Health inspection·January 9, 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 Based on observation, interview, and record review, the facility failed to ensure a safe transfer by not using a gait belt for one resident, (R3), and failed to ensure one resident (R1) was safely transferred. This failure resulted in R1 falling during a staff assisted transfer and sustaining multiple lacerations to her head requiring sutures. This applies to 2 of 3 residents (R1 and R3) reviewed for safety in the sample of 3. The findings include: 1. R1's Care Plan shows, Transfer Program: 1. Set up devices for transfer. 2. Encourage [R1] to stand using chair arms or edge of bed to push off from and come to a standing position. 3. Encourage [R1] to turn using walker until back of body is in front of source to transfer to. 4. Encourage [R1] to reach back and place hands on chair arms or edge of bed prior to sitting. 5. Encourage [R1] to sit down slowly. R1's Emergency Department Note, dated 1/3/25, shows, Pt (Patient) states she fell while getting out of bed. Pt has laceration to forehead Patient hit her face on the ground. She presents with a laceration type injury to her left forehead as well as underneath her left orbit. She complains of pain at the laceration site Laceration 1 .Forehead .left .7 cm (centimeters) .7 sutures Laceration 2 .under left orbit .4 cm 4 sutures On 1/9/25 at 8:55 AM, R1 was sitting in a wheelchair in her room. R1 had a laceration to the left side of her forehead, with sutures in place, and a laceration to under her left eye, with sutures in place. There was yellow/purple bruising around both lacerations. R1 stated, I fell out of bed. On 1/9/25 at 9:43 AM, V4, Certified Nursing Assistant (CNA) said she went into R1's room the morning of 1/3/25 to get R1 up to the shower. V4 said she assisted R1 to sit on the side of the bed and put on R1's slippers. V4 said she applied a gait belt on R1, and positioned her wheelchair near her bed. V4 said she positioned herself between the side of the bed and the wheelchair, placed her right hand onto the gait belt, and had R1 stand up. V4 said R1 took one or two steps to turn to sit in her wheelchair when she fell forward. V4 said her hand slipped off of the gait belt due to the force, so she was unable to assist her to the floor. V4 said she fell forward and hit her head on the floor. V4 said R1 was not using a walker during the transfer. On 1/9/25 at 11:00 AM, V7 (Physical Therapy Assistant) said staff should always use a gait belt when assisting a resident with a transfer for the resident's safety. V7 said if a resident starts to fall, the staff member can either prevent the fall or assist them to the ground in a controlled manner to try and prevent any injuries. V7 said staff should be holding the gait belt during the entire (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 01/09/2025 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)