Inspection·August 19, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few forehead with soap and water. Three sutures noted and a hematoma formed. Upon investigation, it was determined that when R1 was being transported in her wheelchair, she had firmly placed her feet on the floor, which resulted in her falling forward out of her wheelchair. On 8/19/25 at 8:47 AM, V1 (Administrator) stated, (V2, Director of Nursing/DON), did the incident investigation. (R1) was going to pull the fire alarm and (V3, Certified Nursing Assistant/CNA) went to stop her. (V3) moved (R1), and when she did this, the resident planted her feet on the floor. This caused a forward motion. (R1) fell out of her wheelchair and hit her head. (R1) had a laceration to her head. V1 stated when he came to the facility in September 2024, he did training/in servicing with the staff about using foot pedals when pushing a resident in their wheelchair. V1 stated it is his rule for resident safety. (V3) did not follow the rule for resident safety. (V3) didn't follow the procedure. When someone plants their feet, then staff should stop immediately right there and call for help, and put the foot pedals on. It is done for the resident's safety.On 8/19/25 at 9:17 AM, V3, CNA, stated, (R1) was having behaviors all day, and she was exit-seeking. (R1) did not have foot pedals on her wheelchair because she moves around in her chair on her own. (R1's) wheelchair is reclined in back a little, but she doesn't sit all the way back in it; she never does. I went to move (R1) away from the door and when I turned (R1) around, she planted her feet. (R1) fell out of her wheelchair. (R1) did not have any foot pedals assigned to her.2.R4's Face Sheet, dated 8/19/25, showed vascular dementia, parkinsonism, atherosclerotic heart disease, long term use of antithrombic/antiplatelets, hyperlipidemia, overactive bladder, retention of urine, pain, vitamin deficiency, abdominal pain, depression, anticoagulant use, elevation of levels of lactic acid dehydrogenase, constipation, shortness of breath, vomiting, and hypoxemia.R4's MDS, dated [DATE], showed severe cognitive impairment; partial/moderate assistance needed for toileting, upper body dressing, personal hygiene, and wheeling in a manual wheelchair 50 feet. R4's Care Plan, dated 6/27/25, showed resident is at risk for falling related to need for staff assist with daily activities and well as safety reminders. Staff assist of one with walker or grab bar for pivot transfers. Instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Orientate resident to room, surrounding areas, and use of call light system. Encourage resident to use side rails/enablers as needed. Provide resident with specialized equipment i.e. walker and wheelchair. Assist resident with activities of interest. On 8/19/25 at 11:31 AM, V4, CNA, brought R4 into the dining room. V4 was pushing R4 in his wheelchair without any foot pedals in place. On 8/19/25 at 11:39 AM, V4 stated when pushing residents in the wheelchair, they should have the footrests on their chairs. V4 stated there is a blue bag on the back of the chair that holds the footrests. V4 she is supposed to use them, just got in the moment, and forgot. All residents should have a bag on the back of their wheelchair with the footrests in them. V4 stated they are supposed to use them for the resident's safety.3.R5's Face Sheet, dated 8/19/25, showed diagnoses including Peripheral vascular disease, unspecified hypertensive urgency, dysphagia, left sided weakness, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with necrosis of muscle, laceration without foreign body, left foot, subsequent encounter, atrial septal defect, unspecified, hypomagnesemia, left wrist contracture, hypertension, abnormal posture, dysarthria and anarthria, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder due to known physiological condition, constipation, long term (current) use of antithrombotic/antiplatelets, and cognitive communication deficit.R5's MDS, dated [DATE], showed severe cognitive impairment; dependent for toileting, shower/bath, upper body dressing, lower body dressing, persona hygiene, and wheeling in a manual wheelchair 150 feet; partial/moderate assistance wheeling in a wheelchair 50 feet. On 8/19/25 at 11:33 AM, V5, Licensed Practical Nurse (LPN), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146102 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 146102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pushed R5 into the dining room in his low padded wheelchair. R5's foot was sliding across the floor when she was pushing him. There wasn't a footrest in place. V5 stated she did not know why there wasn't a footrest on his chair; his chair would not have footrests like a regular wheelchair. V5 stated when residents are pushed in their wheelchairs, the foot pedals are supposed to be on the chair. V5 stated there is a blue bag on the back of the wheelchairs that holds the foot pedals. V5 stated the foot pedals should be used for residents' safety.4.R6's Face Sheet, dated 8/19/25, showed diagnoses including cerebral infarction, spinal stenosis, dysarthria following cerebral infarction, muscle weakness, unspecified fall, subsequent encounter, aphasia following cerebral infarction, dysphagia following cerebral infarction, hypertension, other abnormalities of gait and mobility, hyperlipidemia, benign prostatic hyperplasia without lower urinary tract symptoms, (osteo)arthritis, pain, insomnia, constipation, and long term (current) use of antithrombotic/antiplatelets.R6's Care Plan, updated on 8/4/25, showed: Resident at risk for falling related to generalized muscle weakness and need for staff assist with daily cares. Staff assist of two with stand aid for transfers with arm sling on right arm, high-profile toilet to aid in rest room use. Provide resident with specialized equipment, wheelchair, walker. Instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Orientate resident to room, surrounding areas, and use of call light system. Encourage resident to use side rails/enablers as needed. Assist resident with activities of interest.R6's MDS, dated [DATE], showed moderate cognitive impairment; substantial/maximal assistance needed for toileting and lower body dressing; Partial/moderate assistance needed for shower/bath, upper body dressing, personal hygiene, and wheeling in a manual wheelchair 150 feet. On 8/19/25 at 11:37 AM, R6 did not have footrests on his wheelchair when V4, CNA, was pushing him into the dining room for lunch.On 8/19/25 at 11:39 AM, V4 stated when pushing residents in the wheelchair, they should have the footrests on their chairs. V4 stated there is a blue bag on the back of the chair that holds the footrests. V4 she is supposed to use them, just got in the moment, and forgot. All residents should have a bag on the back of their wheelchair with the footrests in them. V4 stated they are supposed to use them for the resident's safety.On 8/19/25 at 12:23, V1 (Administrator) stated he did not have a policy for footrests being on wheelchairs when he did the in-service and training. V1 stated corporate told him there was a policy; so he did the in servicing. V1 stated he ordered the blue bags for the back of the wheelchairs to hold the footrests. At 12:26 PM, V1 stated V2, Director of Nursing (DON), contacted the corporate nurse who told her there wasn't a policy related to footrests, but all wheelchairs should have them. The In-Service Education/Meeting Report, dated 7/28/25, showed, this is our policy and for their safety. All residents that are using a wheelchair must have wheelchair peddles. If for any reason you need to push a resident in a wheelchair, they must have pedals on at all times. If you don't have pedals, you don't push them.The facility's Safe Resident Handling policy (11/2012) showed the facility is dedicated to providing quality care to residents who have entrusted their lives to us and provide a work environment that is safe and enjoyable to staff. Our Safe Resident Handling Program is designed to meet the following goals: Protect staff and residents from injury. All residents will be assessed for safe resident handling and moving. The assessment will consider: Staff and resident safety. The facility's Geriatric Chairs policy (2/2004) showed, adjust foot pieces. On 8/19/25, the facility did not have a policy regarding the use of foot pedals on wheelchairs. Event ID: Facility ID: 146102 If continuation sheet Page 3 of 3