Health inspection·February 26, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide a call light to a resident, and failed to provide supervision to a resident while up in her wheelchair. This applies to 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 6. The findings include: R2's electronic face sheet printed on 2/26/25 showed R2 has diagnoses including, but not limited to dementia with behaviors, hypertension, osteopenia, anxiety disorder, and pain. R2's facility assessment, dated 1/3/25, showed R2 has severe cognitive impairment and requires substantial/maximum staff assistance for transfers. The facility's accident/incident report showed R2 has experienced 9 falls within the past 6 months. R2's care plan, dated 7/8/24, showed, Resident at risk for falling related to need for safety reminders, occasional incontinence and generalized muscle weakness .alternate call light .when (R2) becomes agitated, remove from immediate area to a space that is quiet and calms her down, encourage (R2) to remain in a common area where staff are present to deter falls, staff to not leave her unattended, keep bed in lowest position . R2's nursing progress notes, dated 1/11/25 at 1:33PM, showed, Resident found lying on the floor next to her (reclining chair) in her room. aides report resident had been in room about 5 minutes prior to fall. No injuries noted. Vital signs within normal limits. No new complaints of pain or discomfort. Resident has been restless all day and was 1:1 supervision with nurses and activity from 0900-1130 On 2/26/25 at 10:15AM, R2 was laying in her bed, alert and oriented to person only. R2 stated she does not have a call light and doesn't know what she would do if she needed help. R2's call light was detached from the wall unit and no call light could be found around or near R2's bed. On 2/26/25 at 10:22AM, V6 (Certified Nursing Assistant) stated, (R2) does not use a call light so she does not need one in her room. (R2) has had recent falls and that staff are to keep an eye on her and make sure she is not left alone in her room when she is up in her chair. This intervention has been in place for a while for (R2) as she gets very agitated and restless and can easily fall out of her chair. She has a history of putting herself on the floor so that is why we keep an eye on her when she is up in her chair. (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 02/26/2025 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)