Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
(continued on next page)
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 4
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
07/02/2024
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
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145895
If continuation sheet
Page 2 of 4
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
07/02/2024
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
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145895
If continuation sheet
Page 3 of 4
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
07/02/2024
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
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145895
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the July 2, 2024 survey of STEPHENSON NURSING CENTER?
This was a inspection survey of STEPHENSON NURSING CENTER on July 2, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STEPHENSON NURSING CENTER on July 2, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.