Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Dekalb during CMS and state inspections, most recent first.
The facility failed to maintain the south shower room in a safe, sanitary, functional, and comfortable condition for residents on the south wing. Multiple residents reported that the south shower provided only cold to lukewarm water and chose to use the north shower instead. Staff, including LPNs, a CNA, and an activities aide, described longstanding black spots on the walls and ceiling, a musty odor, and lack of warm water, stating that residents complained and often refused to use the room despite it still being used at times. The Maintenance Director observed widespread black growth and a rusted vent grate, linked the problem to a previously nonfunctioning exhaust fan, and measured shower water temperatures in the 80s–90s°F even after running for several minutes, while a nearby sink reached 109°F. The DON reported being unaware of these issues despite using the room, and the Administrator acknowledged seeing the black spots and rusted vent and confirmed there were no general maintenance or mold policies available.
A resident with dementia, a history of falls, recent fractures, severe cognitive impairment, and dependence for transfers experienced multiple unwitnessed falls after being moved to a room far from the nurses’ station. The care plan and fall prevention program called for placement in highly visible areas and close monitoring, and staff acknowledged the resident frequently attempted unassisted transfers and could not reliably use the call light. On the night of one fall, several CNAs did not know when the resident returned to her room or did not enter the room, and the fall was only discovered after the resident was found on the floor with a knee abrasion, demonstrating inadequate supervision and inconsistent implementation of fall-prevention interventions for this high-risk resident.
Two residents did not receive or have documented wound care as ordered, with multiple missed entries on the TAR and no explanations in progress notes. One resident reported that staff were sometimes too busy to perform wound treatments, and the facility could not provide a wound care policy when requested.
Two residents did not receive their prescribed medications due to pharmacy rejections and lack of communication among staff. In one case, a nurse borrowed medications from other residents and administered the wrong formulation and dose, while in another, a resident missed multiple doses of a bladder medication without being notified. Facility policy prohibiting such practices was not followed, and the DON was not informed of the medication issues.
Dietary staff, including aides and a cook, were observed preparing and handling food without having completed the required food handler training within thirty days of hire. Two aides had been employed for three months without certification, and there was no facility policy in place to ensure compliance with this requirement. The administrator was aware of the lapse, and documentation confirmed the missing certificates, affecting all residents receiving meals from these staff.
A resident with a surgical wound did not receive wound care as ordered, with daily iodoform packing omitted and care provided only three times a week. This deviation from prescribed treatment led to worsening of the wound, increased drainage, infection, and ultimately required hospitalization for surgical intervention and intravenous antibiotics.
A CNA verbally abused a resident with communication difficulties by mocking her crying and raising her voice after an accidental incident involving the resident's communication device. Multiple staff members confirmed hearing the mocking and raised voice, and the DON acknowledged that such behavior constitutes verbal abuse under facility policy.
A resident with a history of stroke and requiring substantial assistance for bed mobility fell out of bed and sustained a humeral fracture due to inadequate supervision. The CNA attempted to reposition the resident alone, contrary to the care plan that required two-person assistance. The resident's weak side was unsupported, leading to the fall. The incident revealed a critical oversight in staff awareness and adherence to care protocols.
The facility failed to identify and treat pressure ulcers in two residents, leading to increased risk of infection and delayed healing. One resident returned from a hospital stay with an unstageable coccyx ulcer that was not previously identified by staff, while another resident had a heel wound without treatment orders. The facility did not conduct required weekly skin assessments or document skin issues, compromising resident care.
A facility failed to notify a resident's family about an advanced stage coccyx pressure ulcer, which was discovered during a hospital admission. The resident, with severe cognitive impairment, required total staff assistance. The resident's daughter, who visited frequently, was informed of the wound by the hospital, not the facility. The facility's policy mandates notifying family of significant changes, which was not followed.
A resident at moderate risk for pressure injuries developed two stage 3 ulcers on the ears due to inadequate preventative measures and skin assessments. Despite being dependent on staff for care, the facility failed to anticipate the risk from oxygen mask straps and did not conduct timely risk assessments, leading to advanced-stage injuries.
A resident experienced a change in condition marked by weakness, but the facility failed to notify the physician in a timely manner. Although a Nurse Practitioner was informed, no actions were taken, and there was no documentation of communication with the primary care physician. Staff interviews revealed that nurses assumed others had notified the physician, contrary to the facility's policy requiring timely communication of significant changes.
A resident with multiple health conditions experienced a change in condition marked by weakness, which was not properly documented or communicated by the facility staff. Despite the resident's symptoms persisting and worsening, there was a lack of timely assessment and physician notification. The resident was eventually transferred to the hospital with dehydration and a UTI. The facility's policy on change in condition was not effectively implemented, leading to a deficiency in care.
A resident with a history of joint replacement surgery and major depressive disorder was mistakenly given Hydrocodone instead of the newly prescribed Oxycodone due to a nurse's failure to verify updated medication orders. The nurse administered the discontinued medication based on the resident's statement without checking the MAR, leading to a breach in medication administration protocols.
A facility failed to follow its abuse policy by not immediately removing a CNA from resident care during an abuse investigation. A resident alleged that the CNA pushed him, but the CNA continued working for over an hour before being sent home. The facility's policy requires immediate removal of staff accused of abuse, which was not adhered to in this case.
The facility failed to supervise a resident at risk for aspiration during meals and did not ensure safe transfer practices for two residents, as staff did not use gait belts as required. Additionally, medical equipment for three residents was improperly connected to power strips instead of wall outlets, compromising safety.
The facility did not follow food service safety standards when a cook placed a fallen oven mitt back on a clean prep table without washing hands, affecting residents on pureed diets. The Food Service Director confirmed the need for proper hand hygiene and separation of clean and dirty areas.
The facility failed to provide necessary treatment for a resident with a fractured arm, as the resident was observed without a required splint, and staff were unaware of its whereabouts. Additionally, the facility did not obtain daily weights for a resident with congestive heart failure, despite physician orders, with the resident reporting inconsistent weighing practices and a broken scale as reasons for missed measurements.
The facility failed to provide prescribed medications to two residents, leading to deficiencies in pharmaceutical services. One resident did not receive Farxiga and Memantine due to unavailability, while another self-administered undocumented eye drops. The DON was aware of these issues but did not ensure proper medication administration and documentation.
The facility failed to ensure proper evaluation and monitoring of residents on PRN antipsychotic medications. A resident had an active PRN order for Seroquel without a stop date, contrary to guidelines limiting such orders to 14 days. The attending physician did not evaluate the resident after 14 days. Additionally, another resident was not monitored for antipsychotic side effects using the AIMS assessment every 6 months as required, with assessments conducted 13 months apart.
The facility failed to administer medications as prescribed, resulting in a 10.34% error rate. A resident did not receive Farxiga and Memantine due to unavailability in the dispensing system, and another resident received an incorrect dosage of Aspirin. The facility's policy requires adherence to physician orders, which was not followed.
A resident was not adequately informed about a binding arbitration agreement upon admission. The resident, who was cognitively intact, did not recall signing the agreement and stated it was not explained to her. The facility's administrator confirmed that the agreement is completed upon admission but is not mandatory for admission, and residents have 30 days to rescind it.
The facility failed to ensure staff wore PPE for residents on Contact Isolation and Enhanced Barrier Precautions. A CNA and an LPN entered a resident's room without PPE, despite the resident being on contact isolation for a urinary tract infection. Another CNA provided care to a resident with a urinary catheter on Enhanced Barrier Precautions without wearing a gown, contrary to facility policy.
A facility failed to provide timely incontinence care for a resident dependent on staff for ADLs. The resident, who is cognitively intact, was found in bed with a faint odor of urine and reported not being changed since early morning, despite being incontinent and taking a water pill. A CNA confirmed the delay in care, which should occur every 2 hours per facility policy.
Unsanitary South Shower Room With Inadequate Hot Water
Penalty
Summary
The deficiency involves the facility’s failure to maintain the south shower room in a safe, sanitary, functional, and comfortable condition for 51 residents residing on the south wing. Multiple residents reported that the south shower room did not provide adequately warm water, describing the water as cold to lukewarm and stating they preferred to use the north shower room instead. One resident stated it would be nice if the shower room on that side of the building had warm water and that they had been required to shower there a few times in cold to lukewarm water. Another resident confirmed receiving showers in the north shower room because the south shower did not have warm water. Staff interviews and direct observations further documented unsanitary and uncomfortable conditions in the south shower room. During a tour with an LPN, the surveyor observed black spots all over the shower room ceiling and walls, with a concentration near a rusted vent grate that had peeling paint, and noted a musty odor throughout the room. The LPN stated it looked like mold and attributed the odor to it. Another LPN reported trying to prevent residents from using the south shower due to lack of hot water and “gross” growth on the walls, and stated that most residents refused that shower room, although some CNAs and hospice CNAs still used it. A CNA and an activities aide both stated that the mold, smell, and lack of warm water had been ongoing issues since January and that management had been notified, but they did not believe anything was being done. The Maintenance Director confirmed the presence of black spots on the ceiling and walls and a rusted vent grate, describing the substance as likely mildew from water and lack of ventilation, and acknowledged the exhaust fan had been broken for an unknown period and had not been reported by staff. With the shower running, the water temperature in the south shower was measured at 89.2°F after six minutes and 94°F after ten minutes, and the Maintenance Director stated he would not want to shower in that water and that it should not take that long to warm up. He noted that the sink across the hall reached 109°F, suggesting a possible valve issue in the shower. The DON stated she was not aware of mold/mildew or water temperature concerns in the south shower room, although she used the room without looking at the walls or ceiling, and acknowledged that mold/mildew could put residents at risk for health concerns and that residents are encouraged to take showers rather than bed baths. The Administrator acknowledged seeing black spots on the ceiling and walls and a rusted vent, and confirmed there was no general maintenance or mold policy available when requested by the surveyor.
Failure to Adequately Supervise High Fall-Risk Resident After Room Relocation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and fall prevention measures for a resident with a known history of falls and significant functional and cognitive impairments. The resident had multiple diagnoses including dementia, history of falling, unsteadiness on feet, gait and mobility abnormalities, osteoporosis, osteoarthritis, and recent fractures of the right patella and right pubis. Facility assessments documented severe cognitive impairment, dependence for transfers, and the need for substantial to maximal assistance with bed mobility and bathing, as well as urinary and bowel incontinence. Despite these conditions, the resident experienced three unwitnessed falls within a short period, including falls from the edge of the bed and in the bathroom, resulting in abrasions to the right knee. The resident’s care plan identified her as at risk for falls related to a prior fall with patella fracture and included interventions such as placing her in highly visible areas when not in bed and anticipating and meeting her needs. Staff interviews confirmed that the resident frequently attempted to get up and transfer without assistance, often forgetting instructions to use the call light due to dementia, and that she was considered a high fall risk who required close observation. Although CNAs reported efforts to keep her in common areas and stated that when she was in her room they should check on her frequently, there was no clear documentation or consistent staff awareness of when she returned to her room on the night of one of the falls, and several CNAs reported not knowing when she went back to her room or not entering her room at all that evening. The facility moved the resident from a room on the north hall to a room on the south hall that was not near the nurses’ station and was described as around the corner and halfway down a long hall. The resident’s POA and the DON both acknowledged that the new room was far from the nurses’ station, and the POA stated that the resident could not remember to use her call light and had to yell for help. Staff, including the DON, indicated that a room closer to the nurses’ station would have allowed staff to keep a closer eye on her, but there was no such room available when she was moved. The facility’s Fall Prevention Program required implementation of safety interventions for residents identified at risk, but the pattern of unwitnessed falls, the resident’s placement in a less visible room, and staff uncertainty about her whereabouts and monitoring on the evening of the fall demonstrate a failure to ensure adequate supervision and implementation of fall prevention interventions for this high-risk resident.
Failure to Provide and Document Ordered Wound Care
Penalty
Summary
The facility failed to provide and document ordered wound care for two residents with multiple wounds, as evidenced by missing documentation on the Treatment Administration Records (TAR) and lack of progress notes for several dates when wound care was scheduled. One resident, with diagnoses including dementia, diabetes type 2, heart failure, and an antibiotic-resistant infection, had orders for daily wound treatments to both legs. The TAR and progress notes showed that wound care was not documented as completed on multiple occasions, and there was no explanation for the missing treatments. The Director of Nursing confirmed that wound care should be documented when performed and that documentation is necessary to verify completion. Another resident with skin tears to the left foot and knee had orders for wound care three times a week. The TAR indicated that wound care was not documented as completed on specific dates for both wounds. The resident reported that staff were sometimes too busy to perform wound treatments. Additionally, when requested, the facility was unable to provide a policy for wound care treatment.
Failure to Provide and Administer Correct Medications
Penalty
Summary
The facility failed to provide ordered medications and administer the correct medication to two residents. One resident with a history of stroke, heart failure, and atrial fibrillation did not receive her prescribed doses of diltiazem (an extended-release cardiac medication) and duloxetine for depression because the pharmacy rejected the refills. The nurse on duty borrowed duloxetine from another resident and substituted regular diltiazem from a different resident, administering multiple tablets to approximate the prescribed dose. The nurse was inconsistent in reporting the number of tablets given and acknowledged that the medications were not the correct formulation. Facility policy prohibits administering medications prescribed for one resident to another and requires staff to notify the Director of Nursing if medications are unavailable or rejected by the pharmacy. Another resident with diagnoses including dysuria, urinary tract infections, and kidney cancer did not receive her prescribed mirabegron for incontinence on multiple occasions, as documented in the Medication Administration Record. The nurse confirmed the medication was not available and had not checked the emergency supply. The resident was not notified about the missing medication and was unsure if she was still receiving it, though she continued to experience symptoms of overactive bladder. The Director of Nursing stated she was not informed of the pharmacy rejection and could not determine the last day the resident received the medication. The facility's failure to ensure the availability and correct administration of medications, as well as the lack of communication and adherence to policy regarding medication shortages and pharmacy rejections, resulted in residents missing essential doses and receiving medications not prescribed to them. These actions directly violated facility policy and the standard of care for medication administration.
Failure to Ensure Timely Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary support staff completed a food handler's training course within thirty days of hire, as required by Illinois Department of Public Health (IDPH) regulations. During observations in the main dining room and kitchen, several dietary aides and a cook were seen preparing and handling resident food. Interviews revealed that two dietary aides had been employed for three months but had not obtained their food handler's certificates. One aide was unaware of the requirement, and neither could provide a start date for the course. The cook confirmed the absence of a dietary manager for about a month, with the administrator currently overseeing dietary staff. The administrator acknowledged that two of the three dietary aides working did not have their food handler's certificates and confirmed the lack of a facility policy to ensure completion of this training. Review of documentation showed no certificates for the two aides in question. This deficiency affected all 80 residents currently residing in the facility, as all resident meals were prepared by the dietary staff who had not met the required training standards.
Failure to Follow Wound Care Orders Resulting in Wound Deterioration and Hospitalization
Penalty
Summary
The facility failed to follow wound treatment orders for a resident with a surgical wound on the left lower leg, which ultimately led to the deterioration of the wound and required hospitalization and surgical intervention. The resident had a history of surgery on the knee, followed by infection and subsequent treatments, including oral antibiotics and wound care. Despite the wound nurse practitioner's order for daily iodoform packing to manage tunneling and drainage, the wound care was only performed on Mondays, Wednesdays, and Fridays, contrary to the prescribed daily regimen. Interviews with facility staff revealed a lack of awareness and adherence to the wound care orders. The wound nurse practitioner emphasized that daily packing is necessary to prevent infection and promote healing, especially in residents colonized with MRSA. However, the wound care was not performed as ordered, and the wound nurse practitioner was not informed of this deviation. Documentation showed inconsistencies in the transcription of physician orders, with some orders omitting the required packing and others specifying a reduced frequency of dressing changes. As a result of the failure to follow the prescribed wound care regimen, the resident's wound developed increased drainage, tunneling, and signs of infection. The wound deteriorated, leading to the need for hospital transfer, where an abscess and possible osteomyelitis were identified. The resident underwent an incision and drainage procedure, received intravenous antibiotics, and returned to the facility with a wound vacuum in place. The facility's policy required adherence to physician orders for wound care, but this was not followed in the resident's case.
Verbal Abuse of Resident by CNA
Penalty
Summary
A certified nursing assistant (CNA) was observed and reported to have verbally abused a resident who uses a communication device. On the evening in question, the CNA appeared frustrated while assisting the resident, and the communication device accidentally fell onto the resident's leg, causing the resident to cry. Multiple staff interviews confirmed that the CNA responded by mocking the resident's crying and imitating her speech, and also raised her voice, telling the resident to be quiet. Other staff members in the vicinity heard the incident, with one registered nurse (RN) and another CNA corroborating that the resident was being mocked and told to be quiet. The Director of Nursing (DON) stated that such actions, including yelling or mocking a resident, are considered verbal abuse and are not acceptable, especially given the resident's communication difficulties. The resident involved has a care plan indicating the use of a communication device to express needs. The facility's abuse prevention policy affirms residents' rights to be free from abuse, neglect, and mistreatment by staff. The incident was substantiated through interviews and record review, showing that the staff member's actions violated the resident's right to be free from verbal abuse and did not align with facility policy or the resident's care plan.
Failure to Provide Adequate Supervision During Bed Repositioning
Penalty
Summary
The facility failed to safely reposition a resident in bed, resulting in the resident rolling out of bed and sustaining a humeral fracture. The resident, who had a history of stroke and was dependent on staff for bed mobility, was being cared for by a CNA who attempted to reposition her alone. The resident's care plan indicated that she required substantial assistance from two staff members for bed mobility due to her condition, which included hemiplegia and an inability to use her left arm and leg. During the incident, the CNA rolled the resident onto her right side, away from the CNA, causing her legs to slide off the bed. The resident's weak side was up, and she was unable to grab the side rail due to her impaired left arm. This resulted in the resident falling to the floor, where she was found kneeling with an abrasion on her left knee and complaining of left arm pain. An X-ray confirmed a fracture in the surgical neck of the humerus. The Director of Nursing acknowledged that the resident was on a low air loss mattress and should have been assisted by two staff members. The CNA involved was not aware of the requirement for two-person assistance, which was a critical oversight. The resident's pain management was adjusted following the fall, and the incident highlighted a failure in ensuring adequate supervision and adherence to the care plan for residents requiring extensive assistance.
Failure to Identify and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility failed to identify and treat pressure ulcers in two residents, leading to significant deficiencies in care. Resident 1, who had multiple diagnoses including encephalopathy, diabetes, and Alzheimer's disease, was at moderate risk for pressure ulcer development. Despite this, the facility did not conduct weekly skin assessments or document any skin issues until after the resident returned from a hospital stay, during which an unstageable coccyx pressure ulcer was discovered. The facility's staff, including CNAs and nurses, failed to identify the wound in a timely manner, resulting in an increased risk of infection and delayed wound healing. Resident 2 was found to have a deep tissue injury (DTI) on the right heel, but there were no treatment orders in place for this wound. The facility's records showed that the treatment order for the heel wound was discontinued in February, and no new orders were established until the day of the survey. This lack of treatment orders meant that the wound was not being properly cared for, increasing the risk of infection and delayed healing. The facility's staff, including the Wound Care Nurse and Director of Nurses, acknowledged the oversight and the need for immediate clarification and continuation of treatment. The facility's policy required weekly skin assessments by licensed nurses and daily observations by CNAs, but these were not consistently performed or documented. The failure to adhere to these protocols resulted in the late identification and treatment of pressure ulcers, compromising the residents' health and safety. The facility's leadership, including the VP of Clinical Operations and the Director of Nurses, recognized the deficiencies and the importance of early detection and treatment of skin issues to prevent further complications.
Failure to Notify Family of Resident's Advanced Stage Wound
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the development of an advanced stage wound. The resident, who had severe cognitive impairment and required total staff assistance, was admitted to the hospital where a wound consult revealed an unstageable coccyx pressure ulcer. This wound was present upon the resident's admission to the hospital, indicating it had developed while the resident was under the facility's care. The resident's daughter, who visits almost daily, was not informed by the facility about the wound. Instead, she was notified by the hospital staff. The facility's Wound Care Nurse acknowledged that any new or worsening wound should be reported to the physician and family promptly. The Director of Nurses confirmed that the family was not notified by the facility, which is a violation of the facility's policy requiring notification of significant changes in a resident's condition.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to adequately identify and manage the risk of pressure injuries for a resident who was at moderate risk for developing such injuries. The resident, who had a history of sepsis, acute respiratory failure, and other conditions, was dependent on staff for personal care and mobility. Upon admission, the resident was assessed as being at moderate risk for pressure injuries, but the facility did not implement sufficient preventative measures or conduct adequate skin assessments, leading to the development of two stage 3 pressure injuries on the resident's ears. The resident's care plan initially included interventions such as using ear protectors with the oxygen cannula and documenting weekly treatment of skin breakdowns. However, these measures were not effectively implemented or monitored. The resident developed a stage 3 pressure ulcer on the left ear, which was identified during a wound assessment, and later a similar ulcer on the right ear. Despite the presence of ear protectors, the facility did not recognize the potential for pressure injuries from the oxygen mask straps until after the injuries occurred. Interviews with the Director of Nursing and the Wound Care Nurse revealed that the facility did not anticipate the risk of pressure injuries from the mask straps and failed to conduct a repeat pressure ulcer risk assessment after the second injury was identified. The facility's policy required daily skin assessments and prompt notification of skin breakdowns, but these procedures were not adequately followed, resulting in the resident's pressure injuries being identified at an advanced stage.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of an ongoing change in condition for a resident in a timely manner. The resident experienced a change in condition characterized by weakness starting on December 18, 2024. Although a Nurse Practitioner was notified of the change, no actions were taken, and there was no documentation in the resident's chart indicating that the primary care physician or Nurse Practitioner was informed of the condition from December 18th to December 22nd, 2024. Interviews with staff revealed that the Registered Nurse who worked with the resident on December 18th and 21st reported the initial change to the Nurse Practitioner but did not update the physician when the resident's condition remained unchanged. Another Registered Nurse who worked with the resident on December 19th and 20th also failed to notify the physician, assuming that a colleague had done so. The facility's policy requires timely communication of significant changes in a resident's condition to the physician and family, which was not adhered to in this case.
Failure to Assess and Communicate Change in Resident's Condition
Penalty
Summary
The facility failed to identify and assess a resident for an ongoing change in condition, which was observed in one of the three residents reviewed for quality of care. The resident, who had a history of cerebral infarction, diabetes mellitus II, cerebral aneurysm, hemiplegia, adjustment disorder with anxiety, and dementia, experienced a change in condition characterized by weakness on December 18, 2024. Despite this, there was no documentation in the resident's electronic medical record regarding the change in condition until two days later, on December 21, 2024. During this period, the resident's symptoms remained unchanged, and there was no evidence of physician notification or intervention. The resident's condition continued to deteriorate, with decreased oxygen saturation and signs of dehydration noted on December 22, 2024. The primary care physician was contacted, and the decision was made to transfer the resident to the emergency room, where she was diagnosed with a urinary tract infection and dehydration. Interviews with the facility staff revealed a lack of communication and follow-up regarding the resident's condition. The registered nurse who initially noted the change in condition did not recall the specific orders given and did not work again until December 21, 2024, by which time the resident's condition had not improved. The facility did not provide a change in condition policy, only a notification of change in condition policy, which outlines the need for timely communication with the resident's physician and family in the event of a significant change in the resident's status. However, this policy was not effectively implemented, as evidenced by the lack of timely assessment and communication regarding the resident's deteriorating condition. The resident's power of attorney expressed concerns about the lack of communication from the facility regarding laboratory results and the resident's condition, highlighting the deficiency in the facility's response to the resident's change in condition.
Failure to Verify Medication Orders Before Administration
Penalty
Summary
The facility failed to ensure medication orders were verified prior to administering medications for a resident who had recently returned from a podiatrist appointment with new medication orders. The resident, who had undergone joint replacement surgery and had a history of major depressive disorder and falls, was prescribed Oxycodone to replace Hydrocodone for pain management. Despite the updated orders, an agency nurse administered the discontinued Hydrocodone to the resident, relying on the resident's statement rather than verifying the current physician's orders. The incident occurred when the agency nurse, without checking the Medication Administration Record (MAR), gave the resident Hydrocodone after the resident mentioned having an order for it. Upon later review, it was discovered that the order for Hydrocodone had been discontinued, and the Oxycodone prescription was in place. The nurse found both medications in the locked narcotic box, indicating a failure to update and verify medication orders before administration. This oversight led to the administration of a medication that was no longer prescribed, highlighting a lapse in following proper medication administration protocols.
Failure to Remove Staff During Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy by not removing a staff member from resident care during an abuse investigation. On the morning of 9/12/24, a Certified Nursing Assistant (CNA) was asked to assist a resident, who later alleged that the CNA pushed his shoulder, causing him distress. Despite the allegation, the CNA continued to provide care to other residents on the north hall for at least an hour before being called into a meeting and eventually sent home. The facility's policy mandates that employees accused of abuse be removed from resident contact immediately, which was not followed in this instance. The incident involved a resident with a history of making false allegations and cognitive impairments. The Social Services Director and the Administrator were informed of the allegation, but the CNA was allowed to continue working until nearly three hours after the incident. The CNA's timesheet confirmed she worked from 7:26 AM to 10:52 AM on the day of the incident. The failure to adhere to the facility's abuse prevention policy compromised the safety protocols intended to protect residents during an abuse investigation.
Deficiencies in Supervision, Transfer Practices, and Equipment Safety
Penalty
Summary
The facility failed to provide adequate supervision and safe practices for several residents, leading to multiple deficiencies. One resident, who was at risk for aspiration due to dysphagia, was observed eating a pureed breakfast without supervision, contrary to her care plan which required supervision during meals. This lack of supervision was confirmed by the Director of Rehabilitation, who acknowledged the resident's need for a pureed diet and supervision due to her risk of aspiration. Additionally, the facility did not ensure safe transfer practices for two residents. One resident, who required assistance and a gait belt for transfers, was transferred by a CNA without a gait belt, using the resident's arm instead, despite the resident's recent fall and arm fracture. Another resident, also dependent on staff for transfers, was transferred without a gait belt, contrary to the facility's policy mandating its use. Furthermore, medical equipment for three residents was improperly connected to power strips instead of wall outlets, as confirmed by the Maintenance Director, who stated that medical equipment should be plugged into wall outlets for reliable power.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation and distribution of pureed diets. On July 15, 2024, a cook was observed picking up an oven mitt that had fallen on the floor and placing it back onto the clean food prep table without washing her hands. This action occurred near the blender used for preparing pureed pasta and meat. The Food Service Director confirmed that items that fall on the floor should be placed in a dirty area and not near clean food, and that hand washing should be performed after picking up items from the floor. This deficiency affected five residents who were on pureed diets.
Failure to Provide Necessary Treatment and Monitoring
Penalty
Summary
The facility failed to provide necessary treatment for a resident with a fractured arm. The resident, identified as R34, experienced an unwitnessed fall and was diagnosed with a fracture of the left ulna. Despite a physician's order to maintain a splint at all times, observations revealed that R34 was without a splint, cast, sling, or compression wrap on multiple occasions. The resident expressed discomfort and pain, indicating that the cast was missing. A Certified Nursing Assistant (CNA) confirmed the absence of the cast and transferred the resident without proper support, allowing the injured arm to dangle freely. Additionally, the facility failed to obtain daily weights for a resident with congestive heart failure, identified as R18. Despite a physician's order for daily weights to monitor for significant weight changes, numerous dates were recorded without any weight measurements. The resident, who is cognitively intact, reported having to remind staff to weigh her and noted that some staff cited a broken scale as a reason for not weighing her. The Director of Nursing acknowledged the responsibility of a restorative person to assist with daily weights and the need to document any refusals, which were not recorded in this case.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide prescribed medications to two residents, resulting in deficiencies in pharmaceutical services. For one resident, the Medication Administration Summary indicated that they should receive Farxiga and Memantine at specific times. However, on a particular day, the RN administering medication omitted these drugs because they were not available in the medication cart. The Director of Nursing was aware of the issue and contacted the pharmacy, which indicated that the medication was reordered too soon, but the reason for this was unclear. Another resident was found to be self-administering eye drops that were not documented in their Physician Orders. The resident had been instructed by an eye doctor to use specific eye drops, but these orders were not reflected in the facility's records. A CNA discovered the eye drops on the resident's nightstand and informed the resident that medications could not be kept at the bedside. The Director of Nursing acknowledged that the nurse should have clarified the orders with the eye doctor and updated the resident's medication orders accordingly.
Failure to Evaluate and Monitor Residents on PRN Antipsychotic Medications
Penalty
Summary
The facility failed to ensure proper evaluation and monitoring of residents on PRN antipsychotic medications. One resident, identified as R32, had an active PRN order for Seroquel, an antipsychotic medication, without a stop date, which is against state and federal guidelines that limit PRN antipsychotic orders to 14 days. The attending physician did not evaluate the resident after 14 days to determine the appropriateness of continuing the medication, as required. The Director of Nursing acknowledged that the PRN order should have been limited to 14 days, and a physician evaluation should have been conducted before reordering. Additionally, the facility did not adequately monitor another resident, identified as R11, for side effects of antipsychotic medication using the AIMS assessment. The facility's policy requires AIMS assessments every 6 months to monitor for tardive dyskinesia, a potential side effect of antipsychotic drugs. However, R11's AIMS assessments were conducted 13 months apart, and psychiatry notes indicated assessments were done 9 months apart, failing to meet the 6-month requirement. The Director of Nursing confirmed that AIMS assessments should be conducted every 6 months.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to administer physician-prescribed medications as ordered, resulting in a medication error rate of 10.34%, which exceeds the acceptable threshold of 5%. This deficiency was observed in two residents during a medication pass. Resident R2 was supposed to receive Farxiga 5 mg and Memantine 10 mg at 9:00 AM, with an additional dose of Memantine at 5:00 PM. However, on the morning of July 16, 2024, the RN did not administer these medications because they were not available in the medication dispensing system. The Director of Nursing confirmed the omission of these medications. Resident R12 was prescribed a delayed-release Aspirin, 325 mg, to be administered once daily at 9:00 AM. Instead, an LPN administered an 81 mg enteric-coated Aspirin tablet. The facility's Medication Administration policy mandates that medications should be administered according to physician orders, which was not adhered to in these instances.
Failure to Explain Arbitration Agreement to Resident
Penalty
Summary
The facility failed to adequately inform a resident, identified as R68, about the binding arbitration agreement upon admission. During an interview, R68 stated she did not recall signing the arbitration agreement and mentioned that it was not explained to her. She expressed that she would not have signed the document if she had understood it, as she did not want to waive her right to litigation. The facility's administrator, V1, confirmed that the arbitration agreement is completed upon admission but clarified that signing it is not a requirement for admission, and residents have 30 days to rescind it. The resident's Minimum Data Set (MDS) indicated a BIMS score of 15, showing she was cognitively intact at the time. The arbitration agreement was signed on 12/3/23, but the resident did not recall being informed about it.
Failure to Adhere to PPE Protocols for Isolation and Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore Personal Protective Equipment (PPE) for residents on Contact Isolation and Enhanced Barrier Precautions. In the first instance, two staff members, a CNA and an LPN, entered the room of a resident on contact isolation without wearing PPE. The resident was on isolation due to a urinary tract infection caused by ESBL-producing organisms, which are resistant to common antibiotics. The CNA acknowledged that they should have worn a gown and gloves while providing care to the resident. In the second instance, a CNA provided incontinence care to another resident on Enhanced Barrier Precautions without wearing a gown. This resident had a urinary catheter and was under Enhanced Barrier Precautions as per a physician's order. The facility's policy required staff to wear gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions. Both the RN and the Director of Nursing confirmed that staff should adhere to these requirements.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who is dependent on staff for assistance with activities of daily living. The resident, who is cognitively intact, was observed lying in bed with a faint odor of urine and reported not being changed since 5 AM, despite being incontinent of urine and wearing a brief. The resident also mentioned taking a water pill, which could increase the frequency of urination. A Certified Nursing Assistant confirmed that the resident had not been changed that morning and acknowledged that incontinence care should be performed every 2 hours and as needed. The facility's Incontinence Care Policy, revised in 2018, also states that care should be provided every 2 hours and as needed to prevent skin breakdown.
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What surveyors actually found near you
We read the 198 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dekalb
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dekalb County Rehab & Nursing | 2.8 mi | ★★★★★ | 0 | 0 |
| Oak Crest | 3.7 mi | ★★★★★ | 2 | 0 |
| Bethany Rehab & Hcc | 3.9 mi | ★★★★★ | 30 | 0 |
| Prairie Crossing Lvg & Rehab | 12 mi | ★★★★★ | 0 | 0 |
| La Bella Of Rochelle | 15.4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.