Stephenson Nursing Center

• Star rating

  The CMS overall star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0686. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on July 13, 2026.

  CMS has cited this home for F0686 4 times since 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 13, 2026.

  CMS has cited this home for F0880 3 times since 2024.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.3 to 3.4 hours per resident per day.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

285 of 664 Illinois homes (43%) got a citation at the actual harm level in 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on February 27, 2026.

  CMS has cited this home for F0689 5 times since 2024.

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CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

285 of 664 Illinois homes (43%) got a citation at the actual harm level in 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 6, 2026.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on March 6, 2026.

  CMS has cited this home for F0812 3 times since 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on March 6, 2026.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on March 6, 2026.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on March 6, 2026.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on March 6, 2026.

  CMS has cited this home for F0690 2 times since 2025.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on March 6, 2026.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 6, 2026.

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CMS fine of $18,450 on February 26, 2026.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Health citation

  CMS removed citation F0689 from the health inspection on May 27, 2025.

• Health citation

  CMS removed citation F0755 from the health inspection on April 3, 2025.

• Health citation

  CMS removed citation F0609 from the health inspection on July 2, 2024.

• Health citation

  CMS removed citation F0689 from the health inspection on July 2, 2024.

• Health citation

  CMS removed citation F0609 from the health inspection on April 30, 2024.

• Health citation

  CMS removed citation F0610 from the health inspection on April 30, 2024.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.

• Citation F0628. Severity G: actual harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on June 20, 2025.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 2, 2025.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.7 to 2.9 hours per resident per day.

CMS lists this as a complaint inspection.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on April 11, 2025.

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CMS stopped payment for new admissions from February 26, 2025, for 114 days.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.

• Citation F0697. Severity G: actual harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on February 28, 2025.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on February 7, 2025.

• Citation F0947. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on February 28, 2025.

• Citation F0604. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on March 7, 2025.

• Citation F0602. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from the wrongful use of the resident's belongings or money.

  CMS lists it as corrected on February 28, 2025.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on February 28, 2025.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on February 28, 2025.

  CMS has cited this home for F0609 4 times since 2024.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on February 28, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on February 28, 2025.

  CMS has cited this home for F0684 2 times since 2024.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on February 28, 2025.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on February 28, 2025.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on February 7, 2025.

  CMS has cited this home for F0803 2 times since 2024.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on February 14, 2025.

  CMS has cited this home for E0004 2 times since 2024.

• Citation E0013. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop Emergency Preparedness policies and procedures.

  CMS lists it as corrected on February 14, 2025.

• Citation E0026. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on February 14, 2025.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on February 14, 2025.

  CMS has cited this home for E0037 3 times since 2022.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on February 14, 2025.

  CMS has cited this home for E0039 3 times since 2022.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 28, 2025.

• Citation K0293. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on February 14, 2025.

• Citation K0351. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on February 14, 2025.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on February 6, 2025.

  CMS has cited this home for K0920 2 times since 2022.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Fine

  CMS changed the fine from December 8, 2022 from $15,555 to $15,881.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Fine

  CMS changed the fine from December 8, 2022 from $15,000 to $15,555.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on July 19, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on July 19, 2024.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 13, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on May 13, 2024.

  CMS has cited this home for F0610 2 times since 2024.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Fire safety citation

  CMS removed citation K0353 from the fire safety inspection on January 24, 2024.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on February 10, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 10, 2024.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on February 10, 2024.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on February 10, 2024.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on February 10, 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 7, 2024.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on February 10, 2024.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on February 23, 2024.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on February 23, 2024.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on February 23, 2024.

• Citation E0024. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on February 23, 2024.

• Citation E0032. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on February 23, 2024.

  CMS has cited this home for E0032 2 times since 2022.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on February 23, 2024.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on February 23, 2024.

• Citation E0041. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement emergency and standby power systems.

  CMS lists it as corrected on February 23, 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on February 23, 2024.

  CMS has cited this home for K0918 2 times since 2022.

• Citation K0926. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

  CMS lists it as corrected on February 23, 2024.

• Citation K0281. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install proper backup exit lighting.

  CMS lists it as corrected on February 23, 2024.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on February 23, 2024.

• Citation K0916. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have a battery powered remote alarm panel in a location accessible by operating personnel.

  CMS lists it as corrected on February 23, 2024.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on February 23, 2024.

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CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on January 21, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on January 21, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on January 21, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on January 21, 2024.

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CMS lists this as a complaint inspection.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on December 19, 2023.

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CMS lists this as a standard inspection.

• Citation E0032. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on February 14, 2023.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on March 5, 2023.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on March 5, 2023.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on January 19, 2023.

• Citation K0352. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly install and monitor supervisory attachments on automatic sprinkler systems.

  CMS lists it as corrected on January 19, 2023.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on February 6, 2023.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on February 3, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 24, 2023.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on February 2, 2023.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on January 12, 2023.

• Citation K0346. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on February 3, 2023.

• Citation K0354. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on February 1, 2023.

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