Health inspection·April 30, 2024

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. Based on interview and record review, the facility failed to submit a final investigation report to IDPH (Illinois Department of Public Health) within 5 days. This applies to 3 of 3 residents (R1, R2, R3) reviewed for abuse in the sample of 7. The findings include: R1's initial Incident Investigation Report was submitted to IDPH on 2/16/24. IDPH did not receive a final report from the facility. R2's initial Incident Investigation Report was submitted to IDPH on 2/21/24. IDPH did not receive a final report from the facility. R3's initial Incident Investigation Report was submitted to IDPH on 2/26/24. IDPH did not receive a final report from the facility. On 4/30/24 at 11:26AM, V1 (Administrator) stated, I normally submit my reports online but for some reason it wasn't working. I tried to send it and the screen went black. I did not notify anyone at IDPH that I was having difficulties submitting the reports. I also tried to fax the reports to IDPH, but I didn't check to make sure that the fax number was correct or that the fax went through. I also did not verify with IDPH that they received my final investigation reports. I'm struggling with the lack of technology here and nothing seems to work. I should have submitted my final reports within 5 days of the initial investigation, but I guess I didn't. The facility's policy titled, Abuse with an effective date of 3/2021 showed, The following is an abuse prevention program that meets CMS (Centers for Medicare and Medicaid Services) in the updated Appendix PP, effective November 28,2016 .2. Five day final investigation report. Within 5 working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health . Page 1 of 2 145895 145895 04/30/2024 Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to perform a thorough investigation of alleged abuse, failed to maintain records of an abuse investigation. These failures apply to 3 of 7 residents (R1, R2, R3) reviewed for abuse in the sample of 7. Residents Affected - Few The findings include: R1, R2, and R3's Incident Investigation Report Final Summary showed the facility failed to interview the accused staff members, failed to identify any other residents at risk for abuse, failed to interview residents to ensure they felt safe in the facility, and failed to interview employees working on the same shift as the accused staff members. On 4/30/24 at 11:26AM, Surveyor requested abuse investigation files for R1, R2, and R3. Surveyor received abuse investigation files at 2:26PM. V1 stated, I don't keep them in a file, I just jot down notes in my notebook. On 4/30/24 at 2:27PM, V1 (Administrator) stated, I am the interim Administrator and have been here since January 2024. I developed the abuse binder that shows staff what steps need to be taken for any allegation of abuse. As the abuse coordinator, it is my job to report and investigate any allegation of abuse. The investigation should include written statements from as many staff members as possible that worked with the accused staff members to try and help prove or disprove the allegations. Social services should also be involved and help interview residents and staff and should be checking on the resident that made the allegation at different intervals to ensure they feel safe in the facility. We should be updating care plans for these residents, and we have not been. My job is to fix the broken processes but clearly the problem is me in this situation. I didn't do a thorough investigation and I didn't ensure the residents felt safe and that staff felt confident working the accused staff members. The facility's policy titled, Abuse with an effective date of 3/2021 showed, 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 necessary changes to prevent future occurrences .4. 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 with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. 145895 Page 2 of 2