Health inspection·September 17, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their abuse policy by not removing staff from resident care during an abuse investigation for 1 of 3 residents (R1) reviewed for abuse in the sample of 6. Residents Affected - Few The findings include: On 9/17/24 at 11:27 AM, V6 Certified Nursing Assistant (CNA) said the morning of 9/12/24 she was assigned to the north hall. V6 said she went to the south hall to retrieve a sling. V6 said V2 Social Services Director stopped her on the south hall and asked her to assist R1. V6 said she went into R1's room and assisted him to clean up, get dressed and transferred to a wheelchair. V6 said R1 became rude and agitated that V6 had to leave to continue providing care on her assigned hall. V6 said she did not push or lay her hands on R1 in an aggressive manner. V6 said she left the room and reported to the nurse R1's change in temperament and the need for another staff person to approach him. V6 said she returned to the north hall to continue providing care for the residents for at least an hour before she was called in to a meeting with V2 and the Administrator. At 8:51 AM, V2 confirmed she asked V6 to assist R1 with care the morning of 9/12/24. V2 said V6 was assigned to another hall but was just outside R1's door at the time. V2 said she was later stopped by V3 restorative CNA and asked to see R1 as he was upset. R1 told her that V6 pushed his shoulder and that upset him. V2 said she immediately called V1 Administrator on the phone and was directed to keep V6 on the north hall. V2 said R1 has a history of making false allegations and is not always cognitively intact. At 9:44 AM, V3 restorative CNA said on 9/12/24, V6 exited R1's room and said he was ungrateful and threw her hands up. V3 said she entered R1's room and R1 told her V6 put her hands on him. V3 said she immediately told V2 of R1's allegation. At 9:50 AM, V4 Licensed Practical Nurse (LPN) said on 9/12/24 she worked the north hall with V5 CNA and V6. V4 said there were no issues with V6's job performance and no resident complaints of her care. V4 said V6 continued to provide care to residents on the north hall until about lunchtime when she was sent home. At 9:58 AM, V5 CNA said on 9/12/24 she worked the north hall with V6. V5 said she had known V6 about 10 years and loved working with her. V5 had no concerns with V6's care. V5 said R1's memory is not always there, and he asks for things he knows he can't have and gets mad when he doesn't get it. V5 said on 9/12/24, she and V6 provided care to residents on the north hall until about lunch when V6 was sent home. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145261 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Dekalb 1212 South Second Street Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)