Stephenson Nursing Center
Freeport, Illinois · CCN 145895
47 surveys since 2011, 19 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 166
- Surveys
- 47
- Harm or worse
- 19
- Immediate jeopardy
- 5
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 148
- Ownership
- Government - County
- Chain
- Independent
- County
- Stephenson · rural
- Medicare-certified since
- 1996
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 2
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 259 facilities with 128 or more beds in Illinois.
Last survey on record
Jul 7, 2026
125 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.06 | 4.11 |
| Registered-nurse hours per resident day | 0.89 | — |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $18,450 across 1 penalty
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G510.6% | H— | I— |
| No harm, potential for more than minimal | D3268.1% | E510.6% | F510.6% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6865×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F6895×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6094×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F8804×
Provide and implement an infection prevention and control program.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
In the surveyor’s words
From the most serious findings on record at Stephenson Nursing Center, in the surveyor’s own words.
- Immediate jeopardy, widespreadF880May 12, 2021
Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Centers for Disease Control and Prevention (CDC) regarding isolation of new admissions to rule out COVID-19. This has the potential to effect all residents in the facility and has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 05/10/21 when V4 (Certified Nursing Assistant) entered R193's room without a N95 mask or eye protection on. The Immediate Jeopardy was identified on 5/11/2021. V1 (Administrator) was informed of the Immediate Jeopardy on 05/11/21. […]
- Actual harm, isolatedF689Mar 17, 2026
Based on interview and record review the facility failed to supervise a resident at risk for falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 6. This failure resulted in R1 sustaining a left hip fracture. This past compliance occurred from 2/22/26 to 2/23/26. Past noncompliance-no plan of correction required. The findings include:R1's admission Record (Face Sheet) showed an Original admission date of 11/18/25 with diagnoses to include but not limited to Alzheimer's dementia, unsteadiness of feet, weakness, and rheumatoid arthritis. R1's 2/28/26 Minimum Data Set (MDS) showed she was unable to complete the Brief Interview for Mental Status test, and she has both short and long-term memory problems. […]
- Actual harm, isolatedF689Feb 26, 2026
Based on observation, interview, and record review the facility failed to ensure a safe mechanical lift transfer for a resident (R11) dependent upon staff for transfers. This failure resulted in R11 sustaining a right fracture. The facility also failed to ensure a stable chair was provided for a resident (R16) to prevent falls. These failures apply to 2 of 5 residents reviewed for safety and supervision in the sample of 38. The findings include:1. R11's face sheet showed she was admitted to the facility 11/27/2017 with diagnoses to include spastic hemiplegic cerebral palsy, major depressive disorder, hypertension, and primary generalized osteoarthritis. R11's facility assessment dated [DATE] showed she has moderate cognitive impairment and is dependent upon staff for transfers. […]
- Actual harm, isolatedF628Jun 4, 2025
Based on interview and record review the facility failed to ensure discharge services were in place prior to discharging a resident to independent senior housing who requires assistance with activities of daily living. This failure resulted in R1 being found in her apartment soiled in urine and feces and unable to get out of bed. This applies to 1 of 3 (R1) residents reviewed for discharge in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnosis including osteoarthritis left hip, abnormalities of gait and mobility, type 2 diabetes unspecified dementia and cognitive communication deficit. R1's face sheet shows she was admitted to the facility on [DATE] and discharged on 5/30/25. […]
- Actual harm, isolatedF689May 27, 2025
Based on observation, interview, and record review the facility failed to ensure staff applied a gait belt for a resident who is high risk for falls. This failure resulted in R1 falling on the floor while ambulating without a gait belt and sustained a left femur fracture requiring surgical repair. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of 3. The findings include: R1's Final Serious Injury Incident Report dated 5/8/25 shows R1 is an [AGE] year-old female, alert and oriented x3. On 5/5/25 at 10:00 PM, (R1) sustained a fall while exiting the bathroom. V5 (Certified Nursing Assistant-CNA) was assisting (R1) back to the recliner after toileting. […]
Read 34 findings in full →The most serious and the most recent: 34 of 166 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 7, 2026Complaint2 findings
- Mar 17, 2026Complaint1 finding · 1 harm
- Feb 26, 2026Standard8 findings · 1 harm
- Jun 4, 2025Complaint1 finding · 1 harm
- May 27, 2025Complaint1 finding · 1 harm
- Apr 3, 2025Complaint1 finding
- Feb 4, 2025Standard and complaint12 findings · 1 harm
- Jul 2, 2024Complaint2 findings
Show the 39 earlier surveys
- Apr 30, 2024Complaint2 findings
- Jan 18, 2024Standard7 findings
- Jan 9, 2024Complaint4 findings
- Dec 12, 2023Complaint1 finding
- Jan 23, 2023Complaint2 findings · 2 harm
- Dec 22, 2022Complaint2 findings
- Dec 8, 2022Standard5 findings
- Apr 7, 2022Complaint1 finding
- Mar 3, 2022Standard11 findings · 1 harm
- Jan 31, 2022Complaint1 finding
- Sep 30, 2021Complaint2 findings
- May 12, 2021Standard4 findings · 1 harm
- Dec 22, 2020Complaint1 finding
- Dec 1, 2020Complaint2 findings
- Oct 26, 2020Complaint3 findings · 2 harm
- Sep 24, 2020Complaint1 finding
- Mar 11, 2020Complaint1 finding
- Nov 8, 2019Standard11 findings
- Apr 25, 2019Complaint5 findings · 3 harm
- Feb 6, 2019Complaint1 finding
- Dec 14, 2018Standard8 findings · 2 harm
- May 9, 2018Complaint4 findings
- May 1, 2018Complaint1 finding
- Jan 31, 2018Standard10 findings
- Jan 12, 2018Complaint2 findings
- Nov 21, 2017Complaint1 finding
- Feb 16, 2017Standard4 findings
- Apr 12, 2016Complaint2 findings
- Mar 3, 2016Standard9 findings
- Jul 29, 2015Complaint1 finding
- Jan 20, 2015Standard6 findings
- Nov 13, 2014Complaint1 finding
- Mar 17, 2014Complaint1 finding · 1 harm
- Dec 26, 2013—2 findings
- Feb 27, 2013—3 findings
- Jan 27, 2012—7 findings · 1 harm
- Jun 28, 2011—1 finding · 1 harm
- Apr 13, 2011—1 finding
- Mar 11, 2011—7 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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