Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to safely reposition a resident in bed for one of three residents
(R1) reviewed for safety/supervision in the sample of three. This failure resulted in R1 rolling out of bed onto
the floor and experiencing increased pain and a humeral fracture. This past noncompliance occurred from
March 11, 2025- March 17, 2025.
The findings include:
R1's Face Sheet dated March 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses
including hemiplegia, dysphagia, aphasia, unsteadiness on feet, contracture left knee, low back pain,
adjustment disorder with anxiety, depression, and heart failure.
R1's Care Plan initiated December 8, 2022, shows R1 had an ADL self care performance deficit related to
a stroke with left side effected. R1 was at risk for falls.
R1's MDS (Minimum Data Set) dated March 4, 2025, shows, R1 had an impairment to one side of her
upper and lower extremities. R1 was dependent on staff for toileting hygiene. R1 required
substantial/maximal assistance from staff for rolling left and right.
R1's Fall-Initial Occurrence Note dated March 11, 2025, shows, Resident had a witnessed fall March 11,
2025, 3:15 AM. CNA (Certified Nursing Assistant) called this writer and saw that the CNA was holding the
resident on the floor on a sitting position. CNA said that she was changing the resident when her legs went
out of the bed and fell.
R1's Nurses Note dated March 11, 2025, shows R1 complained of left arm pain. The doctor was notified
and gave an order for an X-Ray.
R1's X-Ray report dated March 11, 2025, shows, Transverse fracture lucency in the surgical neck of the
humerus with minor displacement. Generalized extremity edema.
On March 19, 2024, at 8:47 AM, V2 DON (Director of Nursing) said R1 was admitted to hospice services on
March 1, 2025. V2 said R1 had a history of a stroke and could not use her left arm or left leg. V2 said that
R1 was a two person assist for bed mobility. V2 said when residents have had a stroke and are on a low air
loss mattress should always use two staff members for assistance. V2 said V5 CNA (Certified Nursing
Assistant) was the CNA that was caring for R1 when R1 fell out of bed. V2 said V5 rolled R1 onto her right
side, which was away from the CNA. R1's weak side was up when R1's legs slid off of the bed. V2 said R1
slid off of the side where no staff was present. V2 said R1 would
(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 3
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
03/19/2025
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)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
not have been able to grab the side rail because R1 couldn't use her left arm. V2 said R1's family and
hospice decided not to send R1 to the hospital. V2 said R1 was a thin resident that had a decreasing
appetite. V2 said R1 was complaining of left arm pain at lunch time so the doctor ordered an Xray and that's
when they found out R1 had a fracture to her left arm. V2 said that R1's morphine pain medication was
increased after her fall due to the increase in R1's pain. V2 said as long as R1 was still, she did not have
any pain. V2 said staff were in-serviced on if residents have a low air loss mattress, then to use two staff
members to assist with care. V2 said if two staff members were present during R1's fall out of bed, then the
fall could have possibly been prevented.
On March 19, 2025, at 2:04 PM, V6 RN (Registered Nurse) said he was called into R1's room. V6 said he
saw R1 kneeling next to her bed on the floor with V5 holding R1 up. V6 said R1 had an abrasion to her left
knee that was bleeding, so he put a dressing on that. V6 said he gave R1 morphine for her pain after the
fall. V6 said V5 told him that R1 fell out of the bed while V5 was trying to change R1. V6 said he did not
know that R1 required two staff assistance for cares. V6 said he has been in-serviced on using two staff
members while changing dependent residents.
A message was left for V5 CNA on March 19, 2025.
On March 19, 2025, at 11:00 AM, V3 CNA said she took care of R1 a lot prior to her fall. V3 said two staff
members were always used to reposition R1 because she was a difficult resident to care for. V3 said R1
was always a nervous person and always fearful she was going to get hurt. V3 said R1 was not able to
reposition herself.
R1's MAR (Medication Administration Record) shows she had an order for morphine sulfate 20 MG/ML give
0.5 ML by mouth every four hours as needed for pain/air hunger prior to her fall. There was an order
entered after R1's fall and fracture for morphine every two hours for pain. R1 was rating her pain 5-8 on a
0-10 pain scale after her fall occurred. R1 complained of pain one time prior to her fall in March.
The facility's Fall Prevention Program revised November 21, 2017, shows, To assure the safety of all
residents in the facility, when possible. The program will include measures which determine the individual
needs of each resident by assessing the risk of falls and implementation of appropriate interventions to
provide necessary supervision and assistive devices are utilized as necessary.
Prior to the survey date of March 19, 2025, the facility had taken the following actions to correct the
noncompliance:
-Resident was assessed for injuries
-Resident care plan updated and fall assessments updated
-Nursing staff have been re-educated on proper bed mobility and care of residents that require extensive
assistance
-A QA tool has been implemented to monitor compliance with proper assistance with ADL (Activities of
Daily Living) care. DON (Director of Nursing) or designee will conduct daily audits of five residents a week.
-Reviewed current bed mobility and transfer needs to ensure they are accurate and updated if needed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145261
If continuation sheet
Page 2 of 3
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
03/19/2025
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)
F 0689
-Reviewed current residents fall risk score for accuracy and updated if needed.
Level of Harm - Actual harm
-Resident has been assessed for pain and has a pain management plan in place.
Residents Affected - Few
-Facility has reviewed agency usage and communication of resident needs to agency staff.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145261
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the March 19, 2025 survey of APERION CARE DEKALB?
This was a inspection survey of APERION CARE DEKALB on March 19, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at APERION CARE DEKALB on March 19, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.