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
interview and record review, the facility failed to ensure a resident was wearing non-skid footwear and was
being held by the gait belt when being transferred/ambulated for 1 of 3 residents (R1) reviewed for safety
and supervision in the sample of 3 residents. This failure resulted in R1 falling and sustaining a rib fracture,
two transverse process fractures of the lumbar vertebrae, and a skin tear.
The findings include:
R1's Face Sheet, dated 11/25/24, shows R1 was admitted to the facility on [DATE]. R1's diagnoses include,
but are not limited to, fracture of neck of right femur (hip), presence of right artificial hip joint, Parkinson's
disease, muscle weakness, unsteadiness on feet, pain, and an unspecified fall.
R1's Fall Risk, dated 10/2/24, shows R1 was a high fall risk.
R1's Care Plan (problem start date 10/3/24) shows R1 is at risk for falling.
The facility's Event Report, completed 11/20/24 at 3:26 PM, shows R1 had a fall on 11/19/24 at 9:42 PM in
his room. The report shows R1 feels he fell because he slipped as the CNA was transferring him to bed. R1
complained of pain to his left ribs and a skin tear was noted. Evaluation Notes from the report state,
Encourage use of non-skid footwear for transfers and ambulation.
R1's Progress Notes, dated 11/19/24 at 9:24 PM, shows the nurse observed R1 lying on his backside on
the floor in his room. R1 reported he slipped when transferring to his bed without wearing shoes. R1 said he
hit his back and head and felt like he cracked a rib.
R1's Progress Notes, dated 11/19/24 at 11:04 PM, shows facility staff spoke to a nurse at the hospital and
were informed R1 fractured his left posterior twelfth rib and left lumbar vertebrae (L3 and L4) transverse
process and sustained a skin tear on his left arm.
R1's CT abdomen and pelvis without contrast study, dated 11/19/24 at 10:33 PM, shows the following:
Impression: Left posterior 12th rib fracture. Left L3 and L4 transverse process fractures.
On 11/25/24 at 9:20 AM, V3, Licensed Practical Nurse, said she was doing her med pass and the shift
coordinator, V6, reported a resident was on the floor. V3 said V4, Certified Nursing Assistant (CNA), was in
the room with R1 when she arrived. V3 said R1 was lying on his back on the floor and had a skin tear on his
left forearm. V3 said R1 was wearing regular socks, they are slippery socks and no
(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:
146102
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
146102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Freeport
2170 West Navajo Drive
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
shoes. V3 said R1 said it felt like his rib cracked. V3 said R1 told her he slipped. V3 said she was, not sure
why they would put a gait belt on him and not shoes.
Level of Harm - Actual harm
Residents Affected - Few
On 11/25/24 at 11:22 AM, V4 said she was assisting R1 from his recliner to his bed. V4 said R1 stood up
and took a couple steps with his walker and fell back and sideways into the window. V4 said it happened so
fast she was unable to catch him. V4 said she was not holding onto R1's gait belt when he fell, she just had
her hands on his waist and was guiding him. R1 was wearing socks and no shoes. When asked if she
would have done anything differently, V4 replied she would have made sure R1 had shoes on, and would
have held on to him tighter.
On 11/25/24 at 11:42 AM, V2, Director of Nursing (DON), said V4 told her she was transferring R1 to his
bed, and R1's feet started slipping and she could not catch him from falling. V2 said after investigating R1's
fall, she educated staff to make sure they are holding on to the gait belt, and to be cognizant about what the
residents are wearing.
On 11/25/24 at 12:19 PM, V5, Assistant DON, said V5 said R1 was a fall risk. V5 said they treat everyone
as if they are a fall risk and they use a fall risk scale (John Hopkins Fall Risk Assessment Tool) to identify
residents who are at a higher risk for falls. V5 said all residents should have non-skid socks or shoes on
when they get up.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146102
If continuation sheet
Page 2 of 2
