Health inspection·January 9, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to foot to alleviate swelling, however resident refused. States that ice makes him cold all over. No new orders received regarding the foot. This note does not show that V5 (R1's POA) was notified of R1's injury. R1's Face Sheet dated 1/5/24 showed diagnoses to include, but no limited to: chronic atrial fibrillation, urinary tract infection, renal stones, CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), anemia, hypertension, major depressive disorder, Crohn's disease, insomnia, and moderate protein-calorie malnutrition. R1's facility assessment dated [DATE] showed he was cognitively intact and required extensive assistance from the staff for transfers. R1's Power of Attorney for Health Care (POA) Form signed 11/10/14 showed R1 named V5 as his POA for healthcare. On 1/5/24 at 8:55 AM, V10 (Wound Care Nurse) said she didn't know what happened to R1's foot on 10/18/23. V10 stated, Someone notified me he had a bruise on his foot. I was told [R1's] left toe got caught under the plate of the standing scale. He had a small skin tear on the left posterior upper arm. There was a new, purple bruise to the top of his great toe, and it went down underneath his toe. He said he caught it when they were trying to stand him up. I'm not sure who was helping him. I could see if there is an incident report. (R1's chart did not contain an Incident/Event for 10/18/23). A bruise, after an incident and complaints of pain would be a change in condition and the POA should be notified. V10 said R1 was alert and oriented and could make his needs known. On 1/4/23 at 3 PM, V8 (RN) said if a resident had an injury from being weighed; had bruising to the toe and surrounding area; and was complaining of pain, then the POA should have been called. V8 said, the POA is notified for changes like this to keep them informed. On 1/5/23 at 11:51 AM, V2 (DON - Director of Nursing) said she remembered hearing about R1's bruised toe in a morning meeting. V2 stated, Someone mentioned a fall. So, I went right out to speak with the CNAs. It sounded like he just bumped his toe when they stood him up. I don't remember who was assisting [R1] to the stand on the scale. If the staff attempted to call [R1's] POA then that would be charted in their notes. On 1/5/23 at 2:01 PM, V9 (RN) said she does not remember the CNAs reporting that anything happened to R1's toe or that he fell on [DATE]. V9 said she didn't call the POA because she wasn't notified of an incident. On 1/9/23 at 8:54 AM, V12 (LPN) said she worked the evening shift on 10/18/23. V12 said she went to check R1's vital signs before his 5 PM medications. V12 stated, [R1] told her his foot was hurting. I asked him why and he said they tried to weigh me. He couldn't remember who was helping him get weighed that morning. I didn't get anything in report that his toe was hurt. So, I removed his sock and touched the top of his foot. He said, Ouch! That hurt! He was complaining of right toe pain. I got out my flashlight to get a better look. There was a pinpoint red area on the tip of his great toe. He said they used the stand-up scale and when they went to get him up, they hurt is toe. I went to look at the stand-up scale and his foot could have easily went under the platform of the scale. He could move his toes, but I told him that it would probably bruise badly. I put ice on it, but he refused. I told him it would get swollen. They shouldn't have used the standing scale for him. He barely got out of bed. He's very weak. He was getting up with therapy, but then he seemed to give up. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 left a detailed note for [V10 - Wound Care Nurse] to see him. V12 said she did not call V5 (R1's POA). Level of Harm - Minimal harm or potential for actual harm The facility's Notifications of Changes Policy dated 12/2020 showed, The facility is responsible to ensure that notification is made to the resident's family, guardian, representative, or designated party regarding the resident's care whenever there is a change medically or psychologically which may or may not involve changes in their treatment or their plan of care. In collaboration with other disciplines, regarding the nature of the changes, the facility will ensure appropriate notification of resident and/or their designated responsible party (POA/guardian, etc.) and document in the resident's chart/electronic record . A change in the resident's status requires of the discipline (s): 1. To ensure the resident is informed; 2) To consult with the resident's physician, when appropriate; 3) To promptly notify, consistent with his or her authority, the resident representative, when there is - An accident involving the resident which results in injury and has the potential for requiring physician intervention. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed report a resident-to-resident physical altercation to the state agency for 1 of 3 residents (R3) reviewed for resident-to-resident abuse in the sample of 7. The findings include: On 1/5/24 at 11:30 AM, R3 was sitting up in her wheelchair. R3 said back in September she was sitting at the end of [NAME], watching TV. R3 said R7 came in and started arguing with her over the TV remote. R3 said R7 attacked her and scratched her arm. R3 said there wasn't any staff in the area at the time it happened. R3's Skin Integrity Events -- Scratches dated 9/23/23 showed R3 had an argument with another resident over a TV remote control, resulting in a bleeding scratch to her left forearm. This document showed R3 experienced moderate pain, rated at a 4 on a 1-10 pain scale. R3's Progress Notes dated 9/23/23 at 6:45 PM showed, Resident was allegedly attacked by another resident due to TV remote control. Resident sustained a minor cut to her left forearm, bleeding ceased, band aid applied. DON notified of incident. Family notified . R3's Face Sheet dated 1/5/24 showed she had diagnoses to include, but not limited to: heart failure, COPD (chronic obstructive pulmonary disease), paroxysmal atrial fibrillation, unspecified right humerus fracture, stroke, PVD (peripheral vascular disease), hypertension, GERD (gastro esophageal reflux disease), CKD (chronic kidney disease), arthritis, bipolar disorder, generalized anxiety disorder, major depressive disorder, and morbid obesity. R3's facility assessment dated [DATE] showed she was cognitively intact. On 1/5/24 at 1:55 PM, R7 was self-propelling his wheelchair from the front door of the facility, down the hall to the resident rooms. R7's Facesheet dated 1/5/24 showed diagnoses to include, but not limited to: diabetes, major depressive disorder, stroke, and cerebral palsy. R7's facility assessment dated [DATE] showed he was cognitively intact. On 1/5/24 at 12:05 PM, the surveyor requested the facility's Resident to Resident Abuse Investigation report to the state agency related to R3's injury. At 4:05 PM, V1 (Administrator) said she had not been able to locate the report regarding R3's Resident to Resident Abuse. V1 said she did not know who the other resident involved was. On 1/5/24 at 11:51 AM, V2 (DON - Director of Nursing) said on 9/23/23, V14 (RN) texted her to report that R7 had attacked R3 over the TV remote around 6:45 PM. V2 stated, I told him that we need to consider this abuse and I notified the administrator. The administrator is the abuse coordinator and determines what needs to be investigated. I did not assist with an investigation. I did review the video, on the following Monday, from the TV area at the end of the [NAME] hall - the old memory care unit. It's no longer available for viewing; it only saves for 30 days. I told the previous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administrator she should watch it, but she didn't. I was the only person that had access to the video camera feeds. I did see [R3 and R7] appearing to have a verbal confrontation, then I saw R7 trying to grab the remote from R3. V2 said there should have been an investigation into what happened between R3 and R7 to determine if a report to the state was needed. V2 said, A report to the state is required if a Resident-to-Resident physical altercation was suspected. We do those reports to keep the state informed. The investigation is conducted to determine what happened and keep the staff and residents safe. On 1/5/23 at 12:48 PM, V14 said he was working 9/23/23 and remembered R3 and R7 fighting over the remote. V14 said R3 and R7 were at the end of [NAME] hall - in the old Memory Care TV area. (This area can't be seen from the nurses' station). V14 stated, Someone came up to him and said that [R3] was being hit by [R7] because he wanted the remote. I didn't see what happened. I'm not sure if there were any witnesses. I think it was just the 2 of them. There was a bleeding scratch on [R3's] left forearm. It was better in a few days. I cleaned it and placed a band aid over it. I reported it to the DON right away. The DON said she was going to notify the Administrator and there should be an abuse investigation. We just kept them apart. I was never interviewed by the administrator about what happened. You are the first one to ask me. On 1/5/24 at 1:47 PM, V21 (CNA) said she was at the nurses' station when she heard R3 screaming for help. V21 stated, I ran down there (the end of [NAME] Hall, in the old Memory Care TV area). We didn't even know they were down there. She [R3] kept saying he [R7] was attacking her. Then there were 3 of us down there and he (R7) stated going crazy over the remote. Me, (V19), and I can't remember the other CNA for sure. [R3] had the remote and [R7] was grabbing for it and must have scratched her during it all. She [R3] did have blood on her one arm. V21 said R7 is alert, but he thinks he's going home and he's not discharging. The facility's Abuse Policy dated 3/2021 showed, .Policy: The facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse . This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: . implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences . filing accurate and timely investigative reports . Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or designees shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but no more than two hours of the allegation of abuse. Any incident that does not involve abuse and dose not result in serious bodily injury shall be reported within 24 hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct a thorough investigation of a resident-to-resident physical altercation for 1 of 3 residents (R3) in the sample of 7. Residents Affected - Few The findings include: On 1/5/24 at 11:30 AM, R3 was sitting up in her wheelchair. R3 said back in September she was sitting at the end of [NAME], watching TV. R3 said R7 came in and started arguing with her over the TV remote. R3 said R7 attacked her and scratched her arm. R3 said there wasn't any staff in the area at the time it happened. R3's Skin Integrity Events -- Scratches dated 9/23/23 showed R3 had an argument with another resident over a TV remote control, resulting in a bleeding scratch to her left forearm. This document showed R3 experienced moderate pain, rated at a 4 on a 1-10 pain scale. R3's Progress Notes dated 9/23/23 at 6:45 PM showed, Resident was allegedly attacked by another resident due to TV remote control. Resident sustained a minor cut to her left forearm, bleeding ceased, band aid applied. DON notified of incident. Family notified . R3's Face Sheet dated 1/5/24 showed she had diagnoses to include, but not limited to: heart failure, COPD (chronic obstructive pulmonary disease), paroxysmal atrial fibrillation, unspecified right humerus fracture, stroke, PVD (peripheral vascular disease), hypertension, GERD (gastro esophageal reflux disease), CKD (chronic kidney disease), arthritis, bipolar disorder, generalized anxiety disorder, major depressive disorder, and morbid obesity. R3's facility assessment dated [DATE] showed she was cognitively intact. On 1/5/24 at 1:55 PM, R7 was self-propelling his wheelchair from the front door of the facility, down the hall to the resident rooms. R7's Facesheet dated 1/5/24 showed diagnoses to include, but not limited to: diabetes, major depressive disorder, stroke, and cerebral palsy. R7's facility assessment dated [DATE] showed he was cognitively intact. On 1/5/24 at 12:05 PM, the surveyor requested the facility's Resident to Resident Abuse Investigation and report to the state agency related to R3's injury. At 4:05 PM, V1 (Administrator) said she had not been able to locate the investigation regarding R3's Resident to Resident Abuse. V1 said she did not know who the other resident involved was or what had happened. V1 said an investigation should have been completed to determine what caused the issue and to keep the staff and residents safe. On 1/5/24 at 11:51 AM, V2 (DON - Director of Nursing) said on 9/23/23, V14 (RN) texted her to report that R7 had attached R3 over the tv remote around 6:45 PM. V2 stated, I told him that we need to consider this abuse and I notified the administrator. The administrator is the abuse coordinator and determines what needs to be investigated. I did not assist with an investigation. I did review the video, on the following Monday, from the TV area at the end of the [NAME] hall - the old memory care unit. It's no longer available for viewing; it only saves for 30 days. I told the previous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administrator that she should watch it, but she didn't. I was the only person that had access to the video camera feeds. I did see [R3 and R7] appearing to have a verbal confrontation, then I saw R7 trying to grab the remote from R3. V2 said there should have been an investigation into what happened between R3 and R7. On 1/5/23 at 12:48 PM, V14 said he was working 9/23/23 and remembered R3 and R7 fighting over the remote. V14 said R3 and R7 were at the end of [NAME] hall - in the old Memory Care TV area. (This area can't be seen from the nurses' station). V14 stated, Someone came up to him and said that [R3] was being hit by [R7] because he wanted the remote. I didn't see what happened. I'm not sure if there were any witnesses. I think it was just the 2 of them. There was a bleeding scratch on [R3's] left forearm. It was better in a few days. I cleaned it and placed a band aid over it. I reported it to the DON right away. The DON said she was going to notify the Administrator and there should be an abuse investigation. We just kept them apart. I was never interviewed by the administrator about what happened. You are the first one to ask me. On 1/5/24 at 1:47 PM, V21 (CNA) said she was at the nurses' station when she heard R3 screaming for help. V21 stated, I ran down there (the end of [NAME] Hall, in the old Memory Care TV area). We didn't even know they were down there. She [R3] kept saying he [R7] was attacking her. Then there were 3 of us down there and he (R7) stated going crazy over the remote. Me, (V19), and I can't remember the other CNA for sure. [R3] had the remote and [R7] was grabbing for it and must have scratched her during it all. She [R3] did have blood on her one arm. V21 said R7 is alert, but he thinks he's going home and he's not discharging. V21 said she was not interviewed by the administrator about this. On 1/5/23 at 2:53 PM, V19 (CNA) said she was assisting another resident when she heard the yelling. V19 said she went to the end of [NAME] Hall and R3 was yelling that R7 was attacking her over the remote. V19 said she tried to locate the remote, but while she was doing that R7 snuck around and started grabbing at R3. V19 said R7 was grabbing at the remote that R3 had, and she was bleeding after. V19 said they took the remote, separated the residents, and reported it to the nurse. V19 said nobody from management interviewed her regarding the incident. V19 stated, They probably shouldn't have been down there. I saw in the behavior book that [R7] had issues in the past about the remote. The facility's Abuse Policy dated 3/2021 showed, .Policy: The facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse . This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: . implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences . filing accurate and timely investigative reports . Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or designees shall initiate an incident investigation VII. Internal Investigation: 1. All incidents will be documented, whether or not abuse . occurred, was alleged or suspected. 2. An incident or allegation involving abuse . will result in an investigation . 4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 with any pertinent medical records or other documents. Residents to who the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely weigh a resident (R1) and failed to provide adequate supervision for residents involved in a resident-to-resident physical altercations (R3, R7) for 3 of 4 residents (R1, R3, R7) reviewed for safety and supervision in the sample of 7. The findings include: 1. On 1/4/23 at 11:49 AM, V4 (Nurse Practitioner - NP) said she was providing care to R1 while he was in the hospital. V4 said V5 (R1's POA) expressed concerns with R1's care at the facility. V4 said V5 was unable to provide specific details but told her that R1 had injured his foot a few months ago when the facility used the wrong scale to weigh him. V4 said V5 had a large bruise to his left foot, and no one called her to report the injury. V4 said R1 is weak and had not been out of the bed while he was in the hospital. On 1/4/24 at 2:46 PM, V6 (CNA) said the CNAs obtain the residents weights. V6 said if the resident used a walker, then they are a sit to stand. V6 said there is also a wheelchair scale and a scale on the Hoyer lift, but the lift scale is only used for residents that absolutely can't get out of bed. The facility's stand-up scale had a 1-2-inch gap between the bottom of the base and the floor. The platform the resident's stand on was elevated approximately 1- 2 inches. V6 said R1 was alert and oriented and would be able to tell anybody what happened. R1's progress note dated 10/18/23 at 6:54 PM showed, Resident reported to this writer that while being weighed earlier today staff bumped his toe on the scale while positioning him. His left great toe has a small red area on the tip of his toe, only uncomfortable when touched, skin is not broken. While CNAs were assisting him to stand on the scale the CNA on the right side of him held him up by placing her arm in his right axillary area. The CNA on the left placed her hand around his left deltoid (upper arm) which caused bruising to the area and some skin tears on the posterior side (that) residents states were caused by fingernails. This writer cleansed the area with wound cleanser and applied a Triple Antibiotic ointment, covered with non-stick gauze and secured with kerlix. Will have (V10 - Wound Care Nurse) see resident in AM. There were no notes prior to this note on 10/18/23 that described the incident that occurred with R1 and the scale. R1's Progress Note dated 10/18/23 at 7:53 PM showed, While checking residents' foot, there is now bruising across the top of his foot. Resident is still able to move his toes, this writer applied skin prep to the left great toe and next toe, which appears red. R1's Progress Note dated 10/19/23 at 12:29 PM showed, Assessed skin tear to posterior LUA (left upper arm) this a.m. Skin tear noted to be open to air with no dressing in place. 1.0 x 1.5, edges approximated with no drainage, no s/s (signs/symptoms) of infection noted. Applied triple antibiotic cream and applied a band aid. Left great toe noted to be slightly edematous, with limited movement and discomfort with touch and movement. Bruising noted between great toe and to top of foot approximately mid length of the foot below the great toe. Also bruising noted to pad of the great toe on the plantar aspect of the foot. [V11 (NP)] in facility, did see resident and assessed foot. Recommended ice to foot to alleviate swelling, however resident refused. States that ice makes him cold all over. No new orders received regarding the foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Face Sheet dated 1/5/24 showed diagnoses to include, but no limited to: chronic atrial fibrillation, urinary tract infection, renal stones, CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), anemia, hypertension, major depressive disorder, Crohn's disease, insomnia, and moderate protein-calorie malnutrition. R1's facility assessment dated [DATE] showed he was cognitively intact and required extensive assistance from the staff for transfers. R1's Care Plan edited 10/26/23 showed he is unable to ambulate independently and frequently refuses to get up out of bed or ambulate. On 1/5/24 at 8:55 AM, V10 (Wound Care Nurse) said she didn't know what happened to R1's foot on 10/18/23. V10 stated, Someone notified me he had a bruise on his foot. I was told [R1's] left toe got caught under the plate of the standing scale. He had a small skin tear on the left posterior upper arm. There was a new, purple bruise to the top of his great toe, and it went down underneath his toe. He said he caught it when they were trying to stand him up. I'm not sure who was helping him. I could see if there is an incident report. (R1's chart did not contain an Incident/Event for 10/18/23). A bruise, after an incident and complaints of pain would be a change in condition and the POA should be notified. V10 said R1 was alert and oriented and could make his needs known. On 1/5/24 at 11:51 AM, V2 (DON - Director of Nursing) said she remembered hearing about R1's bruised toe in a morning meeting. V2 stated, Someone mentioned a fall. So, I went right out to speak with the CNAs. It sounded like he just bumped his toe when they stood him up. I don't remember who was assisting [R1] to the stand on the scale. On 1/5/24 at 12:13 PM, V15 (RN) said she was working on 10/18/23, but she was not assigned to R1's hall. V15 said she assisted V13 (CNA) with obtaining R1's weight. V15 said, We assisted R1 up to the standing scale and he started to go down. We had to lower him to the platform of the scale. I think both his feet were on the scale. I don't know what happened exactly. It seemed like his legs gave out. I think [V9-RN] was his nurse that day. On 1/5/24 at 2:01 PM, V9 (RN) said she does not remember V15 or the CNAs reporting that anything happened to R1's toe or that he fell on [DATE]. V9 stated, I should have been notified either way, if he fell or if he injured his toe, so I could do an assessment. There is a Fall Event in the computer that we need to complete. (V9 checked R1's Events and there was no event for 10/18/23). On 1/5/24 1:30 PM, V16 (CNA) said R1 doesn't normally get out of bed, but we needed to get his weight. V16 stated, [V15 (RN)] and I were standing [R1] up to get him on the standing scale. I guess he couldn't stand any longer and we had to lower down. I thought his feet were on the scale. I thought [V15] was his nurse, so I didn't report anything. V16 said R1 is alert and oriented and he had never made-up stories to her. On 1/9/23 at 8:54 AM, V12 (LPN) said she worked the evening shift on 10/18/23. V12 said she went to check R1's vital signs before his 5 PM medications. V12 stated, [R1] told her his foot was hurting. I asked him why and he said they tried to weigh me. He couldn't remember who was helping him get weighed that morning. I didn't get anything in report that his toe was hurt. So, I removed his sock and touched the top of his foot. He said, Ouch! That hurt! He was complaining of right toe pain. I got out my flashlight to get a better look. There was a pinpoint red area on the tip of his great toe. He said they used the stand-up scale and when they went to get him up, they hurt is toe. I went to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few look at the stand-up scale and his foot could have easily went under the platform of the scale. He could move his toes, but I told him that it would probably bruise badly. I put ice on it, but he refused. I told him it would get swollen. They shouldn't have used the standing scale for him. He barely got out of bed. He's very weak. He was getting up with therapy, but then he seemed to give up. I left a detailed note for [V10 - Wound Care Nurse] to see him. V12 said R1 didn't get out of bed very often and would have been a better candidate for the Hoyer lift scale or the wheelchair scale. V12 said the standing scale had a little lip on it. 2. On 1/5/24 at 11:30 AM, R3 was sitting up in her wheelchair. R3 said back in September she was sitting at the end of [NAME], watching TV. R3 said R7 came in and started arguing with her over the TV remote. R3 said R7 attacked her and scratched her arm. R3 said there wasn't any staff in the area at the time it happened. R3's Skin Integrity Events -- Scratches dated 9/23/23 showed R3 had an argument with another resident over a TV remote control, resulting in a bleeding scratch to her left forearm. This document showed R3 experienced moderate pain, rated at a 4 on a 1-10 pain scale. R3's Progress Notes dated 9/23/23 at 6:45 PM showed, Resident was allegedly attacked by another resident due to TV remote control. Resident sustained a minor cut to her left forearm, bleeding ceased, band aid applied. DON notified of incident. Family notified . R3's Face Sheet dated 1/5/24 showed she had diagnoses to include, but not limited to: heart failure, COPD (chronic obstructive pulmonary disease), paroxysmal atrial fibrillation, unspecified right humerus fracture, stroke, PVD (peripheral vascular disease), hypertension, GERD (gastro esophageal reflux disease), CKD (chronic kidney disease), arthritis, bipolar disorder, generalized anxiety disorder, major depressive disorder, and morbid obesity. R3's facility assessment dated [DATE] showed she was cognitively intact. On 1/5/24 at 1:55 PM, R7 was self-propelling his wheelchair from the front door of the facility, down the hall to the resident rooms. R7's Facesheet dated 1/5/24 showed diagnoses to include, but not limited to: diabetes, major depressive disorder, stroke, and cerebral palsy. R7's Psychiatric Services Referral dated 8/31/23 showed the reason for referral agitation, irritability, anger, interpersonal conflict, and noncompliance. R7's last psychiatric services in his EMR (Electronic Medical Record) showed he was discharged from services in 2020. R7's Social Services Behavioral Tracking Sheet showed on 5/6/23 R7 was turning the TV while his roommate was watching it and said his roommate is hoarding the remote. R7 trying to hit his roommate in bed, slammed door on CNA, and tried to hit CNA. R7's roommate was moved. On 8/31/23 R7 grabbed a butter knife and stabbed at the air in the direction of his tablemate during an argument. R7's Care Plan initiated on 3/19/21 showed R7 had a history of criminal behavior and fits the identified offenders' criteria. Behaviors include aggressive, inappropriate behavior r/t aggravated battery and includes history of conflicts/altercations with others and verbal/physical behaviors. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions included standard supervision, evaluate the resident's ability to control anger and impulses; and intervene when any inappropriate behavior is observed. On 1/5/24 at 11:15 AM, V3 (Restorative Nurse) and V17 (CNA - Certified Nursing Assistant) said R3 is alert and oriented and will be able to tell you what happened. They said they were not there when it happened. They thought it was the evening shift on 9/23/23. V3 said she thought it was R7 that scratched R3. V17 initially said she thought it was another resident, but then stated, that's right, it was [R7] and it was over the tv remote. It was at the end of the [NAME] hall - the old memory care unit. We leave that door open so the residents can use the common area and TV. On 1/5/24 at 11:51 AM, V2 (DON - Director of Nursing) said on 9/23/23, V14 (RN) texted her to report that R7 had attached R3 over the tv remote around 6:45 PM. V2 stated, I told him that we need to consider this abuse and I notified the administrator. The administrator is the abuse coordinator and determines what needs to be investigated. I did not assist with an investigation. I did review the video, on the following Monday, from the TV area at the end of the [NAME] hall - the old memory care unit. It's no longer available for viewing; it only saves for 30 days. I told the previous administrator that she should watch it, but she didn't. I was the only person that had access to the video camera feeds. I did see [R3 and R7] appearing to have a verbal confrontation, then I saw R7 trying to grab the remote from R3. On 1/5/23 at 12:48 PM, V14 said he was working 9/23/23 and remembered R3 and R7 fighting over the remote. V14 said R3 and R7 were at the end of [NAME] hall - in the old Memory Care TV area. (This area can't be seen from the nurses' station). V14 stated, Someone came up to him and said that [R3] was being hit by [R7] because he wanted the remote. I didn't see what happened. I'm not sure if there were any witnesses. I think it was just the 2 of them. There was a bleeding scratch on [R3's] left forearm. It was better in a few days. I cleaned it and placed a band aid over it. I reported it to the DON right away. The DON said she was going to notify the Administrator and there should be an abuse investigation. We just kept them apart. On 1/5/24 at 1:47 PM, V21 (CNA) said she was at the nurses' station when she heard R3 screaming for help. V21 stated, I ran down there (the end of [NAME] Hall, in the old Memory Care TV area). We didn't even know they were down there. She kept saying he [R7] was attacking her. Then there were 3 of us down there and he (R7) started going crazy over the remote. Me, (V19), and I can't remember the other CNA for sure. [R3] had the remote and [R7] was grabbing for it and must have scratched her during it all. She did have blood on her one arm. I heard he's done stuff like this before over the TV remote V21 said R7 is alert, but he thinks he's going home and he's not discharging. On 1/5/23 at 2:53 PM, V19 (CNA) said she was assisting another resident when she heard the yelling. V19 said she went to the end of [NAME] Hall and R3 was yelling that R7 was attacking her over the remote. V19 said she tried to locate the remote, but while she was doing that R7 snuck around and started grabbing at R3. V19 said R7 was grabbing at the remote that R3 had, and she was bleeding after. V19 said they took the remote, separated the residents, and reported it to the nurse. V19 said nobody from management interviewed her regarding the incident. V19 stated, They probably shouldn't have been down there without any staff. On 1/5/24 at 2:01 PM, V9 (RN) said R7 has some behaviors. V9 said R7 is very specific about certain things, and we have to constantly keep an eye on him. V9 said R7 can get out of control and it's very difficult to redirect him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/5/24 at 1:30 PM, V13 (Social Services Director) said if a resident is determined to be an identified offender, then the State Police are notified, and an evaluator comes out to evaluate the residents. V13 said R3 and R7 are considered identified offenders and should be supervised. V13 said R7 is alert and oriented to self but believes that he will be able to return home and that is not possible. V13 said R7 can become agitated if he feels someone is not behaving properly. V13 said often R7 just needs to be removed from the situation and allowed to settle down. V13 said R7 had been doing well at the facility and was discharged from Psychiatric services for a while. V13 said R7 had some recent behaviors that she believed were brought on by his family member and only support moving out of the state. V13 said that's why she asked R7's family to sign the referral (on 8/31/23). V13 said R7 was seen by the new psychiatric provider on 1/2/24, but the notes were not dictated yet. There was no psychiatric care from 8/31/23 (the incident with the butter knife) until 1/2/24. Event ID: Facility ID: 145895 If continuation sheet Page 13 of 13