Inspection·February 4, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tablets. V2 said R41's family had brought in a bottle of Norco to the facility. V2 said 41 also had a bingo card of Norco from the facility's pharmacy. V2 said staff are supposed to count both the bottle of Norco and the bingo card of Norco at the end of every shift and at the beginning of every shift. V19 told V2 that V18 wanted V19 to just correct the count. V2 said she came in early the next morning on February 1, 2025 to begin the investigation. V2 said she reviewed the facility's cameras. The only thing that V2 noted from the cameras was V18 may have opened the narcotic box at 3:46 PM, 7:20 PM, and 7:41 PM. V2 said the actual narcotic box was obscured by another medication cart, but V18 made the arm motion like she was opening the narcotic box. V2 said V18 gave residents a narcotic medication during the 7:20 PM time and 7:41 PM time but could not find where V18 would have given a narcotic at 3:46 PM. V2 said she called and made a report to the local police department and called the agency where V18 worked. V2 said she did not talk with V18 after the incident but that V18 emailed V2 an unsigned statement. V2 said she still has not accounted for the Norco yet. V2 said the police came to the facility and they are doing their investigation. 2. R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. On February 4, 2025 at 9:46 AM, V2 DON said she has not investigated any potential for misappropriation in the last three months regarding a missing fentanyl patch. V2 said she was not aware of the missing fentanyl patch on R11. V2 said V24 no longer works for the facility due to attendance issues. V2 said staff are supposed to notify her right away if the see that a fentanyl patch is missing off a resident. On February 4, 2025 at 11:18 AM, V19 LPN said she calls the director of nursing and administrator if a fentanyl patch is missing off a resident because it is a controlled substance and it could mean that someone took it. The facility's Medications-Controlled policy effective April 2020 shows, A count of controlled drugs is maintained by nurses of the off-going and oncoming shifts. The facility's Abuse policy effective April 2020 shows, This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 2 of 19 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 02/04/2025 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 ensure residents were not restrained from being able to exit their beds for 4 of 13 residents (R5, R11, R19 and R35) reviewed for restraints in the sample of 13. Residents Affected - Some The findings include: 1. On 2/2/25 10:26 AM, R11 was lying in bed. R11 had siderails on the upper half of her bed in a raised position on both sides of her bed. R11 had bolsters (wedge shaped cushions) attached to each side of her bed measuring 33 inches long and 7 inches high. The bolsters were attached to the bed with two straps holding them in place. There was 23 inches from the end of the bolster to the end of her bed. On 2/4/25 at 9:40 AM, R11 was lying in bed and the siderails and bolsters were in the same position. On 2/4/25 at 9:40 AM, V15 (Certified Nursing Assistant) said R11 has the bolster in place so she does not get out of bed. V15 said R11 is not able to independently use her side rails for positioning herself. R11's Fall Care Plan dated 11/26/24 shows, [R11] is at risk for falls r/t (related to) the need for assistance with all transfers, a visual deficit requiring the use of glasses, a hx (history) of anxious behaviors bolster cushions on bed. R11's Informed Consent Regarding Physical Device Usage form dated 12/5/23 shows the device she uses is half side rails on both sides of bed. The form shows, I also understand that the reason/need for use of the physical device will be reassessed quarterly or if there is a change in resident's/my condition. I am aware that attempts may be made to reduce/remove the use of the physical device as the resident's/my condition warrants . On 2/4/25 at 1:00 PM, V2 (Director of Nursing) said she does not have any restraint assessments nor siderail assessments to provide for R11. On 2/3/25 at 2:48 PM, V2 (Director of Nursing) said side rails can be considered a restraint if the resident is not using them to help with positioning. V2 said R11 cannot use her siderails for self-assisted bed mobility. V2 said bolsters are not a restraint, they are a positioning device. 2. On 2/2/25 at 2:52 PM, R5 was lying in bed. R5 had bolsters (wedge shaped cushions) attached to the middle of each side of his bed measuring 33 inches long and 7 inches high. The bolsters were attached to the bed with two straps holding them in place. R5 had his left leg over the side of the right side of his bed resting on the bolster. On 2/2/25 at 2:52 PM, V15 (CNA) said R5 has bed bolsters because he tries to get out of bed and is at fall risk. On 2/4/25 at 11:53 AM, V15 said if R5 did not have the bolsters in place, he would be able to get out of bed but it is not safe for him to do it by himself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 3 of 19 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 02/04/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R5's Fall Care Plan dated 10/31/24 shows, [R5] is at risk for falling r/t (related to) dependent on staff with mobility, hx (history) of restlessness d/t dx (diagnosis) of anxiety and alz (Alzheimer's disease). Safety precautions diminished Ensure bolsters are in place and are attached properly. The facility's Restraint Device Evaluation Policy dated 4/2020 shows, Upon admission, quarterly and with a change in condition, every resident is evaluated for restraint use by completing the Device Observation, Education, and Consent form. Use of side rails for bed mobility/physical functioning is not considered a restraint .Make sure the restraint allows for freedom of movement. Do not attach any restraint to side rails or bed frame . 3. R19's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, polyosteoarthritis, anxiety disorder, and depression. Transfer status: mechanical lift for all transfers. R19's Care Plan edited November 25, 2024 shows, R19 has arthritis and has pain with flexion of right and left shoulder joints past level of shoulders, dementia, unable to participate in active range of motion exercises. R19's Minimum Data Set, dated [DATE] shows she is not cognitively intact. R19 is dependent on staff to roll left and right in bed. On February 2, 2025 at 1:35 PM, V21 and V22 CNAs (Certified Nursing Assistants) transferred R19 into bed via a mechanical lift. There were tall barriers on each side of R19 while she was in bed. These barriers were about as long as R19's body was and went higher than R19's body when she was lying in bed. V22 CNA said the barriers are used so she doesn't get out of bed. Although she doesn't really need them anymore because she doesn't move as much as she used to. 4. R35's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses of congestive heart failure acute respiratory failure, altered mental status, adjustment disorder, and delusional disorder. R35's Care Plan created on January 2, 2025 shows, [R35] has a history of falling. Place bolsters on either side of bed. R35's Minimum Data Set (MDS) dated [DATE] shows he is not cognitively intact. On February 2, 2025 at 9:42 AM, R35 was in his bed. R35's top half of his body was out of bed near the floor. There were tall barriers noted under each side of R35's bed. At 11:56 AM, R35 was still in bed, there were tall barriers on each side of R35 while he was lying in bed. On February 4, 2025 at 1:16 PM, V28 CNA said the tall barriers are there so that R35 does not fall out of bed. V28 said that R35 cannot climb over the barriers, nor can he remove them. On February 3, 2025 at 7:51 AM, V2 DON (Director of Nursing) said there is no restraint assessment for R19 or R35. The facility's Restraint Device policy effective April 2020 shows, Restraint use requires an evaluation, recommendation and an order and resident/legal representative permission before application. Use of restraints will be in accordance with state/federal regulations. Make sure the restraint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 4 of 19 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 02/04/2025 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 0604 allows for freedom of movement, do not attach any restraint to side rails or bed frame. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 5 of 19 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 02/04/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure their abuse policy was implemented for one of four residents (R11) reviewed for abuse policy and procedures in the sample of four. Residents Affected - Few The findings include: R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. On February 4, 2025 at 9:46 AM, V2 DON said she has not investigated any potential for misappropriation in the last three months in regard to a missing fentanyl patch. V2 said staff are supposed to notify her right away if the see that a fentanyl patch is missing off a resident. On February 4, 2025 at 11:18 AM, V19 LPN said she calls the director of nursing and administrator if a fentanyl patch is missing off a resident because it is a controlled substance and it could mean that someone took it. The facility's Abuse Policy effective April 2020 shows, 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: orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 6 of 19 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 02/04/2025 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 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 a missing controlled substance for one of four residents (R11) reviewed for reporting abuse in the sample of four. The findings include: R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. On February 4, 2025 at 9:46 AM, V2 DON said she has not investigated any potential for misappropriation in the last three months in regard to a missing fentanyl patch. V2 said she was not aware of the missing fentanyl patch on R11. V2 said V24 no longer works for the facility due to attendance issues. V2 said staff are supposed to notify her right away if the see that a fentanyl patch is missing off of a resident. On February 4, 2025 at 11:18 AM, V19 LPN said she calls the director of nursing and administrator if a fentanyl patch is missing off a resident because it is a controlled substance and it could mean that someone took it. The facility's Abuse Policy effective April 2020 shows, 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: Identifying occurrences and patterns of potential mistreatment. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property the observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 7 of 19 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 02/04/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff for Activities of Daily Living (ADLs) was provided incontinence care in a timely manner for 1 of 13 residents (R5) reviewed for ADLs in the sample of 13. Residents Affected - Few The findings include: On 2/3/25 at 8:13 AM, R5 was in the dining room eating breakfast. At 10:34 AM, V11 (Certified Nursing Assistant) and V12 (Registered Nurse) transferred R5 into bed using a mechanical lift. R5's mechanical lift sling was removed from under him and then his blankets were pulled up. V11 and V12 then exited the room. V11 or V12 did not check to see if R5's incontinence brief needed to be changed. At 11:29 AM, V11 provided incontinence care to R5. R5's incontinence brief was saturated. R5's green sweatpants had visible wet spots on the back of them. R5's front perineal area was reddened. R5 had a small amount of stool present. R5's buttocks was reddened. On 2/3/25 at 2:48 PM, V2 (Director of Nursing) said residents should be checked for incontinence every 2 hours and as needed. V2 said if staff are putting a resident to bed, they should check the incontinence brief to see if it needs to be changed. R5's Care Plan dated 11/17/24 shows, He is dependent on staff with mobility, eating and hygiene .incontinent of bowel and bladder Render peri care every incontinent episode-Keep clean and dry as possible. Minimize skin exposure to moisture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 8 of 19 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 02/04/2025 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure protective arm sleeves were applied to a resident with fragile skin and a history of skin tears for 1 of 13 residents (R11) reviewed for quality of care in the sample of 13. Residents Affected - Few The findings include: R11's Nursing Notes dated 12/13/24 shows, Resident bumped arm on table at breakfast and sustained a skin tear of 2.5 cm by 0.5 cm to (R) outer forearm . R11's Nursing Notes dated 1/29/25 shows, Resident bumped her right FA (forearm) on the table at lunch and sustained a 1.5 cm (centimeter) x 0.5 cm skin tear On 2/2/25 at 10:26 AM, V15 (Certified Nursing Assistant) and V16 (Registered Nurse) provided incontinence care to R11 and got her up into her high back wheelchair. R11 had arm protector sleeves on her bedside table. R11 had a short sleeved shirt on. R11 had a dressing to her right forearm. V16 stated that it was a skin tear from bumping her arm on the dining room table. At 12:11 PM, R11 was sitting at the dining room table. R11 did not have protective arm sleeves on. R11 did not have long sleeves on. On 2/3/25 at 12:21 PM, R11 was sitting at the dining room table. R11 did not have arm protective sleeves on. R11 did not have long sleeves on. On 2/3/25 at 10:02 AM, V4 (Wound Care Registered Nurse) said that they implemented R11's protective arm sleeves after she received a skin tear. V4 said that she has very fragile skin and bruises easily. V4 said that R11 should be wearing the sleeves when she is out of bed to prevent skin tears and bruising. R11's Health Care plan created on 11/26/24 shows, Resident is at risk for bruising r/t (related to) impaired skin integrity, resistance to care at times, and anticoagulant use Dress resident in long sleeves shirts and pants. Protect extremities. R11's Health Care Plan created on 2/3/25 shows, Resident has a skin tear to RFA (right forearm) below elbow Use arm protectors while out of bed to reduce trauma/damage to the skin surface. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 9 of 19 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 02/04/2025 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 to ensure pressure ulcer prevention interventions were implemented for a resident at risk for pressure ulcers and failed to ensure dietary recommendations were implemented for a resident with a stage 3 pressure ulcer. This applies to 2 of 4 residents (R5 and R11) reviewed for pressure ulcers in the sample of 13. Residents Affected - Few The findings include: 1. On 2/2/25 at 2:52 PM, V10, Certified Nursing Assistant (CNA) was in R5's room assisting R5's roommate. R5 was lying in bed. R5's air mattress was not plugged into the wall. When the mattress was pressed on slightly, the metal bed frame was able to be felt. At 3:00 PM, V10 exited the room. R5's air mattress was still unplugged. On 2/2/25 at 2:52 PM, V15 (CNA) said R5 was placed back into bed around 1:00 PM. On 2/2/25 at 3:49 PM, V4 (Wound Care Registered Nurse) said R5 has an air mattress due to him being at high risk for pressure ulcers. V4 went into the room and plugged R5's air mattress into the wall. R5's air mattress was set for a weight of 80 pounds. On 2/3/25 at 11:29 AM, R5 was lying in bed. R5's air mattress was still set at 80 pounds. On 2/3/25 at 11:29 AM, V4 said that R5's air mattress should be set at 160 pounds. R5's Weight Report shows that he weighed 151 pounds on 1/8/25. R5's Physician's Order Sheet shows, and order dated 6/27/24 for, Air mattress on bed to relieve pressure. Make sure it is set at correct weight-159. R5's Care Plan shows, [R5] has a hx (history) of pressure ulcers. He is dependent on staff with mobility, eating and hygiene Air mattress provided to relieve pressure. Staff to check and make sure it is set at correct weight. R5's Pressure Ulcer Risk form dated 12/30/24 shows he is a moderate risk for developing pressure ulcers. 2. R11's Wound assessment dated [DATE] shows, Stage 3 pressure ulcer noted to coccyx measuring 1.4 x 0.6 x 0.2 . R11's Dietary Note dated 1/23/25 shows, With Stage 3 open area present nursing requested re-evaluation for HPS (High Protein Supplement) to promote healing. Suggest HPS TID (three times a day) with meal and will add sandwiches BID (twice a day) goal for complete healing. On 2/2/25 at 12:11 AM, R11 was served her lunch tray. There was no sandwich on R11's lunch tray. On 2/3/25 at 12:21 PM, R11 was served lunch. There was no sandwich on R11's lunch tray. On 2/4/25 at 8:57 AM, V14 (Dietitian) said R11 has a stage 3 pressure ulcer and on 1/23/25, the wound nurse asked her if they could try providing her sandwiches to help her with wound healing. V14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 10 of 19 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 02/04/2025 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 said the sandwich would give her a little more protein to promote wound healing. V14 said with add ons like ice cream or sandwiches, they do not need a physician's order. V14 said that typically she fills out a recommendation form and gives it to the dietary manager, but she forgot to do one for R11's sandwiches. V14 said she put the recommendation in her progress notes but did not notify the dietary department. On 2/4/25 at 9:45 AM, V4 (Wound Care Registered Nurse) said V14 (Dietitian) and V3 (Dietary Manager) and herself all spoke about R11 getting a sandwich for more protein due to her having a pressure ulcer. V4 said that in the meeting, V14 agreed to the sandwiches. On 2/4/25 at 10:49 AM, V3 (Dietary Manager) said she did speak with V14 and V4 about providing R11 with sandwiches but during the meeting, she did not hear a for sure answer. V3 said she received V14's recommendations for that day and providing R11 with sandwiches was not one of the recommendations. V3 said, It must have slipped all of our minds that day. R11's Meal Ticket printed on 2/3/25 does not show that she should get a sandwich twice a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 11 of 19 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 02/04/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident did not wear a urinary drainage leg bag while in bed for one of two residents (R35) reviewed for catheters in the sample of 32. The findings include: R35's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including congestive heart failure, altered mental status, chronic kidney disease, urinary retention, and obstructive and reflux uropathy. R35's Care Plan started September 7, 2024 shows, [R35] requires an indwelling urinary catheter. History of retention and urinary tract infections. On February 2, 2025 at 9:35 AM, R35 was lying in bed. R35 had his knees bent up and he was laying on his back. There was no urinary drainage bag visible on either side of R35's bed. At 9:40 AM, V7 CNA (Certified Nursing Assistant) said R35 has a catheter (urinary drainage device). V7 said R35 has a leg bag on while he's in bed. At 9:42 AM, there was a sing about R35's bed that showed, Do not leave leg bag on when in bed. At 9:54 AM, V7 detached R35's leg bag from his lower leg and laid it on the side of R35's bed. There was amber urine noted in the tubing and in the urinary drainage bag. On February 4, 2025 at 9:28 AM, V2 DON (Director of Nursing) said R35 should not have a leg bag while he is in bed. V2 said R35 is at risk for urinary tract infections. There is a potential for urine back flow if R35 has his leg bag on while he's in bed. The facility's Foley Catheter-Use and Management policy effective June 2024 shows, Proper management of resident with a foley catheter include the following: urinary drainage tubing should be kept below the bladder level to promote free flow of urine, by gravity. Urinary legs bags should be evaluated for use, if used the following should be done; If a leg bag is determined appropriate, it should be only used when out of bed. A leg bag will be considered for discontinuation if a urinary tract infection [NAME] is identified. A leg bag should be positioned below the bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 12 of 19 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 02/04/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a residents' pain regimen was adequate to relieve her pain for one of 13 residents (R14) reviewed for pain in the sample of 13. This failure resulted in R14 experiencing unrelieved pain for three days. Residents Affected - Few The findings include: R14's Physician Order Report dated January 3, 2025-February 3, 2025 shows she was admitted to the facility on [DATE] with diagnoses including nonrheumatic aortic valve stenosis, acute diastolic congestive heart failure, depression, gastrointestinal stromal tumor of stomach, age related osteoporosis, scoliosis thoracic region, muscle weakness, and abnormalities of gait and mobility. R14's medications orders show an order for ibuprofen 200 mg two tablets every four hours as needed to start on December 6, 2024, an order for ibuprofen 200 mg three tablets twice a day for pain to start on December 10, 2024, and morphine liquid 10 mg every two hours as needed to start January 30, 2025. R14's Care Plan created December 17, 2024 shows, Resident has complaints of chronic back pain. History of fall with minor injury. Assess past effective and ineffective pain relief measures, monitor and record any nonverbal signs of pain. R14's Care Plan created December 3, 2024 shows, Pain: evaluation of pain will be performed routinely to address pain management needs. I will receive pain medication per physician/nurse practitioner orders. Pain medication effectiveness will be documented and reported as needed. R14's Progress Notes dated December 2, 2024 shows, Spoke to doctor in regard to residents fall and complaints of back pain. Order received and noted. R14's Progress Note dated December 10, 2024 shows, Reports general aches and pains this morning. Ibuprofen administered as now scheduled . R14's Progress Note dated January 9, 2025 shows, Resident is alert and oriented. Refuses all medications except ibuprofen. States pain is related to her skin tear on her right upper arm. R14's Progress Note dated January 26, 2025 shows, Resident has very poor appetite only taking a few bites at each meal. Also only wanting to take ibuprofen and no other medications. Requesting to stay in bed or go back to bed quickly after getting up in chair. MD (medical doctor) and power of attorney notified of general decline . January 29, 2025 shows, Daughter (V20) here to meet with hospice. Daughter upset stating that she does not feel that residents pain is adequately controlled . January 30, 2025 shows, Need for comfort meds communicated to doctor and new orders morphine and Ativan received. Power of Attorney notified. February 2, 2025 shows, Resident putting on call light several different times requesting to have morphine and be repositioned, she was repositioned every single time, this nurse gave her ibuprofen and am waiting on morphine to arrive from pharmacy. I informed her as soon as we receive her morphine, I will bring it in. She stated, 'so I am just supposed to suffer until then?' I reassured her I gave ibuprofen to help for now. On February 2, 2025 at 10:23 AM, R14 was lying in bed. R14 said that the had pain in her heart and pain in her back. R14 said she was waiting for her morphine. R14 said before her ibuprofen was administered, her pain was rated a 9/10. After the ibuprofen, R14's said her pain is rated at 8/10. R14 was thin and frail. R14 had 4-5 blankets on. On February 3, 2025 at 10:15 AM, V20 (R14's Daughter/power of attorney) was sitting at R14's bedside. R14 was pale and barely breathing. R14 was unresponsive. V20 began crying and stated her mom was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 13 of 19 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 02/04/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few actively dying. V20 became tearful when interviewed in regard to R14's pain. V20 said her mom always had chronic pain. V20 said she has been asking for something stronger for pain for R14 since R14 was admitted to the facility. V20 said R14 took ibuprofen at home for pain, but always took more than the recommended amount. V20 said that V4 RN (Registered Nurse) got the process started for a stronger pain medication for R14 but then V20 said she did not know what happened after. Someone dropped the ball.V20 said it took the facility three days to get an order for morphine. V20 said she was very upset. V20 said R14 has aortic stenosis, no stomach due to stomach cancer, was a post-polio baby, and shrunk five inches in height. V20 said that she was told by the facility that staff could not take the morphine out of the emergency box because their pharmacy said the morphine was already on its way to be delivered. V20 said she was very upset when she came in to visit on February 2, 2025 and the morphine still was not in the facility for R14. R14's Medications Administration History dated January 1, 2025-January 31, 2025 shows that R14 asked for her ibuprofen early 17 times. On February 4, 2025 at 9:07 AM, V2 DON (Director of Nursing) said there was an order for hospice for R14 on January 26, 2025. V2 said R14 was refusing to eat and only wanted to take her ibuprofen. V2 said on January 27, 2025 R14's daughter (V20) was upset that R14 did not have morphine for pain. On January 29, 2025 V20 came and talked to V2 again and stated, she just needs to relax so she can die. V2 said that R14 was saying she wanted ibuprofen. V2 said on January 30, 2025, V4 RN contacted R14's doctor to get something stronger for pain because V4 could see that R14 was declining so V4 wanted to get the pain medications so R14 did not have to go through the weekend with no pain medications. V2 said the problem was that the doctor did not call in the morphine prescription into the pharmacy. On February 2, 2025, R14's nurse came to V2 and V4 and said R14 was still asking for morphine. The nurse called the pharmacy and the pharmacy said they did not have a prescription for morphine. So, the nurse called the doctor again and the doctor put the order in to the pharmacy. At 5:18 PM, V2 said the morphine was delivered on February 2, 2025 but did not know why R14 did not get morphine until February 3, 2025. V2 said if R14 was asking for more ibuprofen or asking for it early, then that meant that R14 was in pain. On February 4, 2025 at 9:16 AM, V4 RN said she called the doctor on Thursday night January 30, 2025. V4 said she asked the doctor to get the medication on board because she knows R14 would need them. V4 said she felt that R14 was declining rapidly. V4 said she put the order in the computer, and she knew the medication would not be at the facility until later the next day. V4 said R14's nurse came to her on Sunday February 2, 2025 and said R14 did not have morphine yet. V4 said she told the nurse that V4 would come help the nurse take the morphine out of the emergency box. V4 said staff was not able to take the morphine out of the emergency box because the pharmacy said the morphine was already on the delivery truck. R14's Medications Administration History dated February 1, 2025-February 4, 2025 shows an order for morphine was ordered to start January 30, 2024. This same document shows that R14 did not receive morphine until February 3, 2025 at 7:41 AM. This document also shows that R14 was actively dying at 7:41 AM, 10:05 AM, and 12:06 PM. R14 passed away at 12:30 PM. The facility's Pain Management Policy dated April 2020 shows, The goal is to facilitate resident independence, promote comfort and preserve resident dignity. Residents will be encouraged to report pain early so that pain management can be more effective. Nursing will address pain management issues as soon as they are brought to their attention. Physician or extender notification of inadequate pain management will occur. Nursing will inform the physician or extender about the admission, current (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 14 of 19 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 02/04/2025 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 0697 pain medications and the need for potential supplemental pain medications if appropriate. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 15 of 19 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 02/04/2025 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 - Few 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 follow the facility's posted menu for residents on a pureed diet for 3 of 7 residents (R5, R12, R19) reviewed for pureed diets in the sample of 13. The findings include: A facility list dated 2/2/25 showed R5, R12, and R19 received a pureed diet. The facility's lunch menu dated 2/2/25 showed residents were to be served servings of ham, spinach au gratin, sweet potatoes, a dinner roll, and pineapple cake. On 2/2/25 at 11:48 AM, R5's lunch tray was placed in front of him. Food items on his tray included pureed ham, spinach, sweet potatoes, and cake. No pureed roll or bread item was noted on his tray. At 12:20 PM, R5 was being fed by facility staff. No pureed roll or bread item was noted on his tray. On 2/2/25 at 12:21 PM, R12 and R19 were seated in the dining room being fed their pureed lunch by facility staff. No servings of a pureed roll or bread were noted on R12's or R19's lunch tray. On 2/2/25 at 1:15 PM, V3 Dietary Manager stated residents on pureed diets should receive the same food items as residents on regular diets. V3 stated she was not aware that R5, R12, and R19 had not gotten a pureed roll at lunch. The facility's Food: Quality and Palatability policy dated 9/2017 showed, The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 16 of 19 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 02/04/2025 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. Based on observation, interview, and record review the facility failed to maintain their kitchen in a clean and sanitary manner. The facility failed to ensure staff handled kitchen utensils in a manner to prevent cross contamination. These failures have the potential to affect all 46 residents in the facility. The findings include: The facility's Long-Term Application for Medicare and Medicaid form dated 2/2/25 showed a resident census of 46. On 2/2/25 at 9:26 AM, an initial tour of the facility's kitchen was conducted. During the tour, the following observations were noted: 1. Dried grease and food debris noted across the top of the stove, down the front of the ovens, and down the sides of the steamers. 2. Four, individual plastic quart containers, each containing dried cereal, were noted on one of the kitchen counters. Each lid, on the containers, appeared dirty and were sticky to the touch. A brown, sticky substance was noted on the side of one of the containers. 3. A plastic milk crate, noted on the bottom shelf of a rack next to the stove, was covered with grease and sticky food debris. On 2/2/25 at 10:25 AM, a second tour of the facility's kitchen was conducted. During this time, the following observations were noted: 1. Dried liquid and food debris was noted on the bottom shelf of the food prep table. 2. The lid and sides of the facility's commercial grade food processor were covered with a greasy substance. 3. The shelf under the facility's plate warmer rack was covered with salt packets and napkins. The packages of salt were opened with salt lying all over the shelf. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 17 of 19 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 02/04/2025 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 4. Level of Harm - Minimal harm or potential for actual harm Dried liquid and food debris was noted down the front and sides of the facility's steam table. 5. Residents Affected - Many A dirty oven mitt was on the floor under the steam table. On 2/2/25 at 11:22 AM, V3 Dietary Manager began placing food items on the steam table in the kitchen. Without washing her hands, V3 then walked over to a plastic bin containing miscellaneous scoops and kitchen utensils and began rummaging through the bin with her bare hands. V3 picked up multiple scoops with her bare hands and carried the scoops over to the kitchen steam table. V3 placed a scoop (each) into the containers of spinach, sweet potatoes, pureed spinach, pureed sweet potatoes, pureed ham, and mechanical soft ham. On 2/2/25 at 1:15 PM, V3 Dietary Manager stated kitchen staff are to wear gloves when handling kitchen utensils and/or dishes to prevent cross contamination. V3 stated the last time the facility's kitchen was deep cleaned was probably over a month ago. The facility's Food: Preparation policy dated 9/2017 showed, All staff will practice proper hand washing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful, physical, biological, and chemical contamination. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 18 of 19 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 02/04/2025 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 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review the facility failed to ensure certified nursing assistants (CNA) working in the facility received their annual abuse and dementia care training/education. Residents Affected - Many This failure has the potential to affect all 46 residents in the facility. The findings include: The facility's Long-Term Application for Medicare and Medicaid form dated 2/2/25 showed a resident census of 46. The facility's nursing schedule showed the following agency CNA's provided cares to residents in the facility: V7 CNA on 2/2/25 V8 CNA on 1/20/25-1/24/25 V9 CNA on 1/20/25, 1/23/25-1/31/25 On 2/4/25 at 7:39 AM, V2 Director of Nursing stated V7-V9 CNA's had not completed any abuse or dementia trainings in the last year. V2 stated V7-V9 are agency CNA's. I called their agency. They said (V7-V9 CNA's) had not received the trainings. They didn't attend our abuse or dementia trainings here. The facility's assessment (originally dated 8/18/2017; revised 2025) showed, We accept residents with the following diagnosis, diseases, and condition . Alzheimer's disease, dementia . Human Resources and Nursing Department strive to hire staff that have related health care experience. Training and education are provided upon orientation and throughout the year. The following areas are in the staff education and topics list: . abuse, neglect, exploitation . caring for persons with Alzheimer's or other dementia . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 19 of 19