Health inspection·October 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's Power of Attorney after the resident fell from her bed. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 3. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE]. The Face Sheet showed V5 was R1's Healthcare Power of Attorney and R1's Daughter (HPOA/POA). R1's 9/22/25 Progress Note from 2:00 AM showed R1 fell out of bed. R1 was assessed by the nurse and there were no injuries. Will call POA (Power of Attorney)/Emergency contact around 6:00 AM. (Note was authored by V6, Registered Nurse.) On 10/9/25 at 10:26 AM, V5 stated she was furious because she had not been notified of R1's fall on 9/22/25. V5 stated it is her expectation to be notified of any changes immediately after a regardless of the time. V5 stated, I need to know what's going on with my mom. V5 stated she was notified of the fall by R1's Sister, V5's Aunt, on 9/22/25 sometime after 1:00 PM. V5 said her aunt had visited R1 on 9/22/25 and during the visit R1 had mentioned the fall to her sister. V5 stated her aunt then called her after the visit and notified her of the fall. On 10/10/25 at 8:15 AM, V6 stated she did document she would call V5 at 6:00 AM and she forgot to call V5. V6 stated she believed V5 was notified later that day by the nurse on duty. On 10/10/25 at 8:48 AM, V2, Director of Nursing, stated, Family should be notified immediately for any changes in condition including falls. Notification is important so family members can make informed decision regarding the care of the resident. V2 stated V6 should have called V5 immediately after the fall. The facility's Fall Information Acknowledgement (Adopted 3/2012) showed, Those residents, who fall, shall have the following steps taken: Notify the Physician, Notify the POA. 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 10/10/2025 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)