Health inspection·July 2, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin to the abuse coordinator for one of three residents (R2) reviewed for abuse in the sample of eight. The findings include: R2's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety disorder, rheumatoid arthritis, and age related osteoporosis. R2's Care Plan created February 27, 2023 shows R2 should be checked for any physical marks or injuries and care for injuries according to protocol and when observing or suspecting an incident of abuse and neglect would be reported to the abuse coordinator immediately and follow protocol. On July 2, 2024 at 11:18 AM, V5 CNA (Certified Nursing Assistant) said R2 had a mark to her forehead. V5 said the mark was a red line at first but eventually it turned into a bruise. V5 said she told R2's nurse about the mark on her forehead. V5 said that if she sees a bruise on a resident, then she tells her nurse right away. On July 1, 2024 at 3:07 PM V6 LPN (Licensed Practical Nurse) said V5 CNA pointed out the bruise to R2's forehead to V6. V6 said she filled out the event paperwork regarding the bruise on R2's forehead. V6 said she notified V2 DON (Director of Nursing) of the bruise to R2's forehead. R2's Progress Notes dated June 6, 2024 at 3:15 PM entered by V6 shows, Was reported to this nurse by CNA that resident has a bruise to her forehead. The bruise is 3.5 cm by 2.5 cm, is light purple/blue in color with a red line through the center going horizontally. No swelling noted. Informed DON. Initiated neuro checks. R2's Event Report dated June 6, 2024 entered by V6 LPN (Licensed Practical Nurse) shows R2 had a bruise to the center of her forehead that measure 3.5 cm by 2.5 cm. The cause of the bruise was unknown. On July 1, 2024 at 10:52 AM, V2 DON (Director of Nursing) said, no staff brought up any concerns to her regarding a bruise noted to R2's forehead. V2 said she doesn't remember V6 LPN reporting a bruise to R2's forehead. On July 1, 2024 at 4:32 PM, V1 Administrator said she did not do an abuse investigation for R2. V1 said she was not aware of any bruising to R2's forehead. Page 1 of 4 145895 145895 07/02/2024 Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032

F 0609 Level of Harm - Minimal harm or potential for actual harm On July 2, 2024 at 11:53 AM, V8 RN (Registered Nurse) said if she sees a bruise on a resident, she assesses it. V8 said she reports it to the DON because it could be a sign of abuse. On July 2, 2024 at 11:42 AM, R2 was observed sitting in the recliner near the nurse's station. There was a fading yellow area noted to R2's right upper forehead. Residents Affected - Few The facility's Abuse policy effected April 2020 shows, The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. 145895 Page 2 of 4 145895 07/02/2024 Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032

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 interview and record review the facility failed to ensure a resident was repositioned in bed in a safe manner for one of three residents (R1) reviewed for safety in the sample of eight. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including congestive heart failure, dementia, chronic obstructive pulmonary disease, muscle contractures, major depressive disorder, muscle weakness, and need for assistance with personal care. R1's Care Plan started March 30, 2021 shows R1 is on anti-platelet medication and is at risk for bruising easily and bleeding. Added June 14, 2024: bruising right inner thigh, right leg, right hand, left forearm, left hand, left upper thigh. March 30, 2021 notify medical doctor of any excessive bleeding or bruising. Report anything that may have happened to resident that may cause bruise. R1's Care Plan started March 30, 2021 shows R1 is at risk for bruising due to fragile skin, has a history of chronic bruises related to diagnoses of peripheral vascular disease, cardiac arrhythmia. January 16, 2023-noted hematoma on left outer forehead. Approach state date of April 17, 2021 and edited June 21, 2024-due to fragile skin and resident condition use more gentle measures when providing care to resident. R1's Event Report dated June 13, 2024 created by V9 LPN (Licensed Practical Nurse) shows, Noted bruise to right hand/wrist and right upper arm and right upper foot. On July 2, 2024 at 2:18 PM, V9 LPN (Licensed Practical Nurse) said she worked the night shift on June 13, 2024. V9 said a CNA (Certified Nursing Assistant) came and got her and V10 RN (Registered Nurse) because R1 had bruises on his arm and foot. V9 said she was orientating with V10. V9 said R1's bruises looked fresh. The bruises did not look like they were old. V9 said there was a bruise on R1's foot and one on his wrist. V9 said R1 is very frail. V9 said that R1 is not able to move his legs very much so staff must help him move. V9 did not know how R1 got the bruises. On July 3, 2024 at 9:08 AM, V10 RN said V5 CNA reported the bruises on R1 at the beginning of her third shift. V10 said she went in and assessed R1. R1 told V10 he did not know how he got the bruises. V10 said she reported the bruises to V2 DON (Director of Nursing) the morning of June 14, 2024. On July 1, 2024 at 11:26 AM, V4 CNA said she worked her day shift on June 14, 2024 and saw bruises on R1 when she and V5 CNA boosted R1 in bed. V4 said to R1, Oh my gosh, what happened! V4 said R1 told her R1 got beat up by (person's name). V4 told R1 that she did not know of a person with that name. Then R1 said V7 CNA. V4 said she lifted R1 up in the bed and then went and reported to V2 DON (Director of Nursing) what R1 told her. V4 said R1 had bruises everywhere. V4 said R1 bruises very easily. V4 said she has never seen V7 be aggressive with any residents. V4 said staff must make sure they use the incontinence pad to roll R1 from side to side because his skin is so sensitive. V4 said a pad is in place to help prevent bruising on R1. On July 1, 2024 at 6:27 PM, V7 CNA said he took care of R1 on June 13, 2024 second shift. V7 said while he was repositioning R1 in his bed to clean him up, V7 pulled R1's arms to help him grab the side rails. V7 said he turned R1 to both sides in this manner. V7 said he did not use the incontinence 145895 Page 3 of 4 145895 07/02/2024 Stephenson Nursing Center 2946 South Walnut Road Freeport, IL 61032

F 0689 pad to roll R1 onto his side. Level of Harm - Minimal harm or potential for actual harm On July 2, 2024 at 11:18 AM, V5 CNA said she worked the night shift on June 13, 2024 and then she worked the day shift on June 14, 2024. V5 said that she knew that R1 had gotten a suppository after 11:00 PM so she wanted to check on R1. V5 said she went to check on R1 after 11:00 PM and that's when she noticed two bruises, one on each upper arm. V5 said that R1 bruises very easily. Residents Affected - Few On July 1, 2024 at 2:06 PM, V1 Administrator said after doing an investigation in regard to the bruising to R1, she found that V7 used R1's arms to reposition him which may have caused the bruising. V1 said V7 did not use the pad to reposition R1. On July 1, 2024 at 2:57 PM, R1 was observed in his bed. R1 had a large dark bruise noted to his right wrist with a fading bruise to his left wrist. 145895 Page 4 of 4