Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to administer a resident's (R1) sodium tablets for 12 days
following his admission to the facility. This failure resulted in R1 experiencing a critically low sodium level,
confusion, hallucinations, and a 15 day hospital stay to correct his sodium levels. This applies to 1 of 3
residents reviewed for medications in the sample of 5.
Residents Affected - Few
The findings include:
R1's electronic face sheet printed on 7/8/25 showed R1 has diagnoses including but not limited to
permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic
kidney disease, and malignant neoplasm of bladder.
R1's census report showed R1 was admitted to the facility on [DATE], and discharged to a local hospital on
6/16/25. R1 did not return to the facility.
R1's local hospital discharge orders, dated 6/5/25, showed, NEW: Sodium Chloride 1gm PO (oral) QID (4
times per day) .Discontinued: sodium chloride 1,000mg PO TID (3 times per day) .
R1's physician's orders for June 2025 showed no orders for R1 to receive Sodium Chloride 1gm PO QID.
R1's medication administration record for June 2025 showed no evidence R1 ever received Sodium
Chloride during his stay at the facility from 6/5/25-6/16/25.
R1's nurse practitioner visit note, dated 6/9/25, showed: 4. SIADH- chronic- managed with sodium chloride
1gm po qid .
On 7/8/25 at 10:23AM, V4 (R1's son) stated, (R1) went to an appointment which required them to draw
blood and his sodium level was 115. The facility called my sister to let her know because she was at a
different appointment with (R1), and she took him to the emergency room. He went back to (local hospital)
where they had to slowly increase his sodium levels back up to normal. When she got him to (local
hospital), he was hallucinating and saying he was seeing people outside of his eyes and was completely
disoriented. I have no idea how she even handled him at the appointment. He knew he wasn't right, and he
told us he felt disoriented, and he knew he was hallucinating. It took 2 weeks in the hospital before they got
his levels regulated again. The orders were clearly on his discharge paperwork so I'm unsure why (facility)
never gave him his medications.
On 7/8/25 at 9:48AM, V5 (R1's Nurse Practitioner) stated, SIADH is usually the reason we see
(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
07/08/2025
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)
F 0760
Level of Harm - Actual harm
Residents Affected - Few
someone on a sodium replacement and that's what (R1) was getting it for. 10 days without the sodium tabs
could have detrimental effects and create a critically low sodium level which would put him at risk for
nausea, vomiting, increased confusion, and potentially seizures depending how low his sodium was. I never
saw what his labs were because he was out at an appointment at the time, and they drew the labs and got
the critical lab value. I saw him on 6/9/25 and nobody ever reported to me that he wasn't getting his sodium
tabs, so I assumed what I saw on the discharge report was being given because I certainly did not
discontinue his sodium tabs. I never received any notification that there were any issues with getting the
medication or entering it into the system.
On 7/8/25 at 9:57AM, V3 (Licensed Practical Nurse) stated, If my name was next to the orders for
admission then I must have been the nurse who admitted (R1), but I don't remember much about him.
When I do an admission, I look at discharge paperwork and reconcile the orders. Sometimes the hospital
will send the orders before the resident comes but it usually comes with the resident. I don't recall having
any issues entering any medications or not being able to find medications. If I was the nurse that put the
orders in, then there is another nurse from night shift that checks orders so someone besides me should
have caught this. If a resident is not receiving sodium as ordered, they could potentially have cardiac
effects. I can't really say much because I'm not a doctor or anything.
On 7/8/25 at 10:07AM, V2 (Director of Nursing) stated, When a resident is admitted , the floor nurse enters
the medications. Usually, it is the nurse from that hall but if another nurse is available, they will do it. Third
shift nurses are then responsible for double checking the discharge orders from the hospital and reconciling
it with our list. I remember (R1) a little bit, but he wasn't here long. He went to the hospital because of low
sodium and change in mental status. He was out at an appointment at the time we got the call about his low
sodium, so his daughter drove him to the hospital. I'm not even sure when the labs were done or what the
level was.
On 7/8/25 at 11:42AM, V2 stated, We were able to get the labs from the hospital and it showed (R1's)
sodium levels were 115 when he got to the hospital, which is a critically low level. He was confused and
hallucinating which are signs of low sodium. I have no idea how this order was missed when he was
admitted to the facility because 2 nurses checked the orders so it should have been caught. This is a
perfect example of a significant medication error.
R1's local hospital records showed, 6/16/25 Sodium 115 (Critical Lab Value) 6/17/25 119 (Critical Lab
Value) .
The facility's policy titled, admission of A Resident revised 01/04 showed, Objective: 1. To facilitate the
transition from prior living arrangement to long-term in a caring, professionally comprehensive manner
.Procedure .13. Obtain physician's orders .
The facility's policy titled, Medication Administration revised 02/04 showed, Objective: 1. To provide the
resident with those medications deemed necessary by the physician to improve and/or stabilize specified
diagnosis of the resident .Procedure .5. All physician's orders must be accurately transcribed to the MAR
(medication administration record). 6. All medications must be administered to the resident in the manner
and method prescribed by the physician. 7. In the event that a medication cannot be given, the reason must
be documented in the Nurses Medication Notes on the MAR (Medication Administration Record) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146102
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the July 8, 2025 survey of MANOR COURT OF FREEPORT?
This was a inspection survey of MANOR COURT OF FREEPORT on July 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MANOR COURT OF FREEPORT on July 8, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.