Health inspection·June 4, 2025

F 0628 Level of Harm - Actual harm Residents Affected - Few standby assist with ambulation. R1 was referred to home health services for therapy. V3 said V3 sent the referral but is not sure if R1 is receiving those services. V3 said R1 was calling her throughout the weekend. R1 reported she was doing okay, and V3 has not heard from her since Monday. On 6/4/25 at 9:59 AM, V4 (Restorative Nurse) said she was part of R1's discharge meeting. V3 coordinates the equipment and home health services, and V4 coordinates with therapy and assesses a residents mobility prior to discharge. V4 said, R1 was alert with forgetfulness. By the time of discharge, she (R1) could walk with her walker and required supervision with transfers and was incontinent. V4 said the day of R1's discharge V4 felt uncomfortable about R1's discharge. V4 asked V1 (Administrator) if she could meet R1 at her apartment. V4 said R1 had the facility's walker and did not have her own walker with her prior to discharge. A senior bus picked up R1 to transport her to her apartment and V4 met R1 at her apartment. V4 said she was concerned about R1 getting to her apartment safely so that's why V4 met R1 there. V4 said she assisted R1 off the bus and sat her on a bench and went to get a wheelchair because it was a long walk to her apartment and R1 did not have her walker. V4 said before she left R1's apartment, V4 asked the facility about visiting hours and was told visitors are buzzed in on the phone. R1 did not have a phone with her. V4 said she left R1 and bought a cell phone for her and dropped it off at her apartment. V4 said she was told the independent living center does not have any staff to assist with any care needs. V4 said V11 expressed concerns about R1's discharge but stated, well she (R1) was already there, what are we supposed to do. V4 said she reassured V11 that R1 is capable of doing what she needs to do. R1 can transfer herself, ambulates with walker, and was incontinent of urine. On 6/4/25 at 10:35 AM, V6 (Registered Nurse-RN) said prior to discharge there should discharge planning in place to ensure a resident's needs are set up, the floor staff gets a discharge list about one week prior to discharge. V6 said R1 was alert with forgetfulness. R1 could get up and transfer herself, she self-propelled in the wheelchair and was incontinent. V6 said sometimes R1 would refuse therapy or assistance from staff at times. V6 said V6 thought R1 was being discharged to assisted living setting. V6 said, I don't know if R1 was safe to be discharged to independent living. On 6/4/25 at 12:47 PM, V5 (Director of Therapy) said R1 had multiple refusals with therapy and was non-compliant, R1 was strong-willed and worked with therapy when she allowed us to. V5 said R1 made progress initially in therapy and then she flat lined. R1 lacks safety awareness of her deficits, poor safety, she could ambulate with the walker with standby by assist and would self-propel herself in the wheelchair. V5 said R1 had not practiced going up and down stairs, R1 would refuse services to work with stairs. V5 said, We had concerns about her safety to go home to an independent setting. I'm not sure if any staff reached out to her (R1's) family. R1 would be more appropriate for assisted living or long term care. On 6/4/25 at 1:06 PM, V3 (SSD) said she did not communicate with home health services of R1's new phone number so they could call R1 to set up the service. She does not know if R1's caregiver service has been reinstated and did not know she needed assistance with meals. On 6/5/25 at 10:00 AM, V10 said senior housing apartments are for elderly residents ages [AGE] years old and above. V10 said, They should be independent for all their activities of daily living, including cooking, dressing, transfers, ambulating, and housekeeping needs. V11 (Senior Housing Social Worker) expressed concerns to the facility regarding R1 not being fully independent with activities of daily living. The facility asked if we could pick up R1 to transport her home, we explained we do not provide transportation services. They asked if we could assist R1 off the senior bus, we explained we do not have caregivers to assist with cares. We do not have staff or provide services for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 2 of 3 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 06/04/2025 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 0628 Level of Harm - Actual harm Residents Affected - Few residents we only provide housing. V11 re-instated R1's caregiver service through the senior center and the caregiver arrived on 6/3/25. On 6/3/25, R1 would not answer the door so she (V11) went to open R1's door with the caregiver and found R1 soiled in bed (appeared to be in bed from the previous day). On 6/5/25 at 10:15 AM, V11 (Senior Housing Social Worker) said she went to the facility on 5/28/25 (two days prior to R1's discharge) to talk to R1. V11 asked R1 how therapy was going and how R1 was doing with her activities of daily living. V11 said she spoke with V3 and told V3 the senior housing facility does not offer any assistance with activities of daily living. There are no staff to assist R1 with ADL's, cooking or housekeeping services. V11 asked V3 about R1's transfer status and was told R1 was being discharged on Friday 5/30/25. V11 said the facility was aware of R1's home setting. V11 reminded V3 they only offer housing and no other services. Residents should be independent, and any outside services should be set up prior to discharge. V11 said V3 asked if someone one could assist R1 off the bus the day of discharge and V11 questioned R1's ability getting in and out of the bus. V11 said the day of R1's discharge, the facility asked for assistance to get R1 into her apartment and V11 told the facility again they cannot provide hands on assist with cares. V11 said the facility was well aware of R1's living situation and expressed V11's concerns to V3. On 6/3/25, R1 was found in her apartment soiled with urine and feces (appeared she had been in bed from the previous day) and unable to get out of bed. V11 said the facility should communicate with us the services a resident needs and should be set up prior to discharge. V11 said R1 required meals on wheels, caregiver services and had not been seen by PT/OT. R1's Communication/Order Sheet dated 5/23/25 shows orders including discharge home with current medications, in home PT (Physical Therapy)/OT (Occupational Therapy) services, and four wheeled walker. R1's Discharge Meeting Care Plan Record dated 5/29/25 shows V3 (Social Service Director), V4 (Restorative Nurse) and R1 in attendance. R1's Discharge Plan Notice Form dated 5/30/25 shows R1's discharge date of 5/30/25 to her home apartment and a standard walker has been ordered. R1's Care Conference Report provided on 6/4/25 shows on 5/28/25 faxed documents to set up PT/OT services. On 5/29/25, R1's discharge meeting was held. On 5/29/25, V3 called to inform V10 and V11 that R1 would be discharging on 5/30/25 and asked if they could be looking out for R1 to get off the bus. V10 shared V11 would call V3. On 5/30/25, V4 followed R1 home to assist her off the bus and into her apartment. On 5/30/25, V3 called case manager to inform her R1 had been discharged home in the community so that her care giver service could be reinstated. The facility's Discharge Instructions Policy states, Upon admission and throughout the resident admission, the Social Service Representative, with the involvement of the interdisciplinary team, will review the discharge needs of each resident, and develop a discharge plan, and communicate and finalize discharge instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145895 If continuation sheet Page 3 of 3