Health inspection·May 27, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff applied a gait belt for a resident who is high risk for falls. This failure resulted in R1 falling on the floor while ambulating without a gait belt and sustained a left femur fracture requiring surgical repair. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of 3. The findings include: R1's Final Serious Injury Incident Report dated 5/8/25 shows R1 is an [AGE] year-old female, alert and oriented x3. On 5/5/25 at 10:00 PM, (R1) sustained a fall while exiting the bathroom. V5 (Certified Nursing Assistant-CNA) was assisting (R1) back to the recliner after toileting. (R1) became weak and began to fall .(R1) complained of leg pain and was assessed by the nurse and sent out to the local hospital. R1 sustained a left femur fracture requiring surgical repair. R1's Fall Risk assessment dated [DATE] shows she is high risk for falls. R1 has balance problems while standing and walking, requires the use of assistive device, impaired mobility requires assist with toileting, and has a history of three or more falls in the last three months. On 5/27/25 at 9:05 AM, R1 was observed in her room lying in her bed. Dark and light purple and greenish bruising noted to R1's left forehead and bruising throughout her left forearm to above her elbow. A leg brace and ace wrap was in place to her left lower leg. R1 said she was coming out of the bathroom and fell down trying to get into her wheelchair. R1 said staff was with her but could not recall who. R1 said her legs gave out and once in a while her legs give out. R1 said she did not have a gait belt on and does not remember if she was lowered to the floor. R1 said she has a broken femur and cannot bear weight on her left leg; she is getting therapy in her room and now the staff use a mechanical lift to transfer her out of the bed. On 5/27/25 at 10:37 AM, V3 (Licensed Practical Nurse-LPN) said on 5/5/25, she was alerted by V5 (CNA) R1 fell after toileting. When she entered the room, R1 was laying on the floor outside of the bathroom, her head was partially under the wheelchair touching the top left wheel. R1 did not have a gait belt on, she had a hematoma on the outer side of her left knee with bruising. V5 asked me for a gait belt to assist R1 off the floor. R1's gait is not the greatest, she transfers with one person, walker, and gait belt. V3 does not recall where R1's walker was located. On 5/27/25 at 10:43 AM, V6 (CNA) said she was in another resident's room when V5 reported R1 was on the floor, and she needed help with transferring her. When she entered R1's room, R1 was lying on the floor in between the bathroom and her recliner chair. R1's wheelchair was positioned behind her, (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 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 05/27/2025 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)