture diet with chopped meats. On 4/27/26 at 12:15 PM, R33 was observed in the main dining room eating lunch, and the meal ticket indicated that chopped meats were required. Instead, R33 was served a whole pork chop on the plate and ate half of it by picking it up and taking bites. At 12:30 PM, a dietary aide reviewed the meal ticket and stated that R33 should have been served a chopped pork chop for the noon meal and should not have been served a full pork chop. The facility’s Therapeutic Diet Orders Policy states that the facility provides all residents with foods in the appropriate form as prescribed by a physician, and that dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or nutritive content as prescribed.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to ensure PPE was donned before direct resident care for a resident on Enhanced Barrier Precautions. The resident had a wound evaluation and management summary dated 4/27/26 showing pressure wounds on the sacrum, right posterior thigh, and left upper ear. A sign on the resident’s door stated that she was on EBP and that staff should apply a gown and gloves when performing direct resident care activities, including transferring and providing hygiene. At 11:06 AM, a CNA entered the resident’s room to take her to the toilet without applying a gown, assisted her from her wheelchair into the bathroom, provided perineal care, and then assisted her back to her wheelchair. Later that day, a CNA stated that the resident was on EBP due to wounds and that staff should apply a gown and gloves when providing care, including taking her to the bathroom.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure effective implementation of its Infection Prevention and Control Program by not identifying and surveilling one resident receiving prophylactic antibiotic therapy. R32’s face sheet documented diagnoses including progressive multiple sclerosis and urinary tract infection, and the order summary showed an order for Trimethoprim 100 mg daily for urinary tract infection prophylaxis that began on 1/25/2025. During interview on 4/29/2026, the Infection Prevention Nurse/Assistant Director of Nursing stated that she was responsible for monitoring residents’ antibiotic use, including the clinical reason for the antibiotic, the ordering provider, discontinuation date, signs and symptoms, and medication effectiveness, but she did not know that any resident was on prophylactic antibiotics and confirmed that R32’s antibiotic use had not been evaluated. The facility’s Antibiotic Stewardship plan stated that the IP monitors all antibiotic stewardship activities and that the facility tracks antibiotic use.
Failure to Investigate Unexplained Bruising as Possible Abuse
Penalty
Summary
The facility failed to investigate an injury of unknown origin as possible abuse for one resident with dementia and a right above-elbow amputation. The resident’s face sheet showed cognitive impairment, and progress notes documented bruising to the corner of the left eye, described as dark purple and approximately 3 cm by 0.5 cm, and additional bruising to the left upper arm measuring 10 cm by 5 cm, light purple/blue in color. The resident was alert and oriented to one sphere, confused, had impaired memory, and was unable to explain how either bruise occurred. No one witnessed how the bruising happened. The LPN who discovered the bruising stated she treated it as an injury of unknown origin and possible abuse, notified the DON, and completed a risk management/incident form that documented the unexplained bruising and the resident’s poor ability to report the cause. The DON acknowledged that a risk management form was completed but stated the bruising was considered explainable and therefore not treated as abuse, asserting it was plausible the resident sustained the bruise while swinging or forcefully pulling on a door handle, grab bar, or wheelchair component, despite there being no witnesses to such behavior and no behavior documented that corresponded with this explanation. The risk management/incident report signed by the DON characterized the bruising as plausibly self-inflicted based on behavioral observations, even though the resident was a poor historian, could not recall the cause, and there were no witnesses or prior safety alerts for that area. Social services staff reported the resident would hold the door handle and sometimes flail his arms when staff tried to remove his hands but had never seen the resident hit himself. The administrator later stated that unexplained bruising to the corner of a resident’s eye with no explanation and no witnesses should trigger an injury of unknown origin abuse investigation, and confirmed that no such abuse investigation was conducted, despite the facility’s abuse policy requiring investigation and reporting of suspicious injuries of unknown origin, including a black eye in a resident unable to communicate when no source is witnessed.
Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A resident received another resident’s medications, resulting in a significant medication error. On the morning of 1/29/26 at approximately 8:30 AM, an agency LPN administered a set of medications that were prescribed for a different resident. The medications given included Norvasc 5 mg, ferrous sulfate 325 mg, a fiber tablet, Lasix 10 mg, a multivitamin, potassium chloride 10 mEq, vitamin D3 25 mcg, Florastor, liquid protein, and risperidone 2 mg, none of which were prescribed for the resident who received them. The resident later reported that she tried to tell the nurse the pills were not hers, but the nurse insisted they were and did not ask her name or otherwise confirm her identity before administration. The resident stated she developed a severe headache and felt unwell afterward and noted she had never been prescribed risperidone before. The facility’s medication error report identified that the agency LPN gave the wrong medications and documented contributing factors as inexperienced staff and an old photo of the resident. The ADON confirmed that the resident received the wrong medications and that the LPN recognized the error immediately after administration. At the time of the incident, the resident remained alert and oriented x4, with no immediate symptoms documented other than later sleepiness. The facility’s medication administration policy required licensed nurses to follow the six rights of medication administration, including verifying the right resident, but this verification process was not followed when the LPN failed to properly identify the resident before giving the medications.
Failure to Prevent Staff Abuse During Resident Care
Penalty
Summary
The facility failed to prevent staff-to-resident physical and verbal abuse involving a resident with dementia, psychosis, pain, and moderate cognitive impairment. The resident was incontinent and resistant to care, including yelling out during peri care and moaning or groaning during hands-on assistance, which staff stated was related to catheter discomfort. During care and preparation for dinner, two CNAs entered the resident’s room to provide care and get him ready for supper. According to the facility’s investigation and staff statements, one CNA became frustrated with the resident’s reluctance and quickly pulled the blankets and sheet off him while telling him to "shut up" and "be quiet." The same CNA then used profanity toward the resident, telling him to "shut the f*** up," and reached around a mechanical lift to grab the resident’s nose, twisting and pulling it hard. The other CNA stated she was shocked by the conduct, observed the nose-grabbing and twisting, and reported the incident after separating the resident from the CNA. The facility’s records showed the allegation was substantiated. The resident was alert but pleasantly confused when interviewed and did not recall the incident, and no injury to his nose or face was observed. Staff interviews confirmed the resident’s baseline behaviors during care, and the accused CNA denied the incident. The facility’s abuse policy defined abuse to include verbal and physical abuse and required accused staff to be removed from the facility and suspended.
Improper Cooling of Leftover Foods
Penalty
Summary
The facility failed to ensure that cooked foods were cooled in a manner that limits the growth of potentially dangerous pathogens, which could affect all residents. During an inspection, it was observed that the facility's reach-in freezer contained several leftover food items, such as spaghetti sauce, taco meat, beef barley soup, and meatballs, with preparation and use-by dates indicating they were stored for extended periods. Additionally, leftover chicken noodle soup was found in the refrigerator. The Dietary Manager confirmed that these leftovers were served to residents and were part of the alternative menu. The Dietary Manager admitted that there were no cooling logs for the leftover items in the freezer, which should have been posted on the reach-ins. The facility's General HACCP Guidelines for Food Safety policy requires that cooked food be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and then from 70 degrees Fahrenheit to 41 degrees Fahrenheit within four hours. If these times and temperatures are not met, the food should be reheated to 165 degrees Fahrenheit, and the cooling process restarted. The absence of cooling logs and the improper cooling of food items indicate a failure to adhere to these guidelines, potentially allowing the growth of pathogens.
Failure to Conduct Interdisciplinary Care Plan Conferences
Penalty
Summary
The facility failed to conduct interdisciplinary care plan conferences for a resident, identified as R44, who was reviewed for care plans. R44 has multiple diagnoses, including cerebral infarction, hemiplegia, hemiparesis affecting the left dominant side, dementia with anxiety, and dementia with behaviors, and is noted to have severe cognitive impairment. Despite these conditions, the facility did not involve R44's family or power of attorney in care plan meetings. The power of attorney, V13, expressed frustration over the lack of communication and the absence of care plan meetings, stating that they had never been informed of such meetings. The facility's records showed that care plan meetings were held on three occasions, but no family attendance was recorded. The Social Service Director, V12, acknowledged the lack of family involvement and stated that invitations to care plan meetings are typically made by phone calls, which are not documented. Despite the family's recent increased involvement, they had not been invited to any care plan meetings, and no policy regarding family attendance or documentation of invitations was provided by the facility. The facility had contacted the family six times since R44's admission but failed to invite them to participate in care plan meetings.
Failure to Provide Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and activities of daily living (ADL) assistance for a resident identified as R35. R35 has diagnoses including the need for personal care, muscle wasting and atrophy, morbid obesity, and edema, and requires partial to moderate assistance with toileting hygiene due to mild cognitive impairment. On March 25, 2025, R35 was observed with wet marks on the back of his pants, indicating a need for incontinence care. A Certified Nursing Assistant (CNA), identified as V14, assisted R35 by removing the wet pants and incontinence brief but failed to perform incontinence care before applying a clean brief and pants. V14 admitted to not offering incontinence care because R35 did not request it, despite acknowledging that it should have been offered. Further observations on March 26 and March 27, 2025, revealed that R35 continued to wear the same clothes from March 25, 2025, without any documented refusal to change clothes or receive incontinence care. The Director of Nursing (DON), identified as V2, confirmed that R35 requires assistance with personal care and emphasized the importance of providing incontinence care to prevent skin breakdown and ensure cleanliness. The facility's policy mandates providing incontinent care in a manner that ensures privacy, dignity, and no cross-contamination, which was not adhered to in this instance.
Reopened Pressure Ulcer Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that a healed pressure injury did not reopen for a resident with a history of multiple diagnoses, including congestive heart failure and moderate cognitive impairment. The resident, who required assistance with personal care and was occasionally incontinent of urine, was admitted with a Stage 3 pressure wound that had initially resolved. However, the wound reopened, as documented in a wound evaluation and management summary, with measurements indicating a significant size. Observations revealed that the wound had reopened and was covered with a white paste. The RN noted that the wound had originally been two open areas that merged into one. The Director of Nursing acknowledged that the wound should have been identified and reported before it reached its current size. The facility's policy mandates that residents at risk for pressure ulcers receive necessary treatment to promote healing and prevent new sores, which was not adhered to in this case.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure fall prevention measures were in place for a resident with severe cognitive impairment and a history of falls. The resident, who has diagnoses including a femur fracture, dysphagia, osteoarthritis, dementia with behaviors, and major depressive disorder, was observed without a functioning bed alarm. The resident's care plan and physician's orders indicated the need for a bed and chair alarm to be in place and functioning at all times due to a history of falls and attempted independent transfers and ambulation. On the day of observation, the bed alarm cord was found disconnected and placed in a basin, with the alarm box showing no signs of functioning. Staff interviews revealed confusion regarding the resident's need for a bed alarm, with a Licensed Practical Nurse unaware of the requirement and a Certified Nursing Assistant unsure why the alarm was not plugged in. The Director of Nursing confirmed that the resident should have the alarms plugged in at all times, especially after a recent fall incident. The facility's policy on fall management emphasizes evaluating residents for fall risk and developing preventive interventions, which was not adhered to in this case.
Failure to Follow Insulin Expiration Protocols
Penalty
Summary
The facility failed to adhere to manufacturer instructions regarding the expiration date of in-use insulin for two residents. For one resident, insulin glargine was found in the medication cart with an open date and a discard date that had already passed. Despite this, the insulin was documented as being administered to the resident after the expiration date. The Director of Nursing acknowledged that the expired insulin should not have been used, as the manufacturer's instructions specify that insulin vials should be discarded 28 days after opening due to potential contamination and decreased potency. For another resident, an insulin aspart pen was found in the medication cart without any dates documented on the facility-applied label, which is intended to track the date of opening and the discard date. The Director of Nursing confirmed that insulin pens should be dated once removed from the refrigerator to ensure proper tracking of expiration. The facility's Insulin Administration policy requires checking expiration dates and recording the expiration date and time on new vials, following manufacturer recommendations.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care for a resident with chronic kidney disease stage 4, urinary tract infection, and anxiety disorder. The resident, who has moderate cognitive impairment and is dependent on staff for personal hygiene, was provided incontinence care by two Certified Nursing Assistants (CNAs). During the care, the CNAs did not change their gloves or perform hand hygiene after cleaning feces from the resident's buttocks and before touching clean items such as a new incontinence brief, a mechanical lift remote, bed controls, and the resident's wheelchair. The CNAs were unable to articulate when gloves should be changed and when hand hygiene should be performed, despite the facility's policy requiring glove changes and hand hygiene to prevent cross-contamination. The Director of Nursing confirmed that staff are taught the correct procedures during training and competencies.
Failure to Offer Flu Vaccine Due to Consent Policy
Penalty
Summary
The facility failed to offer a resident the flu vaccine for the 2024/2025 flu season, which was identified during a survey. The resident, who was part of a sample of 26, was diagnosed with dementia but was cognitively intact, as evidenced by a BIMS score of 15 out of 15 and multiple medical notes indicating she was alert and oriented. Despite this, the facility's Director of Nursing (DON) stated that they do not allow residents with a dementia diagnosis to sign consents, relying instead on the Power of Attorney (POA). However, the POA was unavailable due to being in the Intensive Care Unit, and the resident's family was unwilling to make decisions on her behalf. Consequently, the resident did not receive the flu vaccine and subsequently contracted the flu and COVID-19 early in 2025. The facility did not have a specific policy in place for flu vaccinations, and the DON expressed concerns about allowing residents with dementia to sign consents, fearing they might later claim they did not sign the paperwork. The resident's POA documentation allowed her to make her own decisions while she was still capable, but the facility did not assess her cognitive ability at the time of signing consents. The Ombudsman noted that dementia is a spectrum, and individuals with the diagnosis can vary significantly in their decision-making capabilities. The lack of a specific flu vaccination policy and the facility's approach to consent for residents with dementia contributed to the deficiency.
Failure to Offer COVID-19 Vaccine to Cognitively Intact Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to a resident for the 2024/2025 season, despite the resident being cognitively intact and expressing a desire to make her own vaccination decisions. The resident, who was diagnosed with dementia but had a BIMS score of 15 out of 15, indicating full cognitive function, was not offered the vaccine because the facility's practice was to defer to the power of attorney (POA) for consent. The resident's POA was unavailable due to being in the ICU, and the facility did not have a policy in place to assess the resident's cognitive ability to consent at the time of vaccination. The Director of Nursing (V2) stated that the facility's practice was to rely on the POA for consent if a resident had a dementia diagnosis, regardless of their cognitive status. The resident's medical records and interviews confirmed her cognitive awareness and ability to make informed decisions about her health. Despite this, the facility did not offer the COVID-19 booster, and the resident subsequently contracted COVID-19 and influenza. The facility lacked a specific COVID-19 vaccination policy, contributing to the oversight in offering the vaccine to the resident.
Failure to Use Required PPE for Residents on Isolation
Penalty
Summary
The facility failed to ensure that staff wore the required personal protective equipment (PPE) when entering the rooms of residents who were on isolation for influenza. This deficiency was observed in three residents who were diagnosed with influenza and placed on droplet/contact isolation. For Resident 1, there was confusion regarding the isolation status, and the appropriate signage was not initially displayed on the door. An activity aide was observed in the room wearing only a surgical mask, without the full PPE required for droplet/contact isolation. The Director of Nursing confirmed that Resident 1 was to remain on isolation due to worsening symptoms. For Resident 2, a certified nursing assistant entered the room wearing only a surgical mask, despite the presence of a droplet/contact isolation sign indicating the need for full PPE, including a gown, mask, eye protection, and gloves. Similarly, for Resident 3, a certified nursing assistant entered the room with gloves, gown, and mask but lacked eye protection. The Director of Nursing confirmed that all three residents were on droplet/contact isolation and that the required PPE was not consistently used by staff, as indicated by the isolation signage.
Resident's Call Light Removed, Violating Dignity and Rights
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring the resident's call light was within reach, which is a violation of resident rights. A certified nursing assistant (CNA), identified as V5, removed the call light from the resident's reach because it was frequently activated, sometimes accidentally. The resident, a male with diagnoses including cellulitis, COPD, weakness, and dehydration, expressed concern about not being able to call for help if needed. The incident was confirmed by another CNA, V7, and the CNA Supervisor, V6, who found the call light under the resident's bed. The Director of Nursing (DON), V2, was notified of the incident and confirmed through interviews with the resident and staff that the call light had been removed from the resident's reach. The facility's incident report documented that V5 admitted to moving the call light due to its sensitivity and frequent activation. The facility's policy on dignity and resident rights emphasizes that residents should be treated with respect and have their rights maintained, which was not adhered to in this case.
Significant Medication Error Due to Distraction During Medication Pass
Penalty
Summary
The facility failed to administer a physician-prescribed medication as ordered, resulting in a significant medication error for one resident. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, congestive heart failure, and hypertension, was cognitively intact and required moderate assistance with daily activities. On the night of the incident, the Director of Nursing (V2) was working a busy shift and mistakenly administered 40 units of regular sliding scale insulin to the resident, despite the resident's blood glucose level being 103, which did not require any sliding scale insulin. The error occurred while V2 was distracted, attempting to give a shift report to the oncoming nurse while preparing medications. The facility's policy for insulin administration requires checking the blood glucose level and ensuring the correct type and amount of insulin is administered. However, V2 admitted to being distracted and not focusing solely on the medication pass, leading to the error. The following day, the resident appeared tired and experienced one episode of emesis but did not report feeling unwell. The incident was promptly reported to the physician and the resident's Power of Attorney. The facility's administrator emphasized the importance of undivided attention during medication administration.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe bed mobility for a resident, resulting in significant injuries. The resident, who had severe cognitive impairment and required assistance from two or more staff members for bed mobility, was being cared for by a single Certified Nursing Assistant (CNA). During a bed bath, the resident experienced a jerking movement, causing her to fall from the bed, which was raised to waist level. This incident led to the resident sustaining a nasal bone fracture, a femoral neck fracture, and a laceration on her forehead that required nine sutures. The CNA involved admitted to providing care alone despite knowing the resident required two-person assistance. The CNA did not request help, even though other aides were available in the building and communication devices were accessible for such purposes. The Director of Nursing and Assistant Director of Nursing confirmed that the CNA should have sought assistance, as the resident's assessment clearly indicated the need for two-person support for bed mobility. This oversight in following the resident's care plan and facility policy resulted in the resident's injuries.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) and the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The CMS 671 dated 4/11/24 shows 56 residents residing in the facility. The Administrator (V1) acknowledged that the DON had to cover the floor during some meetings and did not attend. The Assistant Director of Nursing (V2), who is also the Infection Preventionist, mentioned that she attended the meetings only when she was in the building and was off for a while on maternity leave. The review of the quarterly QAPI Agenda - Attendance sign-in sheets for 4/27/23, 8/30/23, 11/27/23, and 3/19/24 confirmed that the Infection Preventionist attended only two of these meetings, and the DON attended only one meeting. The previous DON (V10) also confirmed that she missed some meetings due to working the floor or night shifts. The facility's Quality Assurance and Performance Improvement (QAPI) policy mandates that the QAPI Committee must include the Director of Nursing, the Medical Director or designee, at least three other staff members including the administrator, and the infection preventionist. The policy also states that QAPI meetings should be held monthly but at a minimum of quarterly. The failure to ensure the required attendance of the DON and Infection Preventionist at these meetings constitutes a deficiency in the facility's adherence to its QAPI policy, potentially impacting the quality of care for all residents in the facility.
Failure to Prevent Falls and Implement Safety Interventions
Penalty
Summary
The facility failed to prevent a resident from falling from a broken beauty shop chair and did not implement interventions to prevent falls for four residents reviewed for falls. Resident R43, who has moderate cognitive impairment and a history of falls, fell backward and hit her head on the floor when a beauty shop chair broke. The beautician had previously reported the chair's potential mechanical failure to maintenance, but it was deemed functional. The chair was later found to recline completely backward without pulling the lever, indicating it was not safe for use. The facility's investigation into the incident was incomplete and lacked proper documentation. Resident R3, who has severe cognitive impairment and a history of falls, was found without a non-slip pad in her recliner, despite it being a documented intervention to prevent falls. Multiple staff members confirmed that R3 should have a non-slip pad in her recliner at all times, but it was not in place during the surveyor's observations. This failure to follow the care plan put R3 at risk for further falls. Residents R20 and R50, both of whom require bed and chair alarms due to their high fall risk, were observed without these alarms in place. R20 was transferred to bed without the alarm being activated, and R50 was seen in his wheelchair without the alarm on multiple occasions. Staff acknowledged the necessity of these alarms to alert them when residents attempt to get up, but they were not consistently used, increasing the risk of falls for these residents.
Failure to Obtain Physician's Orders and Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to obtain physician's orders for a resident on CPAP therapy and did not store nebulizer and CPAP masks in a sanitary manner for four residents. Specifically, one resident with a history of pneumonia and COVID-19 had a CPAP machine from home without any physician's orders or documented settings. The CPAP mask was left uncovered on the bedside table, and there was no care plan or facility assessment completed for this new admission. Additionally, the facility's policy required respiratory equipment to be stored in plastic bags to prevent bacterial contamination, which was not followed for this resident. Three other residents with various diagnoses, including dementia, upper respiratory infections, and RSV, also had their nebulizer masks left uncovered and exposed to air on their bedside tables. The facility's policy mandated that respiratory equipment be stored in plastic bags marked with the date and resident's name, which was not adhered to. Interviews with the facility's staff confirmed the importance of proper storage to prevent bacterial contamination and the necessity of having physician's orders for respiratory treatments like CPAP therapy.
Failure to Reassess Dietary Needs After Readmission
Penalty
Summary
The facility failed to reassess and update the dietary preferences and nutritional needs of a resident (R22) after a readmission with a diet change to a full liquid diet. R22, who has diagnoses including dementia, gastro-esophageal reflux disease, and a non-pressure chronic ulcer, was readmitted with a new diet order for a full liquid diet. Despite this significant change, the care plan was not updated to reflect the new dietary requirements, and the dietary card did not include the prescribed dietary supplements. The resident expressed confusion about the reason for the liquid diet and mentioned only being able to consume liquids and tomato soup. The Dietary Manager (V5) admitted to not reassessing R22's dietary needs or preferences since the readmission and was unaware of the specific dietary requirements for a full liquid diet. The cook (V6) confirmed that R22 was primarily receiving chicken broth, tomato soup, and occasionally pudding, but noted that R22 had refused pudding and yogurt. The facility's policy mandates that residents at nutritional risk be monitored and assessed by a consultant dietitian within 72 hours of a significant change, which was not adhered to in this case.
Failure to Ensure Physician Assessment Within 30 Days of Admission
Penalty
Summary
The facility failed to ensure that two residents were assessed by a physician within the first 30 days after admission. Resident R22 was admitted 65 days ago with diagnoses including dementia without behavioral disturbance, atherosclerosis, and a non-pressure chronic ulcer of part of the foot. R22's records showed visits by a Nurse Practitioner on three occasions, but no visit by a physician. R22 expressed frustration about not being seen by a doctor and was misinformed by facility staff that a Nurse Practitioner is a doctor. The Clinical Coordinator confirmed that R22 had not been seen by a physician since admission. Similarly, Resident R9, admitted with diagnoses including anxiety, mood disorder, bipolar disorder, hydrocephalus, gastro-esophageal reflux disease, constipation, spinal stenosis, urinary tract infection, and chronic kidney disease, had not been seen by a physician since admission. R9's records showed visits by a Nurse Practitioner but no evidence of a physician's assessment. The facility's policy mandates that a physician must see each resident within the first 30 days of admission, which was not adhered to in these cases.
Failure to Administer Scheduled Medication
Penalty
Summary
The facility failed to ensure a scheduled medication was available for administration for a resident with severe cognitive impairment and multiple diagnoses, including anxiety disorder. The resident's care plan required the administration of Alprazolam three times daily to manage anxiety. However, from 8/25/23 to 8/31/23, the medication was not administered due to various issues, including a malfunctioning narcotic box, unavailability of the medication, and delays in receiving a new prescription from the pharmacy. This resulted in 18 missed doses of Alprazolam over the course of six days. Despite multiple attempts by the nursing staff to resolve the issue, including contacting the pharmacy and the Nurse Practitioner, the medication was not delivered in a timely manner. The Assistant Director of Nursing acknowledged that the medication should have been documented as missed and that follow-up actions should have been taken to ensure its availability. The facility's policy stated that medications should be administered and documented as ordered by the physician, but this was not adhered to in this case.
Failure to Ensure Palatable and Properly Cooked Vegetables
Penalty
Summary
The facility failed to ensure that vegetables served to residents were palatable and prepared according to acceptable standards. During an observation, the surveyor noted that the mixed vegetables were overcooked to the point of being mushy and bland. The cook admitted to boiling the vegetables for 45 minutes and then keeping them warm in the oven, which resulted in the undesirable texture. Additionally, the dietary manager confirmed that salt was omitted from the recipe due to many residents being on a low sodium diet, further contributing to the bland taste. Residents R1 and R13 both expressed dissatisfaction with the vegetables, stating they were too soft and flavorless, leading to uneaten portions on their trays. The dietitian confirmed that vegetables should not be boiled until mushy, and the recipe for mixed vegetables indicated the addition of salt, pepper, and margarine, but did not specify cooking times. The care plans for R1 and R13 indicated that they should consume 75% of their ordered diet daily and that their diets should be modified according to their food preferences. However, the overcooked and bland vegetables did not meet these preferences, resulting in the residents not eating the vegetables as part of their meals.
Failure to Adhere to Contact Isolation Protocols
Penalty
Summary
The facility failed to ensure the correct personal protective equipment (PPE) was worn while providing care for a resident in contact isolation with a multi-drug resistant organism (MDRO). Specifically, a registered nurse entered the resident's room without wearing a gown, despite signage indicating that gown and gloves were required. The nurse performed tasks such as checking the resident's blood sugar and administering insulin, during which her scrub pants came into contact with the resident's bedding. This occurred even though the resident's care plan and room signage clearly indicated the need for contact precautions due to a MRSA infection in an abscess on the resident's back. The infection preventionist confirmed that gown and gloves are required whenever staff enter a contact isolation room to prevent the spread of infection. The facility's infection control policy also mandates the use of contact precautions for residents known or suspected to be infected with transmissible microorganisms. The failure to adhere to these precautions was observed and documented, highlighting a significant lapse in infection control practices within the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Stockton | 9.6 mi | ★★★★★ | 0 | 0 |
| Pearl Pointe Nursing Rehab & Care | 9.9 mi | ★★★★★ | 28 | 0 |
| Manor Court Of Freeport | 10.1 mi | ★★★★★ | 30 | 0 |
| The Citadel At Saint Joseph Village | 12.8 mi | ★★★★★ | 21 | 0 |
| Stephenson Nursing Center | 13.1 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Serenity Estates Of Lena.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.