Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

STEPHENSON NURSING CENTER

FREEPORT, IL · 148 certified beds · Last Life Safety survey February 4, 2025

CMS Certification Number 145895 · first certified November 1996

Ownership

Independently operated (no chain recorded by CMS) · Government - County

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within IL

35 citations — more than 89% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 9 citations; the earlier surveys in the window averaged 13. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (January 2026 to March 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was February 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

Get an email about STEPHENSON NURSING CENTER

One email when it happens. No account; stop it any time with one click.

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

16 of the 35 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 35 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	35
Median facility in IL	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
December 8, 2022	12
January 18, 2024	14
February 4, 2025	9

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
E-0037	Establish staff and initial training requirements.	3	2025-02-04
E-0039	Conduct testing and exercise requirements.	3	2025-02-04
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	2	2025-02-04
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-01-18
E-0032	Provide primary/alternate means for communication.	2	2024-01-18
K-0920	Ensure proper usage of power strips and extension cords.	2	2025-02-04
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	1	2025-02-04
E-0015	Address subsistence needs for staff and patients.	1	2024-01-18

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 16
Smoke Deficiencies 7
Gas, Vacuum, and Electrical Systems Deficiencies 7
Egress Deficiencies 4
Other 1

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	16
Smoke Deficiencies	7
Gas, Vacuum, and Electrical Systems Deficiencies	7
Egress Deficiencies	4
Miscellaneous Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 4, 2025 — 9 citations

Citations issued on February 4, 2025
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (February 14, 2025)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (February 14, 2025)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (February 14, 2025)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (February 14, 2025)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (February 14, 2025)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (February 28, 2025)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (February 14, 2025)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (February 14, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 6, 2025)

January 18, 2024 — 14 citations

Citations issued on January 18, 2024
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (February 23, 2024)
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (February 23, 2024)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (February 23, 2024)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (February 23, 2024)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (February 23, 2024)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (February 23, 2024)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (February 23, 2024)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (February 23, 2024)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (February 23, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 23, 2024)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Deficient, Provider has date of correction (February 23, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 23, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (February 23, 2024)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (February 23, 2024)

December 8, 2022 — 12 citations

Citations issued on December 8, 2022
Tag	What the surveyor checks	Status
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (February 14, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (March 5, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (March 5, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (February 2, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 19, 2023)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (February 3, 2023)
K-0352	Properly install and monitor supervisory attachments on automatic sprinkler systems.	Deficient, Provider has date of correction (January 19, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 6, 2023)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (February 1, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (February 3, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 24, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 12, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.