Inspection·January 18, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a physician's order for calling a resident's physician when blood glucose levels are out of a specified range for 1 of 2 residents (R30) reviewed for quality of care in the sample of 12. Residents Affected - Few The findings include: R30's face sheet, provided by the facility on 1/18/24, showed she had diagnoses including type 2 diabetes mellitus without complications, Exocrine pancreatic insufficiency (a condition in which the pancreas does not release enough digestive enzymes. As a result, the body cannot properly digest food and absorb nutrients. The endocrine pancreas makes the hormone insulin, which helps to control blood sugar levels), long term use of insulin, and adult failure to thrive. R30's facility assessment dated [DATE] showed she is cognitively intact. On 1/18/24 at 8:35 AM, R30 was in her room, lying in bed. R30 was alert and oriented. R30 said her blood sugar levels are high sometimes. R30 said the nurses update her doctor. R30 said she does not have a pancreas, so her body does not make insulin. R30 said her pancreas became hardened and she had to have it removed. R30 said the nurses cannot give her too much insulin because her blood sugars will bottom out if they do; so, they have to be careful. Next to R30's bed was a box containing twinkies, a large bag of potato chips, a large bag of veggie straws and several other snacks and drinks. R30's Physician's Order Report from 12/18/23-1/18/24 showed an order for insulin lispro per sliding scale before meals and at bedtime. The order showed If blood sugar is greater than 400, call MD. R30's Vitals Report from 11/8/23-1/18/24 were provided by the facility on 1/18/24. The Vitals Report showed 36 times where R30's blood sugar levels were above 400 mg/dl. On 1/18/24 at 9:37 AM, V2 (Director of Nursing-DON) said she would expect the nurses to document in the nurse progress notes when the doctor was updated, or to see that a new order was given, and the doctor was updated regarding a resident's high blood sugar levels. At 9:49 AM, V2 (DON) called V10 (Registered Nurse-RN) and put her on speaker phone. V10 said she would document in the progress notes if the doctor was updated about high blood sugar levels. V19 (RN-who was also on speaker phone with V10) said if you enter a blood sugar level into a resident's electronic administration record that is above the level specified by the doctor, the electronic administration system will alert you that the doctor needs to be notified. V19 said the system will not let you enter any unit amount into the electronic emar (electronic medication administration record) system. It will cut it off and a red alert will come up. V19 said you must enter that the doctor was notified and how many units were given on the administration record itself. On 1/18/24 at 10:01 AM, V20 (RN) was called by V2 on the phone and placed on speaker. V20 said he did not update R30's doctor (V21) on 1/16/24 when R30's blood sugar level was 513 mg/dl (above the range specified by V21-R30's Physician). V20 said that he was told by another nurse not to call the doctor, just give her 6 units of insulin (V20 did not remember which nurse told him this). V20 said R30 is a brittle diabetic, and her blood sugar levels go up and down. V20 said he is not aware if there was an actual order to not call, to just give 6 units; that is just what he was told by another nurse. V20 said if there was an order like that given, it should be in R30's orders. V20 said if the order says to notify the doctor if R30's blood sugar level is over 400, then the doctor should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 2 of 12 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 01/18/2024 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 0684 notified. V20 said if the order was changed, it should be placed in R30's orders. Level of Harm - Minimal harm or potential for actual harm On 1/18/24 at 10:10 AM, V7 (RN) said R30's blood sugar level was high on 12/21/23. V7 said she notified V21 (R30's Physician). V7 said the system alerts the nurse when a blood sugar level entered into the system is outside of the physician's specified range. V7 said the nurse must notify the resident's doctor and put in the comments section of the Administration Record that the doctor was notified and any new orders that were given before it will allow you to mark as given. At 10:11 AM, V4 (Wound Nurse/Infection Preventionist-who was also in the room during this interview) said on 12/14/23 R30's blood sugar levels were 516 mg/dl (above the specified level of 400 mg/dl). V4 said she called V21 (R30's Physician) and was told to just give the 6 units per sliding scale and nothing more. V4 said usually V21 will just say to give the 6 units per sliding scale and nothing more. V4 and V7 said the nurse should notify V21 when R30's blood sugar levels are above 400 mg/dl. V4 and V7 said it is important to notify the doctor (V21) per R30's orders to let him know of any changes and if R30 is symptomatic or not. Residents Affected - Few On 1/18/24 at 11:44 AM, V8 (Licensed Practical Nurse-LPN) said every time R30's blood sugar levels were higher than the 400 mg/dl range, she would call V21 or the on-call doctor. V8 said V21's nurse would always tell her to just keep giving R30 the 6 sliding scale units of insulin as ordered and no additional units. On 1/18/24 at 10:44 AM, V2 (Director of Nursing) said the nurses should follow the physician's orders and call the doctor to notify him when R30's blood sugar levels are above 400. He is the physician; he knows the patient. He needs to know so he can make the decision as to whether to give any additional insulin or any other orders he wants to give. On 1/18/24 at 11:35 AM, V21 (R30's Physician) said R30 has had her pancreas removed. V21 said it is almost impossible to control her blood sugar levels. V21 said for the most part, he feels that the nurses at the facility have been notifying him. V21 said he thinks R30 has a lot of behaviors that make it difficult to treat her. She is non-compliant. V21 said he is aware that R30 has had many high blood sugar levels, however he is not sure if he was informed of all of them. V21 said R30 is so brittle, and it is so hard to control her blood sugar levels, adding, even a little change can drop her blood sugars. V21 said he is more worried about hypoglycemia than hyperglycemia with R30 and he would not have given any different orders. The facility's 3/2021 policy and procedure titled Blood Glucose Testing showed Standard: Blood glucose (testing) is performed according to the order and as appropriate. Blood glucose levels for residents/patients with diabetes vary, depending on food intake, medication and exercise. Target glucose levels should be determined by the attending physician. Results that are out of the specified range are reported to the health care provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 3 of 12 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 01/18/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide wound care in a manner to prevent cross-contamination, failed to wash hands during wound care, and failed to provide weekly wound assessments for 1 of 3 residents (R34) reviewed for pressure injuries in the sample of 12. Residents Affected - Few The findings include: R34's Physician's Order Report showed an order dated 1/9/24 for: Wound Order-Abdomen -Medial midline: Cleanse wound, and peri wound with wound cleanser; apply skin prep to peri wound; apply mupirocin to wound vase; cover with AG dressing (calcium alginate dressing) moistened with saline; cover with 2 x 2 gauze, cover and secure with Opti foam gentle dressing. Change dressing every other day. R34's facility assessment dated [DATE] showed she had a stage III pressure injury that was present on admission or reentry into the facility. On 1/17/24 at 9:50 AM, V4 (Wound Nurse) performed hand hygiene, then gathered the supplies needed to perform a dressing change for the pressure ulcer on R34's abdomen. V4 grabbed a paper ruler (for measuring wounds) out of the treatment cart. The ruler was not in any kind of packaging, just sitting in one of the open compartments in the treatment cart. V4 knocked on R34's door and got permission for herself and this surveyor to enter the room. V4 put gloves on and prepared one of the bedside tables for her supplies. V4 moved the bedside table with the supplies on it, and then R34's bedside table. V4 removed the gloves and put clean gloves on. V4 did not perform any further hand hygiene during the procedure. V4 sprayed R34's wound with wound cleanser. spraying above the wound bed, the wound bed, and below the wound bed. R34 was positioned in a manner that the wound cleanser sprayed above the wound was dripping down onto the wound bed. V4 wiped the skin around the wound bed with clean gauze. V4 did not wipe the wound bed. V4 changed gloves. V4 did not perform hand hygiene. V4 used the paper ruler to measure R34's wound bed. The paper ruler was touching R34's wound bed while V4 was measuring the wound. The wound measured 1.6 x 1.7 cm (centimeters). V4 changed gloves but did not perform hand hygiene. V4 applied skin prep to the skin around the wound bed, then applied an antibiotic ointment to the wound bed. V4 placed the calcium alginate dressing over the wound bed and covered the wound with a silicone bordered dressing. V4 removed the gloves, then washed her hands for the first time since she entered R34's room to perform the dressing change. On 1/17/24 at 2:20 PM, V4 said she should have washed her hands between the dirty and clean portions of the procedure. V4 said she should have wiped the wound bed with a clean gauze to remove debris and to keep bacteria out of the wound bed; to promote healing and keep the wound clean. R34's wound note dated 11/16/23 showed a stage 3 pressure ulcer to her medial abdomen, midline measuring 0.86 cm x 1.37 cm x 0.1 cm. On 1/18/24 at 9:14 AM, V4 (Wound Nurse) said R34 goes to the wound clinic every week. V4 said either she or the nurse on duty will perform a dressing change to R34's pressure injury every other day. V4 said she usually looks at R34's wound every Wednesday. V4 said she has documented assessments of R34's wound, but she does not know where to find them. V4 said R34 goes to the wound clinic every Thursday and they assess her wound. V4 said if she were to try to find the most recent assessment, it would be hard to locate. V4 said the assessments are sent to her from the wound clinic. She looks at them and then puts the assessment in the mailbox for V22 (the doctor that reviews R34's wound notes). V4 said after V22 reviews the assessment, she sends it to medical records. V4 said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 4 of 12 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 01/18/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments are not scanned into the resident's medical record because the facility does not have a medical records person at this time. V4 said it would be difficult and take a long time to find the wound assessments from the wound clinic. V4 said she could not locate more recent wound assessments other than the ones that were already provided. The most recent assessment provided was dated 11/16/23. On 1/18/24 at 10:41 AM, V2 (Director of Nursing-DON) said V4 should have dabbed the wound bed with a clean gauze to remove any bacteria, debris, drainage. R34's care plan titled pressure ulcer/injury, edited on 1/16/24, showed, Conduct a systematic skin inspection weekly, Pay particular attention to the bony prominences. The care plan also showed Report any signs of skin breakdown (sore, tender, red, or broken areas). The facility's 4/2020 policy and procedure titled Dressing Changes showed Procedure .3. Wash your hands thoroughly before beginning the procedure .10. Put on disposable gloves .11. Position resident .12. Loosen tape and remove dressing. Pull gloves over dressing and discard into appropriate plastic waste bag. 13. Wash hands. Put on disposable gloves. The facility's 4/2020 policy and procedure titled Prevention and Treatment of Skin Breakdown showed II. Treatment of Pressure Ulcers and Lower Extremity Ulcers .6. Initiate Weekly Wound Documentation. 7. When a pressure ulcer is present, daily wound monitoring occurs. 8. Document on any changes or concerns in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 5 of 12 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 01/18/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure a medication cart was locked when not in sight of the nurse. This has the potential to affect 5 of 5 residents (R9, R12, R30, R31, R34) reviewed for medication storage in the sample of 12, and 14 residents (R1, R4, R6, R7, R11, R13, R14, R15, R18, R22, R24, R26, R28, and R193) outside the sample. The findings include: 1. On 1/17/24 at 9:13 AM, the medication cart for the C/D halls was in the common walking area, between the nursing station and the halls. V18 (Registered Nurse-RN) walked away from the medication cart and entered the first room on the right down the hall. The keys to the medication cart were in the lock on the medication cart. At 9:14 AM, V18 exited the room and walked back to the medication cart. At 9:15 AM, V18 said she should not have left the keys in the medication cart because someone could have opened the medication cart and taken whatever they wanted. On 1/18/24 at 10:28 AM, V7 (RN) and V4 (Infection Preventionist/Wound Nurse) said it is not acceptable for the keys to the medication cart to be left in the lock to the medication cart, for safety reasons. V7 and V4 said residents or staff could open the medication cart and take out medications. On 1/18/24 at 10:31 AM, V2 (Director of Nursing-DON) said V18 worked on the C/D hall on 1/17/24. V2 said all of the residents on the C/D halls would have medications in the C/D medication cart. V2 said the nurse should always have their eyes on the medication cart if it is unlocked. The keys belong on their person. V2 said it is Important because anybody could use the keys to get into that cart and take what they want. Narcotics are in there. V2 said the keys to unlock the narcotics box are on the same key chain as the keys to the medication cart. On 1/18/24, the facility provided a list of residents whose medications are kept in the C/D medication cart. The list identified R9, R12, R30, R31, R34, R1, R4, R6, R7, R11, R13, R14, R15, R18, R22, R24, R26, R28, and R193 as residents whose medications are stored in the C/D medication cart. The facility's 4/2020 policy and procedure titled Medication Storage showed 5. The facility may use a Computer on Wheels type cart that is lockable and contains general nursing supplies to assist with a medication pass. 6. If the facility uses a medication and treatment cart; the cart is locked when it is not in direct view of the nurse. 2. On 1/18/24 at 10:35 AM the C/D hall medication cart was unlocked for inspection. The drawer containing the controlled substance lock box was opened. The controlled substance lock box was left ajar, and it was able to be opened without a key. The controlled substance lock box contained narcotic pain medications. The controlled substance log binder for the C/D medication cart showed R26 had 26 milligrams (mg) of morphine and 29 tablets of hydrocodone/acetaminophen 5 mg/325mg (both are narcotic pain medication). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 6 of 12 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 01/18/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The controlled substance log binder for the C/D medication cart showed R22 had 25 tablets of hydrocodone/acetaminophen 5mg/325mg. The controlled substance log binder for the C/D medication binder showed R31 had 2 mg of morphine. On 1/18/24 at 11:22 AM, V2 Director of Nursing stated the controlled substances should be double locked and the controlled substance box should not have been left ajar. V2 said, the reason for the double lock is the controlled substances are more likely to be diverted other medications. The facility's Medications-Controlled policy (effective 4/2020) showed, Schedule II or higher controlled substances are kept under double lock, either in the medication cart, medication room, or pass thru cabinets . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 7 of 12 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 01/18/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure residents receiving a pureed diet received a dinner roll during the lunch meal for 2 of 2 residents (R31, R39) reviewed for pureed diets in the sample of 12 and 3 residents (R7, R19, R37) outside the sample. The findings include: On 1/16/24, from 10:30 AM-11:40 AM, V23 (Dietary Cook) was observed making the pureed foods for the lunch meal service. At 11:19 AM, V24 (Director of Dietary Services) came into the area and put a sheet pan with dinner rolls on them into the oven. On 1/16/24 from 12:17 PM-12:44 PM, R7, R19, R31, R37, and R39 were observed in the dining room eating lunch. All these residents had a pureed diet. None of these residents received a pureed dinner roll for the lunch meal. On 1/17/24 at 2:42 PM, V24 (Director of Dietary Services) said the residents that are on pureed diets should have received pureed dinner rolls because it is part of their approved menu. The list of residents and their diets, provided by the facility on 1/18/24, showed R7, R19, R31, R37, and R39 as the residents in the facility receiving pureed diets. The facility menu provided by the facility on 1/16/24 showed dinner rolls as one of the items to be served during the lunch meal. The facility's recipe for dinner rolls, provided by the facility on 1/16/24 showed the process for making pureed dinner rolls for the resident's receiving a pureed diet. The facility's policy and procedure titled Menus, with a revision date of 9/2017, showed Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide .4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist or other clinically qualified nutrition professional reviews and approves the menus .6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 8 of 12 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 01/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dishwasher temperatures were at the proper level for sanitation, and failed to ensure food temperatures were maintained at 135 degrees Fahrenheit prior to serving. This failure has the potential to affect the 37 of 39 residents who receive food and beverages from the facility's kitchen. The findings include: The CMS (Centers for Medicare and Medicaid Services) 671 form titled Long-Term Care Facility Application for Medicare and Medicaid, dated 1/16/24, showed 39 residents resided in the facility. The list of residents and their diets, provided by the facility on 1/18/24, showed 2 residents are NPO (take nothing by mouth). On 1/16/24 at 11:08 AM, V23 (Dietary Cook) finished making the pureed pork loin for the lunch meal. V23 took the container and lid used to puree the pork loin into the dishwashing area, rinsed them and place them into a rack to send through the dishwasher. V24 (Dietary Services Manager) went in with V23 and this surveyor into the dishwashing area. V24 said the dishwashing machine was a high temperature dishwasher. V24 placed a test strip onto the container used to make the pureed pork loin, and another test strip on a sheet pan that was on a rack to be sent through the dishwasher after the puree container. The digital gauge on the outside of the dishwashing machine showed the following results: The first test with the accessories-the temperatures on the outside gauge showed prewash 130 degrees Fahrenheit, wash 157 degrees Fahrenheit, and the final rinse 173 degrees Fahrenheit. The test strip had fallen off during the wash and was not available. The second test rack with sheet pan-the temperature gauge showed prewash 127 degrees Fahrenheit, wash 150 degrees Fahrenheit, and the final rinse 172 degrees Fahrenheit. The test strip on the sheet pan did not turn black. V24 verified that the test strip did not turn black indicating the temperature was not hot enough to sanitize the dishes. The third test temperature gauge showed prewash 126 degrees Fahrenheit, wash 150 degrees Fahrenheit, and the final rinse 176 degrees Fahrenheit. The test strip fell off on the third test and was not available. V24 said sometimes it takes a few times to get the temperature back up. V24 said the wash is usually in the 150-degree Fahrenheit range and the final rinse is usually in the 180-degree Fahrenheit range. On 1/16/24 at 11:16 AM, while the third test was being done, V23 (Cook) grabbed the container and lid for the food processor. V23 took them back into the kitchen area. At 11:19 AM, V23 was in the kitchen making the pureed au gratin potatoes in the container he just retrieved from the dishwashing area. On 1/16/24 at 10:55 AM, V24 said the plates are kept in a warmer. The plates are placed onto hotplates (metal plates) that are also warmed. V24 said the food is put on the warmed plates in the kitchen, then covered with the plate protectors. V24 pointed towards the two carts in the kitchen and said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 9 of 12 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 01/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the food is placed in the carts after plating. V24 said one of the carts is taken to the dining area for the staff to pass trays out to the residents in the dining room. V24 said the other cart is taken to the nurse's station and the food is passed out to the residents that eat in their rooms. V24 said the 2 carts are not heated carts. At 11:45 AM, the food was starting to be plated and placed into the carts to be taken out on the unit. On 1/16/24 at 12:17 AM, the residents were being served their trays in the dining room. At 12:19 PM, V24 was asked to obtain the food temperatures from 2 of the trays in the cart. On the first tray, the hamburger was 131 degrees Fahrenheit, the au gratin potatoes were 146.4 degrees Fahrenheit, and the Brussel sprouts were 127.4 degrees Fahrenheit. On the second tray, the pork loin was 128.0 degrees Fahrenheit, the au gratin potatoes were 141.0 degrees Fahrenheit, and the Brussel sprouts were 123.0 degrees Fahrenheit. On 1/17/24 at 2:42 PM, V24 (Director of Dietary Services) said the dishwasher is a high temperature conveyor rack dishwasher. [NAME] is the manufacturer. At 2:46 PM, V24 said the manufacturer's instructions were on the side of machine, near the bottom. V24 squatted down and said the instructions showed the wash cycle temperature should be 160 degrees Fahrenheit and the final rinse should be 180 degrees Fahrenheit. V24 was asked about the testing of the machine on 1/16/24. V24 said it takes a few cycles sometimes to get the temperature up to where it should be. V24 said the container and lid to the food processor were not sanitized properly because the temperatures were not high enough when they were run through the dishwashing machine. V24 said it is important to make sure the dishes are sanitized properly to prevent food-borne illness. V24 was also asked about food temperatures on the two sample trays during the lunch service. V24 said the two trays that she obtained temperatures for on 1/16/24, during the lunch meal both had at least 2 food items that were not 135*Fahrenheit or higher. V24 provided this surveyor with a copy of the information on the side of the dishwashing machine. the document showed for hot water sanitizing, the wash cycle should be a minimum of 160 degrees Fahrenheit, and the final rinse should be a minimum of 180 degrees Fahrenheit. The facility's Dish Machine Log from 1/1/24-1/17/24 showed only one wash cycle temperature at or above 160 degrees Fahrenheit. The log showed 18 entries where the final rinse was below 180 degrees Fahrenheit. The facility's policy and procedure titled Ware washing, with a revision date of 9/2017, showed 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. The facility's policy and procedure titled Food: Preparation, with a revision date of 9/2017, showed all foods are prepared in accordance with the FDA Food Code .4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 10 of 12 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 01/18/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to identify, implement, and document control measures to prevent the growth of opportunistic waterborne pathogens (such as Legionella); failed to establish acceptable ranges for control measures; and failed to identify corrective actions for when control limits are not met. This applies to all residents residing in the facility. Residents Affected - Many The findings include: The facility's CMS 671 dated 1/16/24 showed 39 residents resided in the facility. On 1/17/24 at 10:28 AM, the surveyor requested the facility's Legionella Water Management Program from V4 (Infection Preventionist). V4 looked at the surveyor blankly and stated, I'm not sure if I'm involved in that. I don't know anything about that. I know [V6 - Maintenance Director] checks water temperatures, but that's about it. At 1:02 PM, V4 provided an undated Water Management Program document. This document was the outline of what a facility should do to develop a program but did not contain any facility specific information about the facility's potential areas of legionella growth, the control measures the facility chose, what the facility would do in response to an abnormal result of the control measure, and how the facility would respond to an outbreak of Legionella. On 1/18/24 at 9:48 AM, V4 (Infection Preventionist) stated, I don't really know much about the Legionella water program. We've never had any meetings or discussed a plan if we did have an outbreak. I guess I would call the local health department and notify IDPH if we did have a Legionella outbreak, but that's really all I know. I would appreciate having a meeting to discuss the water plan. I don't think we've had any active cases in the area, so it really wasn't on my radar. [V6 - Maintenance Director] may know more. He does the water testing and once a month he flushes the system. V4 said she knows that stagnant water can lead to growth of the Legionella bacteria, and it can be dispersed through the water, causing potential respiratory infection and symptoms. On 1/18/24 at 9:53 AM, V6 (Maintenance Director) said he's worked at the facility since May 2023. V6 stated, I don't know if we have a specific written Legionella Water Management Program. I've never seen a diagram or flowchart that showed the facility water flow chart that identifies the facility's areas for potential growth. The surveyor showed V6 the undated program provided by V4. V6 replied, I've never seen that before. We do have the north end of the building closed off. I've been flushing the vacant water sources. I usually do that on Friday afternoons. I did turn the hot water off to the north side of the building, but the water still circulates. Right now, we do not do any Legionella water testing at the facility. I come from a hospital background, so I am familiar with the steps that need to be done. We just haven't been doing that here. I test the water temperatures for resident safety, but not with any specific use for the Legionella Water Program. I know some points of concerns are usually shower heads, cooling towers, and anywhere water sits stagnant. On 1/18/24 at 10:04 AM, V1 (Administrator) said her understanding of the Legionella Water Management Program is that facility was not required to test but did need to ensure empty units are having the water flushed. The surveyor showed the undated Water Management Program provided by V4 and asked if there was something that contained the facility specific information. V1 replied, Where did you get that? V1 reviewed the document and looked in her files to see if she had a facility specific plan. V1 said she did not see the facility's Water Management Program. V1 said the purpose of the program is to ensure the facility is following proper procedures to reduce the risk of Legionella growth in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 11 of 12 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 01/18/2024 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 0880 the facility and measures to take to prevent residents from potential illness related to Legionella. Level of Harm - Minimal harm or potential for actual harm The undated Water Management Program provided showed, Purpose: A Water Management Program is designed to actively identify and manage hazardous conditions that support growth and spread of Legionella. The Water Management Program: Identifies building water systems for which Legionella control measures are needed. Assesses how much risk the hazardous conditions in those water systems pose. Applies control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread. Makes sure the program is running as designed and is effective . The facility was unable to provide a Program that provided any building specific information. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 12 of 12