Above 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 Dekalb County Rehab & Nursing during CMS and state inspections, most recent first.
Staff failed to follow required procedures for cooling a cooked turkey roast, including missing documentation and temperature checks, resulting in improper cooling and noncompliance with facility policy.
A staff member was observed clearing dirty dishes and interacting with multiple residents during meal service without performing hand hygiene between tables, even after coughing into her hand and wiping her hands on a soiled clothing protector. The staff member acknowledged awareness of infection control policies, and the facility's infection preventionist confirmed that hand hygiene should be performed between resident contacts and after potential contamination.
A resident with multiple mobility-related diagnoses was pushed in a wheelchair without footrests by a staff member, contrary to facility policy and the resident's care plan. The resident, carrying belongings and being transported quickly, put her feet down and fell forward out of the chair, though no injuries occurred. Staff interviews confirmed that required safety protocols for wheelchair transport were not followed.
A resident with a urinary catheter and a history of UTIs was observed with catheter tubing resting on the floor during a meal, where it was exposed to a milk spill. Staff cleaned the spill but did not remove the tubing from the floor, and the resident's behavior of pulling on the tubing was not addressed in the care plan.
The facility failed to obtain and document accurate monthly weights for a resident with dementia and weight loss, with inconsistent weighing methods and unexplained discrepancies in records. Additionally, another resident with severe cognitive impairment and low BMI was not consistently offered alternative meal options when refusing meals, and meal intake documentation was inaccurate, sometimes completed by staff who did not directly observe the resident. These deficiencies occurred despite facility policies requiring accurate monitoring and documentation of residents' nutritional status.
A resident with multiple chronic conditions was observed receiving oxygen at rates higher than the physician-ordered 1 liter per minute, with staff confirming the discrepancy and the care plan listing inconsistent parameters. The facility did not ensure oxygen was administered as prescribed, as required by policy and physician order.
A resident with multiple chronic conditions and recent hand surgery did not receive ordered occupational therapy services for scar management and range of motion improvement. Despite a physician's referral and care plan updates, the resident was not evaluated or treated by the therapy department due to communication lapses and delays in processing therapy orders.
The facility failed to ensure safe transfers and supervision for two residents, leading to falls. One resident, with Alzheimer's, fell during a transfer due to improper use of a sit-to-stand lift and a disconnected chair alarm. Another resident, with impaired mobility from a stroke, fell off the toilet when left unsupervised by a CNA.
Failure to Properly Document and Monitor Cooling of Cooked Food
Penalty
Summary
The facility failed to properly complete the cooling process for a turkey roast intended to be served to all residents. The Dietary Manager was unable to locate the required cooling log or binder and only produced a blank cool down label sticker sheet. Upon inspection, the turkey roast was found in the refrigerator covered with foil, but there was no documentation of when it was placed in the refrigerator or any temperature checks after removal from the oven. The staff member who cooked the roast was not initially identified, and when located, she reported not knowing when to check the temperature again or where to document it. No cooling logs were started for the turkey roast. The Assistant Dietary Manager confirmed that the facility's policy was not followed, as a sticker should have been placed on the food when first stored for cooling, and the roast should have reached 70 degrees Fahrenheit within two hours. The temperature of the roast was 100 degrees Fahrenheit two and a half hours after being removed from the oven, indicating improper cooling. The facility's policy requires temperature logging at specific intervals and completion of the cooling process within six hours, which was not done in this instance.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
During lunch service in the memory care unit, a staff member responsible for activities was observed moving from table to table, removing dirty plates, cups, silverware, and soiled clothing protectors without performing hand hygiene between tables. The staff member also interacted with residents by encouraging them to eat or drink more, and handled residents' dinnerware with her hands. At one point, the staff member coughed into her closed hand and continued to handle dishes and interact with residents without performing hand hygiene. She was also seen wiping her hands on a used clothing protector before continuing to clear tables and assist residents. The staff member later acknowledged that infection control policies and procedures were covered during her orientation and admitted she should have performed hand hygiene after coughing and when clearing dirty dishes. The facility's infection preventionist confirmed that staff are required to perform hand hygiene after touching their face, coughing, or between resident contacts, and that hand sanitizer should be used between each resident served during meals. The facility's hand hygiene policy emphasizes the importance of hand hygiene before and after contact with potentially contaminated items and between residents, but these procedures were not followed during the observed lunch service.
Failure to Ensure Wheelchair Safety During Resident Transport
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including paroxysmal atrial fibrillation, lymphedema, bilateral osteoarthritis of the knees, polyneuropathy, and osteoporosis, was pushed in a wheelchair without footrests by a staff member. The resident, who had no cognitive impairment, was returning to her room after an activity and was being assisted by an activity aide. The aide failed to attach the foot pedals to the wheelchair before pushing the resident, despite facility policy and care plan interventions requiring the use of leg rests during transportation for safety. The resident had her hands full of belongings and, as the wheelchair was being pushed quickly, she put her feet down and fell forward out of the chair, landing on her knees and hands. The incident was witnessed by staff, and the resident did not sustain injuries. Interviews with staff confirmed that the facility's expectation and policy were not followed, as foot pedals were not used during the transport. The care plan for the resident identified her as being at risk for falls due to impaired mobility and included interventions for staff education on the use of leg rests. The facility's safety policy also emphasized the importance of using leg rests for residents being transported in wheelchairs. The failure to follow these established protocols directly led to the resident's fall.
Catheter Tubing Left on Floor During Meal Service
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including neuromuscular dysfunction of the bladder and a history of urinary tract infections, was observed with their indwelling catheter tubing fully resting on the floor while seated in the group dining room. During the meal, a tablemate's milk cup was knocked over, spilling milk onto the floor and the catheter tubing. Staff cleaned up the milk spill, but the catheter tubing remained on the floor throughout the incident. The facility's Assistant Director of Nurses confirmed that catheter tubing should always remain off the floor to prevent contamination and potential infection. It was also noted that the resident had a behavior of pulling on the tubing, but this behavior was not addressed in the care plan and no interventions had been implemented. The facility's catheter care policy emphasizes the importance of maintaining a sterile environment to prevent bladder infections, but this standard was not upheld in the observed situation.
Failure to Ensure Accurate Weight Monitoring and Meal Intake Documentation
Penalty
Summary
The facility failed to ensure accurate monthly weights were obtained and documented for a resident with a history of dementia, dysphagia, and weight loss. The resident's weight records showed significant discrepancies, with weights fluctuating between 111.0 lbs. and 128.0 lbs. over several months, and some weights being struck out and replaced without clear documentation. The facility's protocol required consistent weighing methods and reweighing in case of discrepancies, but these procedures were not consistently followed. The staff acknowledged the inconsistencies and noted that new scales were being acquired, but at the time of the survey, accurate and reliable weight monitoring was not ensured for this resident. Another resident with severe cognitive impairment and a low BMI was not consistently offered alternative meal options when refusing or consuming minimal amounts of meals. Observations showed that the resident ate less than 25% of several meals, yet was not offered alternatives beyond a health shake, and meal intake documentation did not accurately reflect the actual consumption. Staff interviews revealed that meal intake was sometimes documented by individuals who did not directly observe the resident eating, and that communication about actual intake was informal and not always reliable. The facility's policy required accurate documentation of meal intake and offering of alternatives, but these practices were not consistently implemented. The deficiencies were identified through observations, interviews, and record reviews, which demonstrated failures in both accurate weight monitoring and meal intake documentation, as well as in offering appropriate nutritional alternatives. These lapses affected residents with significant nutritional risks and complex medical histories, and were not in accordance with the facility's own policies and protocols for monitoring and supporting residents' nutritional status.
Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-prescribed rate for a resident with multiple diagnoses, including Parkinsonism, hypertension, dementia, and depression, who required staff assistance for all activities of daily living. The physician's order specified oxygen at 1 liter per minute via nasal cannula to maintain oxygen saturation above 90%, with instructions to wean as tolerated every shift. However, observations over several days showed the resident consistently received oxygen at higher rates—3 liters per minute on one day and 2 liters per minute on subsequent days—contrary to the physician's order. Staff interviews confirmed the discrepancy, with both a CNA and an RN acknowledging the incorrect administration rate and the expectation that nurses check and adjust the oxygen flow as ordered. Additionally, the resident's care plan listed a different oxygen administration parameter (1-2 liters per minute to maintain saturation above 92%), which did not match the physician's order. The facility's policy required obtaining a specific order for the number of liters to be administered. The DON confirmed that oxygen should be administered exactly as ordered and that deviations should be identified and corrected promptly. The failure to follow the prescribed oxygen rate was observed and confirmed by multiple staff members.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
A deficiency occurred when the facility failed to provide ordered occupational therapy (OT) services for a resident with multiple complex medical conditions, including Type 2 Diabetes, congestive heart failure, COPD, chronic respiratory failure, and left-hand osteoarthritis with trigger finger. The resident had undergone a surgical procedure for left thumb trigger finger release and received subsequent cortisone injections, with a physician's order for OT to address scar management and improve range of motion. Despite these orders, the resident reported not having started therapy and was unaware of when it would begin. Record review confirmed that the resident had not been seen by the therapy department since the previous year, and there were no recent therapy evaluations documented. Interviews with facility staff revealed a breakdown in communication and follow-through regarding therapy orders. The therapy department stated they had not received the OT order dated from the physician visit, and only became aware of it several days later. The restorative nurse, responsible for informing therapy of new orders, indicated uncertainty about the process and could not provide documentation of the resident's refusals for restorative programs. The facility's policy required prompt notification of therapy orders, but the lack of timely evaluation and initiation of OT services for the resident demonstrated a failure to ensure specialized rehabilitative services were provided as required.
Failure to Ensure Safe Transfers and Supervision
Penalty
Summary
The facility failed to ensure the safe transfer of a resident (R2) and did not implement care-planned fall interventions. R2, who is severely cognitively impaired due to Alzheimer's disease, was at high risk for falls and required a sit-to-stand lift for transfers. On the day of the incident, R2 was being transferred by CNAs using a sit-to-stand lift, but the resident was anxious and not strapped in, leading to a fall. Additionally, R2's chair alarm was found disconnected and turned off during observations, indicating a lack of proper supervision and intervention. Another resident (R3) was left unsupervised on the toilet by a CNA, which resulted in a fall. R3, who has impaired mobility due to a stroke and is at high risk for falls, was left alone when the CNA left to retrieve a tissue. This lack of supervision led to R3 falling forward off the toilet. The care plan for R3 indicated the need for supervision due to impulsivity and poor safety awareness, yet this was not adhered to, contributing to the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 221 citations issued within 25 miles in the last 12 months — including the 3 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Oak Crest | 2.4 mi | ★★★★★ | 2 | 0 |
| Bethany Rehab & Hcc | 2.5 mi | ★★★★★ | 30 | 0 |
| Aperion Care Dekalb | 2.8 mi | ★★★★★ | 5 | 0 |
| Prairie Crossing Lvg & Rehab | 14 mi | ★★★★★ | 0 | 0 |
| La Bella Of Rochelle | 14.6 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.