Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stephenson Nursing Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, gait unsteadiness, weakness, and documented memory problems, who required assisted ambulation with a gait belt, was being escorted to the toilet by a CNA. Staff and the resident’s spouse had previously observed that the resident tended to walk too far behind her rollator, allowing it to get away from her. During ambulation, the CNA noted the walker moving ahead, the resident’s buttocks protruding, and the resident appearing confused, but left the resident unsupported to retrieve a chair several steps away, without a gait belt in use. The resident fell in the common area and was later found with the left leg externally rotated and in significant pain, and was admitted to the hospital with a left hip fracture, in violation of the facility’s safe resident handling policy requiring continuous hands-on assistance and not leaving a resident unsupported when balance is compromised.
A resident with dementia, mobility issues, and incontinence was discharged to independent senior housing without a documented discharge plan or confirmation that home health and caregiver services were in place. Staff were unclear about the resident's discharge needs and the capabilities of the housing setting, resulting in the resident being found soiled and unable to get out of bed after discharge.
A resident with a history of falls and impaired mobility was assisted by a CNA after toileting without the use of a gait belt, despite care plan requirements. The resident became weak and fell, sustaining a left femur fracture that required surgical repair. Staff interviews and records confirmed the gait belt was not in use at the time, contrary to facility policy for high fall-risk residents.
A resident with dementia and a history of removing dressings had a fentanyl patch repeatedly applied to the chest instead of the back, contrary to physician orders. Nursing documentation showed the patch was missing on one occasion and later found in the resident's mouth, despite staff awareness of the resident's behaviors and the specific order to make the patch inaccessible.
A resident with chronic pain and multiple serious health conditions experienced unrelieved pain for several days due to delays in obtaining and administering prescribed morphine. Despite repeated requests from the resident and her family for stronger pain relief, staff were unable to provide adequate pain management in a timely manner, resulting in ongoing distress for the resident prior to her death.
Surveyors found that the kitchen was not maintained in a clean and sanitary manner, with dried food debris, grease, and dirty containers present throughout. The Dietary Manager handled kitchen utensils with bare hands without washing or wearing gloves, then placed them into food containers, contrary to facility policy requiring glove use and proper sanitation. The last deep cleaning of the kitchen had not occurred for over a month.
Agency CNAs did not receive annual training in abuse prevention and dementia care, as confirmed by facility records and interviews. The facility's policies require such training, and the lapse affected all residents, including those with Alzheimer's disease and dementia.
Several residents were found with bed bolsters, side rails, or tall barriers that restricted their ability to exit bed, with staff confirming these devices were used to prevent unsupervised bed exit or falls. These residents, many of whom were not cognitively intact and dependent on staff for mobility, did not have documented restraint assessments or appropriate orders as required by facility policy.
The facility failed to prevent the misappropriation of controlled substances for two residents. One resident's Norco tablets were found missing during a narcotic count, and an LPN reported the issue after an agency RN suggested unauthorized corrections. Surveillance footage showed the RN accessing the narcotic box without proper documentation. Another resident's fentanyl patch was missing, but the DON was unaware and no investigation was conducted. The facility's policies on controlled substances and abuse were not followed, leading to these deficiencies.
A facility failed to implement its abuse policy when a resident's fentanyl patch was found missing, and a new patch was applied early. The incident was not reported or investigated as potential misappropriation, despite the facility's policy requiring immediate notification to the DON. The resident had multiple diagnoses, including Alzheimer's and was under palliative care. The facility's policy aims to prevent abuse and misappropriation, but it was not followed in this instance.
A resident with multiple diagnoses, including Alzheimer's and anxiety disorder, was prescribed a fentanyl patch. A nurse discovered the patch missing and applied a new one early, but the incident was not reported or investigated for potential misappropriation. The DON was unaware of the missing patch, and the facility's policy requiring immediate reporting of such incidents was not followed.
A resident who was fully dependent on staff for ADLs did not receive timely incontinence care after being transferred to bed by a CNA and an RN. Staff failed to check or change the resident's incontinence brief, resulting in the resident remaining in a saturated brief with visible wetness and skin redness for over an hour, contrary to the care plan and facility policy.
A resident with fragile skin and a history of skin tears was not consistently provided with protective arm sleeves as ordered in their care plan. Despite documented incidents of skin tears and staff acknowledgment of the need for protective measures, the resident was observed multiple times without arm sleeves or long sleeves while out of bed, resulting in a failure to follow the care plan and protect the resident from further injury.
Surveyors found that two residents did not receive appropriate pressure ulcer prevention and care. One resident's air mattress was unplugged and set at the wrong weight despite orders and care plan instructions, while another resident with a stage 3 pressure ulcer did not receive recommended dietary protein supplements due to a lack of communication between staff.
A resident with an indwelling urinary catheter and a history of UTIs was found lying in bed with a urinary drainage leg bag attached, despite facility policy and posted instructions stating leg bags should only be used when out of bed. The DON confirmed this practice was not appropriate and posed a risk for urine backflow and infection.
Three residents on pureed diets did not receive a pureed roll or bread item with their lunch as required by the posted menu. Instead, they were served only pureed ham, spinach, sweet potatoes, and cake. The dietary manager was unaware of the omission, despite facility policy requiring all menu items to be prepared and served as listed.
A resident with Alzheimer's and other conditions had a bruise on her forehead that was not reported to the abuse coordinator as required by the facility's policy. Despite the CNA reporting the bruise to an LPN, who documented it and informed the DON, the DON and Administrator were unaware, and no investigation was conducted.
A resident with fragile skin and a history of easy bruising was found with multiple bruises after being repositioned improperly by a CNA. The CNA used the resident's arms to reposition him instead of using an incontinence pad, which likely caused the bruising. The resident was observed with bruises on his wrists, and staff confirmed the resident's tendency to bruise easily.
The facility failed to submit final investigation reports to IDPH within the required 5-day period for three residents reviewed for abuse. The Administrator experienced technical difficulties with the online submission system and did not notify IDPH or verify fax submissions. The facility's policy mandates a complete written report within 5 working days, which was not followed.
The facility failed to thoroughly investigate alleged abuse and did not maintain proper records, affecting three residents. The interim Administrator admitted to not conducting a thorough investigation and failing to ensure residents felt safe. The facility's policy mandates a comprehensive investigation process, which was not followed.
Failure to Safely Supervise High-Risk Resident During Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and safely assist a resident with known fall risk and ambulation difficulties, resulting in a left hip fracture. The resident had diagnoses including Alzheimer’s dementia, unsteadiness of feet, weakness, and rheumatoid arthritis. A recent MDS indicated she was unable to complete the Brief Interview for Mental Status and had both short- and long-term memory problems. A restorative note documented that staff on the locked memory care unit and the resident’s husband had observed that when she was tired or not walking well, she tended to walk too far behind her rollator, and that the rollator sometimes "gets away from her." Staff interviews, including with the DON and nursing staff, confirmed that the resident required assistance with ambulation and the use of a gait belt for safety. On the day of the incident, a CNA was taking the resident to the toilet shortly after lunch while the other CNA on the unit was in a room providing care and the nurse assigned to the memory care unit was off the unit performing wound care on other units. The CNA observed that the resident’s walker was getting away from her, with the resident’s buttocks sticking out and her arms stretched out toward the walker. The CNA reported that the resident appeared confused and did not understand coaching to move toward the walker. Believing the resident would not make it safely to the bathroom, the CNA decided to step away a few steps to get a chair, during which time the resident fell. The CNA acknowledged that a gait belt was not in use and that she left the resident’s side despite recognizing the resident’s compromised positioning and confusion. Following the fall, the nurse responded and observed the resident lying on her back in the common area with the left lower extremity bent at the knee and externally rotated, and the area was immobilized. The nurse noted that the resident, who typically did not have pain, was experiencing significant pain, especially when the left leg was touched, and she believed the leg was broken based on the pain and rotation. The resident was subsequently admitted to the hospital with a left hip fracture. The facility’s Safe Resident Handling/Transfers policy required proper hands-on assistance during ambulation and specified that residents should never be left unsupported when balance is compromised or when the resident stops walking. Staff interviews, including with the DON and other CNAs and RNs, consistently indicated that the resident required assistance with ambulation and a gait belt, and that the CNA should not have left the resident unsupported but should have called for assistance and, if needed, used a gait belt to lower her to the floor.
Failure to Ensure Discharge Services for Resident with ADL Needs
Penalty
Summary
The facility failed to ensure that appropriate discharge services were in place prior to discharging a resident with significant care needs to an independent senior housing apartment. The resident, an elderly female with diagnoses including osteoarthritis, gait and mobility abnormalities, type 2 diabetes, unspecified dementia, and cognitive communication deficits, required staff assistance with ambulation, was incontinent, and needed help with activities of daily living (ADLs). Despite these needs, the resident was discharged without a documented discharge plan addressing her required services, and there was no confirmation that home health or caregiver services were arranged prior to her return to independent living. Multiple staff interviews revealed a lack of clear communication and coordination regarding the resident's discharge needs. The Social Service Director (SSD) admitted to not knowing the type of setting the resident was being discharged to and did not ensure that caregiver services or home health were set up before discharge. The Restorative Nurse and Director of Therapy both expressed concerns about the resident's safety and appropriateness for independent living, noting her need for supervision, incontinence, and lack of safety awareness. The senior housing staff repeatedly informed the facility that they did not provide any care or assistance with ADLs, and that all necessary services should be arranged prior to discharge. However, these services were not confirmed to be in place, and the resident was left without adequate support. As a result of these failures, the resident was found in her apartment soiled in urine and feces, unable to get out of bed, and appeared to have been in bed since the previous day. Documentation showed that while referrals for home health and therapy were made, there was no follow-up to ensure these services were initiated, and critical information such as the resident's phone number was not communicated to service providers. The facility's own discharge policy requires the interdisciplinary team to review and develop a discharge plan based on the resident's needs, but this was not completed in this case.
Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
Staff failed to apply a gait belt while assisting a high fall-risk resident during ambulation after toileting. The resident, an alert and oriented female with a history of multiple falls, impaired mobility, and balance problems, was being assisted by a CNA when she became weak and fell while attempting to move from the bathroom to her recliner. The resident was not wearing a gait belt at the time of the fall, as confirmed by multiple staff interviews and direct observation after the incident. The resident sustained a left femur fracture requiring surgical repair as a result of the fall. The resident's care plan and fall risk assessment indicated she required one-person assistance, a gait belt, and a walker for transfers and ambulation due to her unsteady gait and high risk for falls. Staff interviews confirmed that the use of a gait belt was standard practice for this resident, but it was not in use at the time of the incident. The facility's fall program policy required evaluation and implementation of interventions for residents at risk for falls, but these interventions were not followed during the incident, directly leading to the resident's injury.
Failure to Apply Narcotic Patch in Inaccessible Location for Resident with History of Removal
Penalty
Summary
The facility failed to ensure that a narcotic pain patch was applied in an inaccessible location for a resident with a known history of removing such patches. The resident, who had diagnoses including scoliosis and dementia, was dependent on staff for most functional abilities and had both short- and long-term memory problems. Despite a physician's order to apply the fentanyl patch to the resident's back and cover it with a transparent film dressing, nursing documentation showed that the patch was repeatedly applied to the resident's chest. This occurred even after the order change intended to prevent the resident from accessing and removing the patch. Nursing notes and medication administration records indicated that the patch was missing on one occasion and later found in the resident's mouth on another, despite staff being aware of the resident's history of picking at dressings and patches. The facility's own policy required following special directions for medication administration, but staff failed to adhere to the specific order for patch placement. Interviews with nursing staff and the Director of Nursing confirmed that the patch was not applied as ordered, resulting in the resident being able to access and remove the narcotic patch.
Failure to Provide Timely and Adequate Pain Management
Penalty
Summary
A resident with multiple complex medical conditions, including nonrheumatic aortic valve stenosis, congestive heart failure, gastrointestinal stromal tumor, osteoporosis, scoliosis, and chronic back pain, was admitted to the facility and had a history of chronic pain. The resident's care plan indicated that pain should be routinely evaluated and managed according to physician orders, with effectiveness documented and reported as needed. Despite these plans, the resident experienced ongoing, inadequately controlled pain, as evidenced by frequent requests for ibuprofen, reports of high pain levels, and repeated requests for stronger pain medication by both the resident and her daughter. The resident's pain management regimen initially consisted of ibuprofen, which was not effective in controlling her pain, as she continued to report pain levels of 8-9 out of 10 even after administration. The resident's daughter repeatedly requested stronger pain medication since admission, and staff recognized the need for additional comfort measures as the resident's condition declined. Although a physician order for morphine was eventually obtained, there was a significant delay in the medication being delivered and administered. The resident waited several days for the morphine, during which time she continued to experience unrelieved pain, as documented by staff and reported by the resident herself. Communication breakdowns occurred between nursing staff, the physician, and the pharmacy, resulting in the morphine prescription not being promptly processed and delivered. Staff were unable to access morphine from the emergency box due to pharmacy instructions, and the resident did not receive the ordered morphine until several days after the initial request. During this period, the resident's pain remained inadequately managed, and she was observed to be in significant distress prior to her death.
Failure to Maintain Kitchen Sanitation and Prevent Cross Contamination
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen during two separate tours. Dried grease and food debris were found on the stove, ovens, steamers, and the bottom shelf of the food prep table. Several plastic containers holding dried cereal had visibly dirty and sticky lids, with a brown, sticky substance on one container. A plastic milk crate was covered with grease and food debris, and the commercial food processor was noted to have a greasy residue. The shelf under the plate warmer rack was cluttered with opened salt packets and napkins, and the steam table had dried liquid and food debris on its surfaces. A dirty oven mitt was also found on the floor under the steam table. During food service, the Dietary Manager handled multiple kitchen utensils and scoops with bare hands, without washing hands or wearing gloves, and placed these utensils directly into various food containers. The Dietary Manager later confirmed that staff are required to wear gloves when handling utensils or dishes to prevent cross contamination and stated that the last deep cleaning of the kitchen was likely over a month ago. The facility's policy requires proper hand washing, glove use, and cleaning and sanitizing of all utensils and food contact surfaces after every use.
Failure to Provide Required Abuse and Dementia Training to Agency CNAs
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs), specifically agency staff, received required annual training in abuse prevention and dementia care. Record review and interviews confirmed that three agency CNAs had not completed any abuse or dementia training in the past year, and neither the facility nor the agency provided this education. The facility's own assessment and policy documents indicated that staff are expected to receive training in these areas upon orientation and throughout the year. At the time of the deficiency, the facility had a census of 46 residents, including individuals with Alzheimer's disease and dementia, who were potentially affected by this lapse.
Failure to Prevent Use of Physical Restraints Without Proper Assessment
Penalty
Summary
The facility failed to ensure that four residents were free from the use of physical restraints unless required for medical treatment. Observations revealed that several residents had devices such as side rails and bolsters attached to their beds, which restricted their ability to exit the bed independently. For example, one resident was observed with half side rails and bolsters secured with straps, and staff confirmed these were in place specifically to prevent the resident from getting out of bed. Documentation showed that the resident was not able to use the side rails for positioning, and there was no restraint or side rail assessment available for this resident. Another resident was found with bolsters attached to both sides of the bed, and staff stated these were used because the resident was at risk of falling and would otherwise attempt to get out of bed unsafely. The care plan for this resident indicated a history of restlessness and fall risk, with instructions to ensure bolsters were properly attached. However, the facility's own policy required evaluation and documentation for restraint use, which was not completed for this or other residents observed with similar devices. Additional residents were observed with tall barriers or bolsters on both sides of their beds, with staff confirming these were used to prevent the residents from getting out of bed or falling. In these cases, the residents were not cognitively intact and were dependent on staff for mobility. Despite the use of these restrictive devices, there were no documented restraint assessments or appropriate orders as required by facility policy and regulations.
Misappropriation of Controlled Substances in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for two residents, R41 and R11. For R41, the issue arose when five Norco tablets were found missing during a narcotic count. The discrepancy was discovered by an LPN who noted that the count was off by five tablets. The LPN reported the issue to the Director of Nursing (DON) after an agency RN suggested correcting the count without proper authorization. The DON's investigation included reviewing surveillance footage, which showed the agency RN accessing the narcotic box at times that did not align with medication administration records. The missing tablets were not accounted for, and the police were involved in the investigation. For R11, the deficiency involved a missing fentanyl patch. The resident's progress notes indicated that a new patch had to be applied earlier than scheduled because the existing patch was not found on the resident's body. The DON was unaware of this incident and had not conducted an investigation into the missing patch. The facility's policy requires staff to report missing controlled substances immediately, but this protocol was not followed in R11's case. The RN who documented the missing patch no longer worked at the facility, and there was no follow-up on the incident. The facility's policies on controlled substances and abuse affirm the residents' rights to be free from misappropriation of property. However, the failure to adhere to these policies resulted in the misappropriation of controlled substances for both residents. The lack of proper narcotic counts and failure to report missing medications contributed to the deficiencies identified in the report.
Failure to Implement Abuse Policy for Missing Fentanyl Patch
Penalty
Summary
The facility failed to implement its abuse policy for a resident who was admitted with multiple diagnoses, including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and was receiving palliative care. The resident had a physician's order for a fentanyl patch to be administered every 72 hours. On December 21, 2024, a registered nurse noted that the fentanyl patch was missing from the resident's body and applied a new patch earlier than scheduled. This incident was not reported or investigated as a potential misappropriation of a controlled substance, which is a requirement under the facility's abuse policy. The Director of Nursing (DON) admitted that no investigation into potential misappropriation had been conducted in the last three months, despite the missing fentanyl patch. The facility's policy mandates that staff notify the DON immediately if a fentanyl patch is missing, as it could indicate theft. An LPN confirmed that the protocol is to inform the DON and the administrator if such an incident occurs. The facility's abuse policy, effective since April 2020, aims to prevent abuse, neglect, exploitation, and misappropriation of property by training employees to recognize and report such occurrences. However, in this case, the policy was not followed, leading to a deficiency in the facility's compliance with its own procedures.
Failure to Report Missing Controlled Substance
Penalty
Summary
The facility failed to report a missing controlled substance, specifically a fentanyl patch, for a resident diagnosed with anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and receiving palliative care. The resident was prescribed a fentanyl patch to be administered every 72 hours. On December 21, 2024, a registered nurse (RN) noted that the current patch was missing and applied a new one early. Despite this, the incident was not reported to the Director of Nursing (DON) or investigated for potential misappropriation. The DON was unaware of the missing fentanyl patch and stated that no investigation had been conducted regarding any potential misappropriation in the past three months. The facility's policy requires staff to report any suspicion of misappropriation immediately to the administrator or a compliance officer. However, this protocol was not followed, as the missing patch was not reported or investigated, leading to a deficiency in the facility's handling of controlled substances and potential abuse reporting.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for activities of daily living, including incontinence care, was not provided timely assistance. After being transferred to bed by a CNA and an RN using a mechanical lift, the staff did not check or change the resident's incontinence brief. Over an hour later, the resident was found with a saturated incontinence brief, visible wet spots on their clothing, redness in the perineal and buttocks areas, and a small amount of stool present. The resident's care plan required staff to render perineal care after every incontinent episode and to keep the resident clean and dry. Facility policy, as stated by the DON, was to check residents for incontinence every two hours and as needed, especially when putting a resident to bed.
Failure to Apply Protective Arm Sleeves for Resident with Fragile Skin
Penalty
Summary
A resident with a history of fragile skin, skin tears, and anticoagulant use was not consistently provided with protective arm sleeves as ordered in their care plan. Nursing notes documented multiple incidents where the resident sustained skin tears to the right forearm after bumping it on a table during meals. Observations on several occasions showed the resident sitting at the dining room table without protective arm sleeves or long sleeves, despite the care plan specifying the use of these interventions to protect the resident's skin while out of bed. Staff interviews confirmed that protective arm sleeves were implemented following a previous skin tear and that the resident should be wearing them when out of bed to prevent further injury. The resident's care plan, updated after the most recent skin tear, reiterated the need for arm protectors while out of bed. However, the resident was repeatedly observed without these protective measures in place, leading to a failure to provide care according to the resident's assessed needs and care plan.
Failure to Implement Pressure Ulcer Prevention and Dietary Interventions
Penalty
Summary
Surveyors identified deficiencies in pressure ulcer prevention and care for two residents. For one resident with a history of pressure ulcers and dependent on staff for mobility, eating, and hygiene, the air mattress intended to relieve pressure was found unplugged and set at an incorrect weight for an extended period. The mattress was supposed to be set at 159 pounds according to physician orders and the care plan, but it was observed set at 80 pounds, despite the resident weighing 151 pounds. Staff interviews confirmed the mattress had been unplugged and incorrectly set for several hours, and the care plan specifically directed staff to ensure the mattress was set at the correct weight. For another resident with a stage 3 pressure ulcer on the coccyx, dietary recommendations to promote wound healing were not implemented. The dietitian had recommended high protein supplements three times daily and sandwiches twice daily to increase protein intake, but the recommendation for sandwiches was not communicated to the dietary department. As a result, the resident did not receive the additional sandwiches with meals as intended. Staff interviews revealed that the recommendation was discussed but not formally documented or relayed to the dietary manager, and the resident's meal tickets did not reflect the dietary changes.
Failure to Remove Urinary Leg Bag While Resident in Bed
Penalty
Summary
A deficiency was identified when a resident with a history of urinary retention and urinary tract infections was observed lying in bed with a urinary drainage leg bag attached. The resident's care plan indicated the need for an indwelling urinary catheter, and facility policy specified that leg bags should only be used when the resident is out of bed. During observation, the leg bag was not visible initially, but a CNA confirmed that the resident had a leg bag on while in bed. A sign above the bed also instructed not to leave the leg bag on when the resident is in bed, yet the leg bag was found attached and then detached by the CNA during the surveyor's visit. The Director of Nursing confirmed that the resident should not have a leg bag while in bed due to the risk of urinary tract infections and potential for urine backflow. The facility's policy on Foley catheter management emphasized that urinary drainage tubing should be kept below bladder level and that leg bags, if used, should only be in place when the resident is out of bed. The failure to follow these protocols resulted in the resident remaining in bed with a leg bag attached, contrary to both the care plan and facility policy.
Failure to Provide All Menu Items for Pureed Diets
Penalty
Summary
The facility failed to follow its posted menu for residents on pureed diets, as observed for three residents who were supposed to receive a pureed roll or bread item with their lunch. On the specified date, these residents were served pureed ham, spinach, sweet potatoes, and cake, but no pureed roll or bread was present on their trays. The dietary manager confirmed that residents on pureed diets should receive the same food items as those on regular diets and was unaware that the pureed roll had not been provided. The facility's policy requires that menu items be prepared according to the posted menu and standardized recipes, but this was not followed for the affected residents.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the abuse coordinator for a resident, identified as R2, who was admitted with diagnoses including Alzheimer's disease, dementia, anxiety disorder, rheumatoid arthritis, and age-related osteoporosis. R2's care plan required immediate reporting of any suspected abuse or neglect. On June 6, 2024, a CNA noticed a bruise on R2's forehead and reported it to an LPN, who documented the incident and informed the Director of Nursing (DON). However, the DON later stated that no staff had reported the bruise to her, and the Administrator confirmed that no abuse investigation was conducted for R2. The facility's policy mandates that suspicious bruises or injuries of unknown origin be reported and documented immediately. Despite this, the bruise on R2's forehead was not reported to the abuse coordinator, and no investigation was initiated. Observations on July 2, 2024, noted a fading yellow area on R2's forehead, indicating the bruise had not been addressed according to protocol. The lack of communication and failure to follow the facility's abuse policy resulted in the deficiency noted in the report.
Resident Bruising Due to Improper Repositioning
Penalty
Summary
The facility failed to ensure a resident was repositioned in bed safely, leading to multiple bruises on the resident. The resident, who was admitted with conditions such as congestive heart failure, dementia, and muscle contractures, was on anti-platelet medication and had a history of bruising easily due to fragile skin. On June 13, 2024, a CNA reported fresh bruises on the resident's arm and foot, which were assessed by an LPN and an RN. The resident, described as very frail and unable to move his legs independently, was found with bruises that appeared fresh and unexplained. Further investigation revealed that a CNA had repositioned the resident by pulling on his arms to help him grab the side rails, rather than using an incontinence pad as required for his sensitive skin. This method of repositioning likely caused the bruising. The resident was observed with a large dark bruise on his right wrist and a fading bruise on his left wrist. Staff interviews confirmed that the resident bruises easily and that the proper technique to prevent bruising was not followed during repositioning.
Failure to Submit Final Investigation Reports Timely
Penalty
Summary
The facility failed to submit final investigation reports to the Illinois Department of Public Health (IDPH) within the required 5-day period for three residents who were reviewed for abuse. Initial Incident Investigation Reports for these residents were submitted on different dates, but the final reports were not received by IDPH. The Administrator admitted to experiencing technical difficulties with the online submission system and did not notify IDPH of these issues. Additionally, attempts to fax the reports were made without verifying the correct fax number or confirming receipt by IDPH. The facility's policy mandates that a complete written report of the investigation's conclusion be sent to IDPH within 5 working days, which was not adhered to in these cases.
Failure to Investigate Alleged Abuse and Maintain Records
Penalty
Summary
The facility failed to perform a thorough investigation of alleged abuse and did not maintain proper records of the abuse investigation. This deficiency affected three residents. The Incident Investigation Report Final Summary for these residents showed that the facility did not interview the accused staff members, did not identify other residents at risk for abuse, did not interview residents to ensure they felt safe, and did not interview employees working on the same shift as the accused staff members. The surveyor requested the abuse investigation files and received them after a delay, only to find that the interim Administrator had merely jotted down notes in a notebook instead of maintaining proper records. The interim Administrator, who has been in the position since January 2024, admitted to not conducting a thorough investigation and failing to ensure the residents felt safe and that staff felt confident working with the accused staff members. The facility's policy on abuse, effective since March 2021, mandates a comprehensive investigation process, including interviewing the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if interviewable. The policy also requires reviewing written statements and pertinent medical records, and interviewing other residents and employees who regularly interacted with the accused. These steps were not followed in the cases of the three residents involved.
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What surveyors actually found near you
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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
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Nursing homes near Freeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Citadel At Saint Joseph Village | 1.9 mi | ★★★★★ | 5 | 0 |
| Pearl Pointe Nursing Rehab & Care | 3.2 mi | ★★★★★ | 27 | 0 |
| Manor Court Of Freeport | 4.4 mi | ★★★★★ | 31 | 0 |
| Serenity Estates Of Lena | 13.1 mi | ★★★★★ | 3 | 0 |
| Allure Of Pinecrest | 17.8 mi | ★★★★★ | 10 | 0 |
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