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 Manor Court Of Rochelle during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and moderate cognitive impairment had a physician order for alprazolam 0.25 mg in the evening, while another resident was ordered alprazolam 0.5 mg at bedtime. A RN mistakenly administered double the ordered alprazolam dose to the first resident after selecting the wrong medication card, discovering the error when the controlled drug count for the second resident’s alprazolam was off. In addition, the prior evening’s MAR showed the first resident’s alprazolam dose as not given with an “other N/A” notation and no explanation, even though the LPN later stated she was sure the medication had been administered and attributed the discrepancy to a charting error and unfamiliarity with the electronic system, contrary to facility policy requiring accurate, real-time MAR documentation.
Two residents did not receive appropriate incontinence and catheter care. One resident, fully dependent for ADLs and always incontinent of bowel and bladder, was found soaked with urine on his clothing, legs, and wheelchair pad during transfer, with a large reddened area on the buttock, despite a care plan and facility practice requiring incontinence care after each episode and rounding about every two hours. Another resident with an indwelling urinary catheter, ESBL colonization in the urine, and a history of UTIs was observed in the dining area with an uncovered drainage bag touching and dragging on the floor; a RN initially failed to notice this, and the DON later confirmed drainage bags should not touch the floor and should be covered, although the resident’s care plan lacked catheter-specific interventions and the catheter policy did not address bag positioning.
Surveyors found that staff failed to follow enhanced barrier precautions (EBP) and proper catheter handling for two residents with indwelling urinary catheters. One resident with colonized ESBL in the urine and a history of UTIs had an uncovered catheter drainage bag dragging on the floor in the dining area, and both an RN and a CNA handled the bag without PPE. Another resident with multiple comorbidities and a catheter had urine aspirated from the catheter tubing by an RN who wore only gloves, despite an EBP sign on the door and a care plan requiring EBP. The ADON and facility policy both specified that gown and gloves should be used for high-contact care involving catheters and other indwelling devices.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe dementia was not properly assessed or treated for pain following a fall that resulted in a hip fracture. Nursing staff failed to document pain assessments, administer ordered pain medications, or notify the physician of the resident's pain complaints, leading to a delay in pain management for several hours.
A resident with Parkinson's disease and dementia, who required assistance with oral care and dentures, experienced a delay in treatment after staff failed to notice and report a missing denture and did not adequately assess new gurgling sounds and diminished lung function. The resident was later hospitalized, where a dental appliance was found lodged in the hypopharynx and removed under anesthesia, and was also treated for pneumonia.
A resident who required assistance with oral care had their upper denture go missing, and the facility did not document any communication with the family or establish a plan for replacement or payment. The investigation into the missing denture did not result in a resolution or identification of a liable party, and facility policies regarding responsibility were not clearly applied or communicated.
The facility did not maintain adequate nursing staff to meet resident needs, leading to missed or delayed showers, incontinence care, and prolonged call light response times. Staff and residents reported frequent short-staffing, particularly on units with higher care needs, and documentation confirmed that scheduled care was not consistently provided. On one occasion, a resident with a fall history was left unsupervised and experienced a fall while the facility was short-staffed.
Several residents did not receive their scheduled showers as required, with staff and residents confirming that showers were missed due to inadequate CNA staffing. Documentation for missed or refused showers was incomplete or missing, and the facility's policy for daily hygiene care was not consistently followed.
A resident with severe dementia and a documented fall risk experienced multiple falls after being left unsupervised due to staffing shortages. Despite a care plan requiring supervision, the resident was found on the floor after attempting to go to the bathroom alone and later fell again in the common area when staff could not reach him in time. Staff interviews and facility records confirmed inadequate supervision and insufficient staffing at the time of both incidents.
The facility failed to complete comprehensive assessments for several residents in a timely manner. The assessments were overdue, with some being several months late. The Interim DON, who also served as the MDS Coordinator, acknowledged the backlog, citing the dual responsibilities taken on after the previous DON's departure as a contributing factor.
The facility failed to complete significant change assessments for four residents in a timely manner. The assessments were overdue by several weeks, and the Interim DON/MDS Coordinator acknowledged the delay, citing challenges in managing dual responsibilities and a backlog from when they assumed the role.
The facility failed to complete quarterly assessments for four residents on time, with assessments overdue and still 'In Process' as of early March. The Interim DON/MDS Coordinator cited the dual responsibilities and a backlog from being three months behind as reasons for the delay.
A facility failed to provide timely incontinence care to a cognitively impaired resident requiring maximum assistance. The resident was found with saturated briefs and wet clothing, indicating a lapse in the protocol of providing care every two hours. CNAs were unsure of the last time the resident received care, leading to prolonged exposure to moisture.
A facility failed to ensure accurate narcotic reconciliation for a resident's Tramadol 50mg medication. An LPN found a discrepancy in the count due to a nurse not signing out a dose given during a shift. The DON confirmed the issue, noting no misappropriation occurred. Facility procedures require controlled substances to be documented and verified by nurses during shift changes.
A facility failed to label a resident's Humalog insulin pen with an opened date, as observed by an LPN and confirmed by the DON. The facility's procedure requires insulin vials to be dated when opened to prevent potency loss after 30 days.
The facility failed to provide smooth puree diets for three residents, as observed during a lunch meal. The cook did not achieve a smooth texture for the Swiss steak, resulting in a gritty consistency with small chunks of meat. Similarly, the creamed corn was not pureed to a smooth texture, containing hulls. The Dietary Manager confirmed the issue, noting that the puree should have been smooth according to the facility's procedure.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control. A nurse provided wound care without a gown, a resident with ESBL lacked EBP signage and PPE, and a student nurse assisted a resident without proper PPE. These actions violated the facility's EBP policy, which requires gown and glove use during high-contact care for residents with wounds or indwelling devices.
A resident with a history of falls and medical conditions experienced an unwitnessed fall resulting in a head injury. The facility failed to perform necessary neurological assessments following the incident. The Director of Nurses acknowledged the oversight, citing unfamiliarity with protocols by agency nurses.
A resident with hemiplegia and hemiparesis, identified as a high fall risk, fell in the bathroom after being left unattended by a CNA. The resident sustained a hematoma and bruising. The care plan indicated the resident should not be left alone, but the facility lacked a fall prevention policy.
A resident with a UTI did not receive prescribed levofloxacin for two days due to unavailability, despite the medication being in the facility's stat safe. Staff were unaware of the missed doses and did not contact the pharmacy or use the stat safe. The pharmacist confirmed delivery, and the physician was not informed of the missed doses.
A resident left the facility against medical advice with their significant other, and the RN on duty failed to notify the resident's POA, contrary to facility protocol. The DON and another RN confirmed that notifying the POA is standard procedure. The POA had been involved in prior medical decisions for the resident.
Medication Administration and Documentation Errors Involving Alprazolam
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered and documented as prescribed for a resident with multiple sclerosis, seizures, dementia without behaviors, and generalized anxiety disorder, who had moderate cognitive impairment. The resident had a physician’s order for alprazolam 0.25 mg to be given once in the evening at 9:00 PM. A registered nurse reported that on an evening shift he accidentally administered double the ordered dose of alprazolam to this resident after grabbing the wrong alprazolam medication card, which belonged to another resident who was ordered alprazolam 0.5 mg at bedtime. The nurse realized the error 30–40 minutes later when the controlled medication count for the second resident’s alprazolam was off by one tablet. The deficiency also includes a failure to accurately document medication administration for the same resident on the prior evening. The medication administration record (MAR) showed that the 9:00 PM dose of alprazolam was not given, with the MAR signed by an LPN and marked as “other N/A,” and no explanation in the chart for why the medication was not administered. In interview, the LPN stated she was sure the alprazolam had been given, believed the MAR entry was likely a charting error related to unfamiliarity with the electronic charting system, and acknowledged that the MAR needs to be correct, especially for a controlled medication. The facility’s Medication Administration policy required that all medications be administered as prescribed by the physician and that documentation on the MAR be completed at the time of administration.
Failure to Provide Timely Incontinence Care and Proper Catheter Management
Penalty
Summary
The deficiency involves failure to provide timely incontinence care and appropriate catheter management for two residents. For one resident with extensive medical conditions including right-sided hemiplegia, Parkinson’s disease, cerebrovascular disease, chronic kidney disease, heart failure, and bowel and bladder incontinence, surveyors observed that when CNAs and a shift coordinator transferred him from a padded wheelchair to bed using a mechanical lift, the back of his pants, his buttocks, and his legs were soaked with urine. The pad and sling in his wheelchair were also wet, and staff verbally acknowledged that both the pad and sling were wet and needed replacement. The resident had a large reddened area on his right buttock. The DON stated that staff are expected to round on residents every two hours and provide toileting or incontinence care as close to every two hours as possible, and the resident’s care plan directed staff to provide incontinence care after each incontinent episode, consistent with the facility’s personal care policy requiring proper daily personal attention and care. The deficiency also includes improper catheter care and infection control practices for another resident with an indwelling urinary catheter and a history of UTI, acute cystitis, and colonization with ESBL in the urine. Surveyors observed this resident seated in a wheelchair in the dining room with the urinary drainage bag under the chair, uncovered by a dignity bag and touching the floor. A RN later moved the resident’s wheelchair without noticing that the drainage bag was dragging on the floor, and upon being informed, acknowledged that the bag should have a cover and should not be touching the floor for infection control reasons. The DON confirmed that catheter drainage bags should not touch the floor and that dignity bags are supposed to be used, with extras available. The resident’s care plan noted enhanced barrier precautions and a history of UTIs but did not include that she had an indwelling urinary catheter or any catheter-related interventions, and the facility’s catheter care policy did not address keeping drainage bags off the floor.
Failure to Follow Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not following enhanced barrier precautions (EBP) and proper catheter handling for residents with indwelling urinary catheters. One resident with an indwelling urinary catheter and a history of urinary tract infections, colonized ESBL in the urine, and multiple comorbidities including Alzheimer disease and morbid obesity was observed sitting in the dining room with an uncovered catheter drainage bag under the wheelchair, dragging on and touching the floor. A RN moved the resident’s wheelchair without noticing the drainage bag on the floor, and when it was pointed out, the RN and a CNA attempted to adjust the drainage bag without wearing any PPE, despite the resident’s care plan indicating EBP due to colonized ESBL and the facility policy requiring gown and gloves for high-contact care involving indwelling devices. In a separate incident, another resident with an indwelling urinary catheter and multiple diagnoses including congestive heart failure, deep venous thrombosis, urinary tract infection, and obesity was observed in her room while a RN, wearing only gloves, aspirated urine from the catheter tubing using a syringe. The RN had clamped the catheter tubing distally to prevent drainage into the bag and was unsure whether the resident was on EBP, even though there was an EBP sign on the resident’s door and the care plan documented enhanced barrier precautions per facility protocol. The ADON confirmed that EBP required gown and gloves when handling catheters, consistent with the facility’s EBP policy stating that residents with indwelling medical devices, including urinary catheters, require targeted gown and glove use during high-contact care activities.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Monitor and Manage Post-Fall Pain
Penalty
Summary
The facility failed to monitor and manage post-fall pain for a resident who sustained a left hip fracture. After the resident, who had severe dementia and other comorbidities, fell in the early morning hours, the nurse on duty assessed her and noted complaints of back and side pain but did not document any pain assessment or administer pain medication. There was no documentation of pain intensity or descriptors, and the resident's care plan did not address pain management either before or after the fall. The nurse also failed to notify the physician of the resident's pain complaints at that time. The following shift, an LPN was alerted by CNAs that the resident was in severe pain and refused to get out of bed, which was unusual for her. The LPN immediately contacted the physician, arranged for the resident to be sent to the hospital, and later learned the resident had a left hip fracture. Review of medication administration records showed no pain medication was given post-fall, despite orders for as-needed analgesics. The facility's pain management policy required regular pain assessments and physician notification for pain indicators, but these procedures were not followed.
Failure to Identify and Respond to Change in Condition Resulting in Delayed Treatment
Penalty
Summary
A deficiency occurred when staff failed to identify and respond to a resident's change in condition, resulting in a delay in treatment. The resident, an elderly male with Parkinson's disease, tremor, and vascular dementia, required assistance with oral care and dentures. On the morning of 5/11/2025, a CNA noticed the resident did not have his dentures but did not report this to anyone, assuming they were misplaced. Other CNAs who assisted the resident over the weekend either did not notice the missing dentures or did not check the care report, and one reported hearing gurgling sounds but attributed it to oral care. The resident's family also reported gurgling noises, which prompted a nurse to assess the resident and order a non-urgent chest x-ray, but no immediate action was taken. Nursing staff noted diminished lung sounds and audible congestion, but the x-ray was not performed until the following day. The resident was found to be lethargic and had further diminished lung sounds, leading to a decision to transfer him to the hospital for evaluation. Paramedics documented difficulty breathing, decreased oxygen saturation, and a Glasgow Coma Scale of 10, indicating moderate impairment. Hospital evaluation revealed a dental appliance lodged in the hypopharynx, which required removal under anesthesia. The resident was also diagnosed with pneumonia and started on antibiotics. The facility's care plan indicated that the resident required staff assistance with oral care and had both upper and lower dentures. Despite this, staff failed to report the missing denture and did not adequately assess or escalate the resident's change in condition, resulting in a delay in identifying the foreign body aspiration. This delay contributed to the resident's hospitalization and the need for surgical intervention.
Failure to Address and Replace Lost Denture
Penalty
Summary
The facility failed to address the loss of a resident's upper denture and did not formulate a plan for its replacement. The resident, who required assistance with oral care and was not responsible for managing their own dentures, had their upper denture reported missing on 4/13/2025. The Social Services Director investigated the missing denture the following day, but the denture was not found. There was no documentation of any conversation with the resident's family regarding the lost denture or any agreement about replacement or payment prior to the survey initiation. The facility's records, including the Loss Control/Damage Report, indicated that the investigation began promptly after the denture was reported missing and was signed off two days later. However, the report did not specify a resolution or identify a liable party for the missing denture. Facility policies stated that the facility would not be responsible for lost or damaged dentures unless negligence by staff was determined or if the dentures were given to the facility for safekeeping. Despite these policies, there was no evidence that the facility communicated with the family or made a determination regarding responsibility or replacement.
Failure to Provide Adequate Staffing Resulting in Missed Care and Delayed Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, record reviews, and staffing schedules. Certified Nursing Assistants (CNAs) reported that staffing levels were frequently below the facility's recommended numbers, particularly on the Liberty Lane unit, which has a high number of residents requiring heavy care and mechanical lifts. Staff described situations where only two CNAs were available for 27 residents, making it difficult to provide timely care, including showers, toileting, and feeding assistance. Staff also reported that when short-staffed, they had to prioritize care, resulting in missed or delayed showers and incontinence care, and longer wait times for call lights to be answered. Residents corroborated these accounts, with one resident documenting long periods between being checked or changed and waiting over 30 minutes for call lights to be answered. This resident also reported missing scheduled showers and feeling dismissed by staff when raising concerns. Another resident stated that it was common to wait 40-45 minutes for call lights to be answered and was told that showers could not be provided due to insufficient staffing. Review of shower sheets confirmed that some residents did not receive the facility's policy of two showers per week, and there were days with no documentation of showers or bed baths for certain residents. The facility's staffing schedules and logs showed multiple days within a two-week period where the number of CNAs on duty did not meet the facility's own recommended levels. On one such day, a resident with a history of falls was left unsupervised and experienced a fall resulting in a hospital visit. Staff and the Director of Nursing acknowledged ongoing staffing challenges, especially during call-ins, and confirmed that these shortages impacted the ability to provide timely and complete care to residents, including supervision, showers, and incontinence care.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers for five out of eight residents reviewed for Activities of Daily Living (ADLs). Multiple residents reported not receiving their scheduled showers, with one resident stating that she is supposed to receive showers twice a week but this does not always occur. Staff interviews confirmed that on days with insufficient staffing, showers could not be provided as scheduled. One CNA reported being unable to provide showers, incontinence care, or feeding to all residents due to low staffing levels. Another CNA stated that when a shower is missed or refused, it should be documented and attempted again, but documentation was missing for several residents on scheduled shower days. Review of facility records and shower sheets revealed that several residents did not receive the required two showers per week, and in some cases, there was no documentation of showers or bed baths for extended periods. The facility's policy requires proper daily attention and care, including as many baths as necessary for hygiene needs. However, the lack of documentation and missed showers indicate that this standard was not consistently met for the residents involved.
Failure to Provide Adequate Supervision for Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a fall risk, resulting in multiple falls. The resident, an elderly male with severe unspecified dementia, anxiety, and altered mental status, was admitted with a care plan indicating a risk for falls due to weakness and a new environment. On two separate occasions, the resident was left unsupervised or insufficiently supervised due to staffing shortages. On one occasion, the resident attempted to go to the bathroom alone, fell, and hit his head, requiring hospital evaluation. Staff interviews confirmed that the resident should not have been left alone and that the unit was short-staffed at the time of the incident. On another occasion, the resident, who was supposed to be kept in the common area for supervision, was able to stand up and fall before staff could intervene, again resulting in a head injury and hospital evaluation. Documentation and staff statements consistently indicated that the resident was not provided the necessary supervision as outlined in his care plan, and that staffing levels were below normal on both days when the falls occurred. The facility's records confirmed the occurrence of both falls within a short period.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for residents in a timely manner, as required. This deficiency was identified for four residents who were part of a sample of 18. Specifically, the Minimum Data Set (MDS) Assessment Tracking indicated that the comprehensive assessments for these residents were overdue, with some assessments being several months late. The Interim Director of Nursing (DON) and MDS Coordinator acknowledged the backlog, attributing it to the dual responsibilities taken on after the departure of the previous DON in September. The interim DON stated that the facility was initially three months behind on assessments, and despite efforts to catch up, the assessments remained incomplete at the time of the survey.
Delayed Completion of Significant Change Assessments
Penalty
Summary
The facility failed to complete significant change assessments for four residents in a timely manner. Resident 24's assessment was due on January 30, 2025, Resident 25's on January 29, 2025, Resident 48's on January 22, 2025, and Resident 49's on February 20, 2025. As of March 4, 2025, all these assessments were still listed as 'In Process.' The Interim Director of Nursing (DON) and MDS Coordinator, identified as V2, acknowledged the delay, stating that they had been behind since taking over the role in September after the previous DON left. V2 mentioned that they had sent emails indicating that their part of the assessments was completed, but the remaining parts were pending completion by others. V2 also expressed difficulty in managing both the interim DON responsibilities and keeping up with the MDS assessments.
Delayed Completion of Quarterly Assessments
Penalty
Summary
The facility failed to complete quarterly assessments for four residents in a timely manner, as required by regulations. Specifically, the Minimum Data Set (MDS) Assessment Tracking for these residents showed that their assessments were overdue and still listed as 'In Process' as of March 4, 2025. The assessments for these residents were due between January 1 and January 15, 2025. The Interim Director of Nursing (DON) and MDS Coordinator, identified as V2, acknowledged the delay, attributing it to the dual responsibilities of managing both the DON and MDS roles after the departure of the previous DON in September. V2 mentioned that the facility was initially three months behind on assessments, which contributed to the current backlog.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care and toileting assistance to a resident who required maximum staff assistance for these activities. The resident, who was cognitively impaired and had a history of incontinence, was observed seated in a wheelchair with a strong smell of urine in the room. Upon being transferred to the toilet by two CNAs, it was noted that the resident's sweatpants were wet with urine, and the brief was saturated with urine and contained a moderate amount of soft stool. The resident's buttocks appeared red, indicating prolonged exposure to moisture. One of the CNAs admitted it was their first time changing or toileting the resident that day and was unsure when the resident was last changed, suggesting a lapse in the facility's protocol of providing incontinence care every two hours.
Narcotic Reconciliation Count Inaccuracy
Penalty
Summary
The facility failed to ensure the accuracy of the narcotic reconciliation count for a resident, identified as R274, who was part of a sample reviewed for narcotics. On the morning of March 4, 2025, an LPN discovered that the narcotic count for R274's Tramadol 50mg was incorrect. The resident had two cards of Tramadol, one with 30 tablets and another with 19 tablets, totaling 49 tablets. The discrepancy arose because a nurse did not sign out a dose of Tramadol administered during the 7:00 AM to 10:00 AM shift on March 3, 2025. The Director of Nursing was informed of the issue and confirmed that the count was off due to the nurse's failure to document the administered dose. The facility's pharmaceutical procedures require that controlled substances be documented on individual resident control sheets, with shift counts verified by both off-going and on-coming nurses.
Failure to Date Insulin Pen Upon Opening
Penalty
Summary
The facility failed to label an insulin pen with an opened date, which is a requirement for ensuring the proper management of medications. During an observation on March 4, 2025, at 8:00 AM, it was noted that a resident's Humalog insulin pen was stored in the medication cart without an opened date. This was confirmed by an LPN who acknowledged that the insulin pen should have been dated when opened. Later that day, the Director of Nursing also confirmed that insulin pens should be dated upon opening. The resident's Physician Order Report indicated that the Humalog KwikPen Insulin was started on September 22, 2025. The facility's Insulin Administration Procedure, revised in February 2004, states that insulin vials should be dated when opened to prevent loss of potency after 30 days of use.
Failure to Provide Smooth Puree Diets
Penalty
Summary
The facility failed to ensure that puree diet textures were smooth for three residents on puree diets. During the lunch meal on March 3, 2025, the cook responsible for pureeing the Swiss steak did not achieve a smooth texture, resulting in a gritty consistency with small chunks of meat. Similarly, the creamed corn was not pureed to a smooth texture, as it contained hulls. The Dietary Manager confirmed that the puree served at the noon meal was gritty and identified the three residents receiving these diets. The facility's procedure for pureeing food, dated July 2020, specifies that pureed foods should have a smooth, mashed potato consistency with no lumps or particles visible, which was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control. For one resident with wounds on her left calf and mid-back, a registered nurse provided wound care without wearing a protective gown, despite the presence of an EBP sign on the door. Another resident with a history of ESBL infection and urinary incontinence did not have an EBP sign or PPE cart outside his room until the day after the infection preventionist was notified of his condition. This delay in implementing EBP precautions highlights a lapse in communication and adherence to infection control protocols. Additionally, a student nurse assisted a resident with wounds in the bathroom without wearing a gown and gloves, despite the presence of an EBP sign on the door. The facility's policy requires gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices. These incidents demonstrate a failure to consistently apply the facility's EBP policy, potentially increasing the risk of transmission of multi-drug resistant organisms.
Failure to Conduct Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to perform neurological assessments after an unwitnessed fall involving a resident with a history of falls and medical conditions including right lower leg amputation, dementia, and urinary retention. The resident was found on the bathroom floor with a head injury and was sent to the local hospital for treatment. Despite the presence of a head injury, the facility did not conduct the required neurological checks, which are crucial for monitoring potential changes in the resident's condition following a fall. The incident occurred in the early hours of the morning, and the documentation of the event was completed approximately three hours after the fall. The Director of Nurses acknowledged the oversight and attributed it to the use of agency nurses who may not be familiar with the facility's protocols for post-fall assessments. The lack of immediate and ongoing neurological assessments was identified as a deficiency in the standard nursing care provided to the resident, particularly given the presence of a head injury.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure resident safety by not implementing fall interventions for a resident identified as a high fall risk. The resident, who has a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was found with a hematoma on her forehead and bruising on her left wrist and hand after falling in the bathroom. The resident reported that she was on the toilet and fell while trying to wipe, with no one present in the bathroom at the time. This incident was the second time the resident had fallen in the bathroom. The Certified Nursing Assistant (CNA) involved admitted to stepping out of the bathroom to retrieve clothes, leaving the resident unattended, which led to the fall. The facility's administrator confirmed that the CNA should not have left the resident alone, as per the care plan intervention dated 10/7/24, which explicitly stated not to leave the resident alone in the bathroom. Additionally, the facility lacked a policy on falls or fall prevention, which contributed to the failure to provide adequate supervision and prevent the accident.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that physician-prescribed medication was obtained and administered to a resident diagnosed with a urinary tract infection (UTI). The resident, who was admitted with conditions including adult failure to thrive, urinary retention, unspecified dementia, and protein-calorie malnutrition, was discharged from a local hospital with a prescription for levofloxacin, an antibiotic, to be taken daily for five days. However, the Medication Administration Record indicated that the resident did not receive the scheduled doses on the first two days due to the medication being unavailable. Interviews with facility staff revealed that the medication was available in the facility's onsite medication distribution system, known as stat safe, but was not administered. The Licensed Practical Nurse and Registered Nurse were unaware of the missed doses and did not take action to obtain the medication from the stat safe or contact the pharmacy. The facility's pharmacist confirmed that the order was received and delivered, but the medication was not administered as scheduled. The resident's physician was not informed of the missed doses, which were ordered by the hospital physician and should have been followed as scheduled.
Failure to Notify POA After Resident Leaves AMA
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) after the resident left the facility against medical advice (AMA). On September 10, 2024, a resident expressed a desire to leave the facility and subsequently left with their significant other in a car, despite being advised by staff to remain. The Registered Nurse (RN) on duty did not contact the resident's POA, although it was standard procedure to do so. The Director of Nursing (DON) and another RN confirmed that the facility's protocol requires notifying the POA when a resident discharges. The resident's POA had previously been involved in medical decisions, as evidenced by a surgical consent completed via telephone on September 5, 2024. The POA had been in place since April 2, 2018.
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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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Nursing homes near Rochelle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rochelle Rehab & Health Care Center | 5.7 mi | — | 0 | 0 |
| La Bella Of Rochelle | 6.2 mi | ★★★★★ | 8 | 0 |
| Franklin Grove Living And Rehab | 8.9 mi | ★★★★★ | 15 | 0 |
| Oregon Living And Rehabilitation Center | 9.9 mi | ★★★★★ | 28 | 0 |
| Neighbors Health Center | 14.1 mi | ★★★★★ | 2 | 0 |
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