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 .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145895
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
04/30/2024
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
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145895
If continuation sheet
Page 2 of 2
