Manor Court Of Freeport

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 (Resident R1) reviewed for notification in the sample of 3. The findings include: Resident R1's Face Sheet showed she was admitted to the facility on [DATE REDACTED]. The Face Sheet showed V5 was Resident R1's Healthcare Power of Attorney and Resident R1's Daughter (HPOA/POA). Resident R1's 9/22/25 Progress Note from 2:00 AM showed Resident R1 fell out of bed. Resident 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 Resident 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 Resident R1's Sister, V5's Aunt, on 9/22/25 sometime after 1:00 PM. V5 said her aunt had visited Resident R1 on 9/22/25 and during the visit Resident 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

Event ID:

Printed: 04/13/2026 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

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to safely transfer a resident with a mechanical lift following the resident's fall. This applies to 1 of 3 residents (Resident R1) reviewed for falls in the sample of 3. The findings include: Resident R1's Face Sheet showed she was admitted to the facility on [DATE REDACTED] with diagnoses to include but not limited to osteopenia (Low bone density), femur fracture, and gait abnormalities. Resident R1's 9/23/25 Quarterly Minimum Data Set (MDS) showed moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS showed Resident R1 had Range of Motion (ROM) limitations, both upper and lower, to one side of her body. The MDS showed she used a wheelchair for mobility. Resident R1's MDS showed she did not walk. Resident R1's 9/22/25 Progress Note from 2:00 AM showed Resident R1 fell out of bed. Resident R1 was assessed by the nurse and there were no injuries. On 10/9/25 at 12:29 PM, V8, Certified Nursing Assistant, stated he found Resident R1 on the floor next to her bed during his 2:00 AM rounds on 9/22/25. V8 stated he notified Resident R1's nurse (V6, Registered Nurse, RN) after which, V6 assessed Resident R1. V8 stated following V6's assessment, himself, V6, and another nurse put Resident R1 back to bed. V8 stated he picked up Resident R1 by her upper body and the other two nurses picked up Resident R1's lower body and placed her back in bed. On 10/9/25 at 1:41 PM, V9, Licensed Practical Nurse (LPN), stated she assisted Resident R1 back to bed following her fall. V9 stated herself, V8, and V6 lifted Resident R1 without a lift and placed her back in bed. On 10/10/25 at 8:15 AM, V6, RN, stated after Resident R1's fall herself, V9, and V8 placed Resident R1 on a blanket and used the blanket as a sling to lift Resident R1 and place her back in bed. V6 stated a mechanical lift was not used to transfer Resident R1 back in bed. On 10/20/25 at 8:48 AM, V2, Director of Nursing, stated after a fall, residents should be lifted off the ground with a mechanical lift. V2 stated this is to prevent resident injury. V2 stated bedding is not an approved lifting device and is not rated for resident transfer. V2 stated it would be possible for the staff to lose their grip on the bedding and drop the resident.

Event ID:

Facility ID:

If continuation sheet