Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Rochelle Rehab & Health Care Center during CMS and state inspections, most recent first.
A resident was transferred to another facility without proper communication of their medical needs, leading to the resident leaving against medical advice. The transferring facility failed to inform the receiving facility of the resident's need for a private room due to an infection, resulting in inadequate arrangements and the resident's dissatisfaction.
The facility failed to provide timely 60-day discharge notices to two residents, leading to distress and rushed relocations. One resident, with a defibrillator, was given only two days' notice, causing significant emotional harm. The facility's staff confirmed that residents were informed of the closure with insufficient notice, and formal letters were only sent on the day of the survey.
Two residents with dementia were involved in an unwitnessed incident in the dining room, where one resident fell after being pushed by another. Both residents have a history of altercations and require supervision, which was not adequately provided. Staff were unaware of care plan interventions, such as the use of foam cups, and the facility lacked policies on resident safety and supervision.
A resident with a complex medical history experienced a delay in the diagnosis and treatment of shingles due to the facility's failure to properly assess, monitor, and notify the physician of a change in condition. The facility did not adhere to its skin condition monitoring policy, resulting in a lack of documentation and communication among staff, which delayed the implementation of necessary isolation precautions.
The facility failed to lock the treatment cart when not in view, did not double-lock controlled medications, and left medication cart keys accessible to residents and staff. These actions were against the facility's policies and put all 22 residents at potential risk.
The facility failed to maintain the kitchen ceiling, ensure proper food temperature monitoring, and consistently fill out food temperature and dish machine sanitation logs. The ceiling had significant damage and leaks, a thermometer was missing from a refrigerator, and inappropriate devices were used for measuring food temperatures. Logs showed multiple missing entries, indicating non-compliance with the facility's policies and procedures.
The facility failed to ensure enhanced barrier precautions were in place and did not implement their Legionella program or test facility water for Legionella. A nurse was observed providing care without appropriate PPE, and the facility's water management plan was not fully implemented.
The facility failed to provide Advanced Beneficiary Notices (ABNs) to three residents before discharging them from therapy. The Administrator and an Administrator from a sister facility could not provide any documentation showing that ABNs were given, and they were unsure if the notices were completed due to the absence of the business office manager and Social Services Director at that time.
The facility failed to ensure a timely referral to a heart specialist for a resident with multiple diagnoses and did not document an assessment of a new skin condition for another resident. The deficiencies included delays in scheduling a cardiology consult and lack of proper documentation and monitoring for cellulitis treatment.
The facility failed to implement interventions to minimize the risk of elopement for a resident with dementia and Alzheimer's Disease. Despite multiple exit-seeking behaviors, the resident's care plan was not updated, and necessary precautions were not taken, putting the resident at continued risk.
The facility failed to ensure proper care for a resident with a feeding tube, as a nurse did not check tube placement or residual volume before administering medications and feedings. Additionally, the facility did not conduct a timely nutritional assessment for the resident, who had been dependent on enteral feedings since admission.
The facility failed to administer oxygen as ordered for a resident with severe respiratory and cardiovascular issues. Staff removed the resident's oxygen during toileting, causing shortness of breath and respiratory distress, despite physician orders for continuous oxygen therapy.
A facility failed to ensure prescribed Mexiletine medication was available for a resident with heart failure, resulting in a missed dose. The medication was not delivered on time due to a need for physician reauthorization, and the facility's policies on medication administration were not followed.
A resident with multiple medical conditions did not receive ordered physical and occupational therapy services from February to April 2024 due to the facility's change in therapy service providers and corporate bankruptcy. The resident's care plan indicated significant self-care deficits, and the lack of therapy hindered his progress towards independence.
Failure to Provide Pertinent Information During Resident Transfer
Penalty
Summary
The facility failed to provide pertinent medical information for a resident transferring to an alternate facility, resulting in the resident leaving the receiving facility against medical advice (AMA). The resident, who had diagnoses including acute cystitis, type 2 diabetes, hypertension, heart failure, and chronic kidney disease, was transferred without the receiving facility being informed of the need for a private room due to an infection requiring contact isolation. The resident expressed dissatisfaction with the lack of communication and preparation, stating that they were not given a choice and were not informed about the arrangements at the new facility. The facility's administration believed that all necessary communication had been completed, but the receiving facility's administrator reported not being informed of the resident's specific needs, such as the requirement for a private room. The Director of Nursing at the transferring facility admitted to not being able to speak directly with anyone at the receiving facility before the transfer. The facility was unable to provide a policy outlining the information that must be relayed during a patient transfer, indicating a lack of proper procedures in place to ensure smooth transitions for residents.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives before transferring or discharging them, as required by regulations. Specifically, two residents, R1 and R2, were not given the mandated 60-day notice prior to their discharge. R1, who had been residing in the facility for two years and had a defibrillator, was informed on a Monday that she had to leave by Wednesday, causing her significant distress. Her daughter, V7, was also informed of the closure with only two days' notice, leading to a rushed and stressful search for a new placement for R1. The facility's business manager, V5, and the director of development, V3, communicated the closure to residents and their families, but the formal 60-day notice letters were only mailed on the day of the survey, well after the initial communication. R2 was transferred to an assisted living facility without receiving the required notice. The facility's administrator, V1, and other staff members confirmed that residents were told they had to move out within two days due to the facility's closure. The regional director of operations, V4, acknowledged that the residents should have been given a 60-day notice and that the letters were being sent out on the day of the survey. The facility's policy on transfer and discharge procedures was not followed, as it mandates notifying residents and their families of transfers and the reasons for them, except in cases of late payment or nonpayment.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to implement safety interventions for two residents, R1 and R2, who were involved in an unwitnessed incident in the dining room. R1, diagnosed with vascular dementia and other cognitive impairments, has a care plan addressing potential aggression, while R2, diagnosed with dementia and Alzheimer's, has a care plan for disruptive behaviors. On the day of the incident, the administrator heard yelling and found R2 on the floor next to R1's wheelchair. R1 claimed to have pushed R2 away after R2 scratched her cheek, leading to R2's fall. The incident was not witnessed by staff, and both residents have a history of altercations. Interviews with staff revealed that R2 is known to get up from her wheelchair without assistance and has a history of walking alone, while R1 does not like others in her personal space. Staff members, including the CNA Supervisor and Social Service Director, acknowledged that R1 and R2 require supervision when together, especially in the dining room, and should be separated when showing increased confusion. Despite this, the facility did not ensure adequate supervision or implement necessary interventions to prevent the incident. The facility's failure to follow care plan interventions was further highlighted by the use of inappropriate dining utensils. R1 and R2 were supposed to use foam cups due to a history of throwing meal cups, but staff were unaware of this requirement. The Registered Nurse confirmed that care plan interventions are discussed in meetings, yet the necessary changes were not implemented. The facility was unable to provide any policies related to resident safety and supervision, indicating a lack of structured guidance for staff in managing such situations.
Delayed Diagnosis and Isolation for Shingles
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician of a change in condition for a resident, leading to a delayed diagnosis of herpes zoster (shingles) and implementation of isolation precautions. The resident, who had a complex medical history including congestive heart failure, type 2 diabetes, and dementia, was noted to have a rash on 09/15/2024. However, the physician was not notified until 09/17/2024, when a registered nurse assessed the resident and sent a picture of the rash to the physician, who then diagnosed shingles and ordered treatment. The delay in diagnosis and treatment was compounded by a lack of adherence to the facility's skin condition monitoring policy. The policy required that any new skin abnormalities be documented in the nurses' notes and a quality assurance (QA) form be completed. However, no progress notes or QA forms were completed for the resident's rash until after the diagnosis was made. This lack of documentation and communication among the nursing staff contributed to the delay in implementing necessary isolation precautions. Interviews with staff revealed confusion and miscommunication regarding the resident's condition. The Director of Nursing acknowledged that there was confusion about the diagnosis and that the nursing staff did not follow the expected procedures for notifying the physician and documenting the skin condition. The failure to follow the facility's policy and procedures resulted in a delay in the resident receiving appropriate care and isolation measures for shingles.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure the treatment cart was locked when not in view of the nurse on duty, failed to ensure controlled medications were under a double lock in the medication cart, and failed to ensure the keys for the medication cart were not accessible to residents and staff. On multiple occasions, the treatment cart was observed unlocked and unattended, containing various medications including controlled substances. The Director of Nursing (DON) acknowledged the importance of keeping the cart locked, especially given the presence of residents with dementia, but the issue persisted over several days. Additionally, the surveyor found a set of keys left on the counter at the nurse's desk, which were accessible to residents and staff. The DON admitted to leaving the keys on the counter and confirmed that it was against the facility's policy. The facility's policies on medication administration and storage clearly state that medication carts must be locked when not in view and that controlled substances must be double-locked, but these protocols were not followed, putting all 22 residents at potential risk.
Facility Fails to Maintain Kitchen Safety and Food Temperature Monitoring
Penalty
Summary
The facility failed to ensure the ceiling over the serving window and the dishwashing area was free from damage and falling debris. The ceiling had missing drywall and paint, with a large hole above the serving window showing exposed lumber and the roof of the building. This damage had been present for years, and when it rained, the ceiling leaked, causing paint chips or plaster to fall onto the workspace. The facility had not repaired the ceiling despite being aware of the issue, and the Maintenance Director confirmed that no work had been done to fix it since he started working at the facility. The facility's Maintenance Director had communicated the issue to the regional maintenance person, but no action had been taken to resolve it. The facility also failed to ensure a thermometer was present in one of the refrigerators to monitor its temperature. During an observation, the Dietary Cook was unable to locate the temperature gauge in the refrigerator and had to place a new one inside. Additionally, the facility did not use a thermometer that measures internal food temperatures to obtain temperature readings prior to serving. Instead, a laser radiation device, which is not suitable for measuring internal temperatures, was used. This resulted in inconsistent temperature readings, with a significant difference between the laser device and the meat thermometer. The newly hired Dietary Manager confirmed that the laser device was not appropriate for measuring food temperatures. Furthermore, the facility failed to ensure staff were consistently filling out the food temperature logs and the dish machine's chemical sanitation levels as per their policies and procedures. The logs showed multiple missing entries for food temperatures and dish machine chemical tests across several months. The Dietary Manager acknowledged that all food items served should have their temperatures logged, and a thermometer should always be in the refrigerators and freezers to ensure food safety. The facility's policies and procedures for food temperatures, equipment temperatures, and ware-washing were not being followed, leading to potential risks for foodborne illnesses and contamination.
Failure to Implement Infection Control and Legionella Programs
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were in place, failed to implement their Legionella program, and failed to test facility water for Legionella. These deficiencies were identified through observation, interview, and record review, and have the potential to affect all 22 facility residents. The facility's application for Medicare and Medicaid showed there were 22 residents in the facility at the time of the survey. On multiple occasions, a registered nurse (RN) was observed providing care to residents without wearing appropriate personal protective equipment (PPE) such as gowns. This included changing an infected pressure injury dressing, administering tube feedings, and providing care to a resident using a continuous positive airway pressure (CPAP) machine. There were no enhanced barrier precaution signs posted, and no PPE was available outside the rooms. The Administrator/Infection Preventionist and the Director of Nursing were both unaware of the requirements for enhanced barrier precautions for residents with wounds, gastric tubes, or CPAP machines. Additionally, the facility failed to implement their Legionella program and did not test the facility water for Legionella. The Maintenance Director, who started in February, was not provided any training regarding the Legionella program and was unaware of the need for such a program until recently. The facility's water management plan and Legionella policy and procedure were not fully implemented, and there was no documentation of a risk assessment or testing for Legionella. The facility's water temperature logs were incomplete, and the Maintenance Director had only recently started taking water temperatures weekly instead of monthly. The facility had ordered a Legionella testing kit but had not yet conducted any testing.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to ensure residents were provided an Advanced Beneficiary Notice (ABN) prior to therapy discharging them for three residents reviewed. On the morning of 4/24/24, the Administrator was asked for the ABNs for the last three residents admitted to the facility. By the afternoon, the Administrator and an Administrator from a sister facility stated they did not have any documents to provide regarding ABNs being given to the three residents. They mentioned that the business office manager and the Social Services Director were not employed at that time and they did not know if the ABNs were done or not. No documentation was provided to show that ABNs were given to the three residents in question. On 4/25/24, the facility provided instructions for the ABN form, which indicated that the ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. The instructions also stated that the ABN must be reviewed with the beneficiary or their representative, and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance for the beneficiary or representative to consider the options and make an informed choice. The notifier must retain a copy of the ABN delivered to the beneficiary on file.
Failure to Ensure Timely Specialist Referral and Proper Documentation
Penalty
Summary
The facility failed to ensure a resident was referred to a heart specialist as ordered and failed to document an assessment of a new skin condition for two residents. One resident, a [AGE] year-old female with multiple diagnoses including congestive heart failure and respiratory failure, had a physician's order for a cardiology consult dated 2/6/24. Despite multiple hospital admissions for chest pain and heart failure, the appointment was not made until 4/25/24, with the appointment scheduled for August 2024. This delay in scheduling could potentially exacerbate the resident's condition. Additionally, the facility did not provide a policy for consults and referrals when requested by the surveyors. Another resident, admitted with cellulitis of the left lower limb, began Clindamycin treatment on 4/20/24. However, there was no documented assessment of the rash or inflammation in the nursing progress notes for several days. The resident reported that the rash was initially red and warm to the touch but improved with antibiotics. The nurse who assessed the rash did not document the assessment or vital signs, and there was no shift charting or temperature monitoring as required. The facility's nursing documentation guidelines were not followed, leading to a lack of proper monitoring and documentation of the resident's condition.
Failure to Implement Elopement Interventions for Resident with Dementia
Penalty
Summary
The facility failed to implement interventions to minimize the risk of elopement for a resident diagnosed with dementia and Alzheimer's Disease. The resident, identified as R20, was observed attempting to exit the facility on multiple occasions without proper documentation or updated care plan interventions. On one occasion, the resident was seen walking out the front door and later the side door, with no documentation of these incidents in her medical record. The Director of Nursing confirmed the resident's elopement risk but acknowledged the lack of documentation and intervention updates. The resident's care plan had not been updated since October of the previous year, despite multiple exit-seeking behaviors documented in March and April. The facility's policy on missing residents indicated that reasonable precautions should be taken to minimize elopement risks, but these were not effectively implemented. The care plan interventions, such as disguising exit doors and identifying wandering patterns, were not followed, and the resident's chart did not include the necessary frequent checks by CNAs. This lack of action and documentation put the resident at continued risk of elopement and potential harm.
Failure to Ensure Proper Feeding Tube Care and Timely Nutritional Assessment
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube. Specifically, a registered nurse did not check the placement or residual volume of the feeding tube before administering medications and bolus tube feeding. This was observed during a morning medication administration, where the nurse admitted to not checking the residual volume because the resident drinks water, which typically results in about 70 milliliters of residual. However, the resident's physician order required checking the enteral tube residual volume four times daily before bolus feedings and holding the feeding if the residual was over 150 milliliters. The resident's care plan also mandated checking for tube placement and gastric contents/residual volume per facility protocol. The facility's Enteral Feedings Policy specified that tube placement should be confirmed via aspiration of residual or air instillation method before any flush or medication administration. Additionally, the facility did not conduct a timely nutritional assessment for the resident upon admission. The resident, who had been dependent on enteral feedings since admission, only had a dietitian review on 4/19/24, which was the only nutritional assessment done since admission. The facility's Enteral Feedings Policy required the dietitian to monitor all diet orders for tube feedings and recommend changes as needed. The dietitian's review noted that the resident was at risk for weight loss and gain due to dependence on enteral feedings. The facility administrator acknowledged that the nutritional assessment should have been completed sooner.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident (R7) who has multiple comorbidities including respiratory failure, chronic obstructive pulmonary disease, and congestive heart failure. Observations over several days showed that staff removed R7's oxygen during toileting, causing her to become short of breath. On multiple occasions, R7 was observed without her oxygen while ambulating to and from the toilet, which led to episodes of shortness of breath. Staff, including a CNA supervisor, incorrectly believed that R7 could have her oxygen off during these times, despite her physician's order for continuous oxygen at 4 liters per minute. The Director of Nursing confirmed that the oxygen should not be removed, especially during exertion, as it could lead to severe health risks for R7. R7's medical records and care plans indicated a history of severe respiratory and cardiovascular issues, necessitating continuous oxygen therapy. Previous incidents documented in R7's health status notes showed that interruptions in oxygen therapy had led to severe shortness of breath, chest pain, and dangerously low oxygen saturation levels. Despite these documented needs and physician orders, the facility's staff failed to ensure that R7's oxygen was administered consistently, leading to repeated episodes of respiratory distress.
Failure to Ensure Medication Availability
Penalty
Summary
The facility failed to ensure prescribed medications were available for a resident with heart failure and hypertension. The resident had an order for Mexiletine 150 mg capsules to be taken three times daily for heart failure. On the day of the survey, the Registered Nurse (RN) could not find the medication in the medication cart or room and informed the Director of Nursing (DON). The DON stated the medication was en route from the pharmacy, but it had not been delivered by the time the medication was due. The RN had sent a request to the pharmacy the previous day, but the medication was not delivered on time because it needed physician reauthorization. The resident missed the 2:00 PM dose, and the physician was notified and instructed to hold the dose until the next scheduled time. The facility's policy requires medications to be prepared and administered within one hour of the designated time. The Administrator stated that for medications taken three times a day, the nurse should request a refill early enough to allow time for physician reauthorization if needed. The facility's Medication Administration Record (MAR) confirmed that the resident did not receive the 2:00 PM dose of Mexiletine on the day in question. The facility's policies on medication administration and conformance with physician orders were not followed, leading to the deficiency.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide therapy services as ordered for a resident (R13) who was admitted with multiple diagnoses including gastrostomy status, pneumonitis, dysphagia, encephalopathy, sepsis, peripheral neuropathy, cervical disc disorder, epilepsy, and chronic pain syndrome. Despite having physician orders for physical therapy (PT) and occupational therapy (OT) to be provided multiple times a week, the resident did not receive these services from February to April 2024. The Director of Therapy confirmed that there were no current orders to evaluate and treat R13 for PT or OT, and the facility administrator acknowledged that therapy services were not available during this period due to the corporation filing for bankruptcy and changing therapy service providers. R13 expressed that he had not received therapy since an orthopedic appointment where therapy was ordered. The resident's care plan indicated significant self-care deficits requiring assistance for transfers and repositioning. Despite these needs, therapy services were discontinued without a clear rationale, and the facility lacked a policy for consults and referrals. The resident council meeting minutes from February and March also noted the absence of therapy services during those months. The failure to provide the ordered therapy services resulted in the resident being unable to progress towards a more independent setting and remaining dependent on facility care.
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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) |
|---|---|---|---|---|
| La Bella Of Rochelle | 0.5 mi | ★★★★★ | 8 | 0 |
| Manor Court Of Rochelle | 5.7 mi | ★★★★★ | 3 | 0 |
| Franklin Grove Living And Rehab | 13.5 mi | ★★★★★ | 15 | 0 |
| Prairie Crossing Lvg & Rehab | 14.7 mi | ★★★★★ | 0 | 0 |
| Dekalb County Rehab & Nursing | 15.1 mi | ★★★★★ | 0 | 0 |
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