Manor Court of Rochelle

In the surveyor’s words

From the most serious findings on record at Manor Court of Rochelle, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 10, 2022

  Based on observation, interview, and record review the facility failed to supervise a resident, with a history of exit seeking behaviors, from eloping, and failed to ensure the emergency door alarms were alerting staff at all nurse's stations when the doors opened. These failures resulted in R2 exiting the facility through an alarmed door for an unknown amount of time in zero-degree Fahrenheit (windchill) weather on 1/22/22. This applies to 1 of 3 residents (R2) reviewed for safety/supervision in the sample of 3. The Immediate Jeopardy began on 1/21/22 at 10:25 PM The Immediate Jeopardy was identified on 2/8/22 at 9:00 AM. V1 Administrator was notified of the Immediate Jeopardy on 2/10/22 at 9:33 AM. […]

• Actual harm, isolatedF689Jul 24, 2025

  Based on observation, interview and record review the facility failed to monitor post fall neurological checks, failed to notify the physician of an unwitnessed fall and failed to follow care plan interventions for one resident (R3) of three residents reviewed for falls in the sample of three.This Failure resulted in R3 sustaining a left hip fracture from an unwitnessed fall in the unit dining room at 3am in the morning.Findings include:Physician Order Report Summary indicates R3 was admitted to the facility 11/29/23 with diagnoses that include Anxiety, Arthritis, Severe Dementia with Agitation, and Insomnia.Comprehensive Cognitive assessment dated [DATE] indicates R3 is severely cognitively impaired.On 7/24/25 at 1:05pm R3 was observed sitting in a wheelchair during a church group… […]

• Actual harm, isolatedF697Jul 24, 2025

  Based on interview and record review the facility failed to monitor post fall pain and failed to notify the physician of complaints of post fall pain for one resident (R3) of three residents reviewed for falls in the sample of three.This failure resulted in a lack of pain management post fall for 5 hours after R3 sustained a left hip fracture.Based on interview and record review the facility failed to monitor post fall pain and failed to notify the physician of complaints of post fall pain for one resident (R3) of three residents reviewed for falls in the sample of three. […]

• Actual harm, isolatedF684May 20, 2025

  Based on interview, and record review the facility failed to identify a resident with a change in condition resulting in a delay in treatment from 5-11-2025 to 5-12-2025. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 3. This failure resulted in R1 needing to be hospitalized for removal of a denture appliance under anesthesia. The findings include: R1's current Resident Face Sheet shows R1 is a [AGE] year-old male resident with a medical history of Parkinson's, tremor, and vascular dementia with mild behavioral disturbance admitted to the facility on [DATE]. On 5/19/2025 at 2:36PM, V4 Certified Nursing Assistant (CNA) said he took care of [R1] on 5/9/2025 into the morning of 5/10/2025. […]

• Actual harm, isolatedF686Jan 19, 2023

  Based on observation, interview, and record review the facility failed to identify pressure ulcers prior to becoming advanced stages and failed to cleanse a stage two pressure ulcer in a manner to prevent cross contamination for two of five residents (R29, R17) reviewed for pressure in the sample of 15. This failure resulted in R29 waiting for assessment and treatment for an unstageable pressure ulcer. R17?? The findings include: 1. R29's face sheet printed on 1/19/23 showed diagnoses including but not limited to dementia, heart failure, chronic obstructive pulmonary disease, and stage 2 pressure ulcer of buttock. R29's facility assessment dated [DATE] showed severe cognitive impairment and extensive staff assistance required for bed mobility, transfers, and dressing. […]