Inspection Reports for
Hawthorne Inn of Rochelle
2201 Flagg Rd, Rochelle, IL, 61068
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Inspection Report — Sep 23, 2025
Annual Inspection
Date: Sep 23, 2025
Visit Reason
Annual Licensure Survey citing violations of 295.3000 a)h), 295.8000 a)1), and 295.9000 a).
Findings
The establishment was found to have insufficient staffing on the 3rd shift for 44 residents, food service sanitation issues including debris in steam table pans, and failure to maintain required evacuation capability documentation per NFPA Life Safety Code.
Deficiencies (3)
A3000 (295.3000 Personnel Requirements, Qualifications and Training) - The establishment failed to have sufficient staff on the 3rd shift to meet the 24 hour scheduled and unscheduled needs of 44 residents, with only one caregiver on duty, creating a substantial probability of harm.
A8000 (295.8000 Food Service) - The establishment failed to meet the Food Service Sanitation Code due to buildup of debris on the bottom shelf of a freezer and debris in all steam table pans used during lunch service, posing a substantial probability of harm.
A9000 (295.9000 Physical Plant) - The establishment failed to provide documentation demonstrating maintenance of acceptable evacuation capability with a slow evacuation time of 13 minutes or less, as required by NFPA Life Safety Code, with only one caregiver on 3rd shift despite increased resident census.
Report Facts
Residents affected: 44
Residents requiring evacuation assistance: 4
Residents reviewed: 10
Inspection Report — Oct 7, 2024
Annual Inspection
Date: Oct 7, 2024
Visit Reason
Annual Survey conducted on 10/07/2024. For this survey, the establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found in compliance with all applicable regulations during the annual survey.
7 CMS Surveys
Inspection Report — Aug 13, 2025
Date: Aug 13, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have deficiencies related to pressure ulcer care and wound treatment, as well as incomplete and inaccurate medical records for one resident.
Deficiencies (2)
F0686 (Pressure Ulcer Care) - The facility failed to prevent cross contamination during wound care and implement pressure ulcer treatments for one of four residents reviewed, including failure to perform hand hygiene and glove changes during wound dressing.
F0842 (Medical Records) - The facility failed to ensure medical records were complete and accurate for one of four residents reviewed, including lack of documentation of bruising and skin assessments on admission.
Report Facts
Residents affected: 1
Residents affected: 1
Inspection Report — Jun 17, 2025
Date: Jun 17, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to obtain complete physician orders for a resident's immediate care on admission, resulting in significant medication errors and delays in medication administration. Additionally, the facility failed to maintain accurate and complete medical records, including inconsistent code status documentation.
Deficiencies (4)
F0635 - The facility failed on admission to obtain complete physician orders for medication to meet the immediate needs of one resident (R1) of eight reviewed.
F0755 - The facility pharmacy repeatedly failed to provide medications in a timely manner, affecting one resident (R1) of eight reviewed.
F0760 - The facility failed to prevent significant medication errors by failing to clarify incomplete hospital physician orders in a timely manner and failing to obtain medication from the pharmacy promptly, resulting in multiple missed doses for one resident (R1) of eight reviewed.
F0842 - The facility failed to maintain complete and accurate medical records, including inconsistent code status documentation and incomplete POLST form for one resident (R1) of twelve reviewed.
Report Facts
Residents affected: 1
Residents reviewed: 8
Residents reviewed: 12
Missed medication doses: 6
Inspection Report — May 1, 2025
Annual Inspection
Date: May 1, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to prevent falls, inadequate pain management, medication availability issues, and incomplete antibiotic stewardship.
Deficiencies (4)
F0689 - The facility failed to prevent a fall by not utilizing a blind spot mirror before opening a door, resulting in one resident falling.
F0697 - The facility failed to effectively manage pain, assess for pain, and report pain to the provider for two residents, resulting in severe pain and missed therapy sessions.
F0755 - The facility failed to ensure medications were available and administered as ordered for four residents, and failed to notify the pharmacy or provider of unavailable medications.
F0881 - The facility failed to implement antibiotic stewardship by not ensuring symptoms met UTI criteria and not obtaining or reviewing urine cultures for four residents treated for UTIs.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 4
Inspection Report — Apr 17, 2024
Annual Inspection
Date: Apr 17, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to employ a clinically qualified Director of Food and Nutrition Services, inadequate psychotropic medication management, incomplete side rail assessments and consents, failure to provide appropriate respiratory care orders, inadequate feeding tube care, and failure to implement proper antibiotic stewardship and vaccination policies.
Deficiencies (10)
F0638 - The facility failed to timely complete Minimum Data Set (MDS) assessments for four of 18 residents reviewed.
F0640 - The facility failed to timely transmit a Minimum Data Set (MDS) assessment for one of 18 residents reviewed.
F0693 - The facility failed to ensure residents received the recommended amount of enteral feeding for two of two residents reviewed.
F0695 - The facility failed to obtain Physician's Orders for oxygen administration and failed to care plan for oxygen use for one of two residents reviewed.
F0700 - The facility failed to accurately and routinely assess side rail use, obtain consent, document alternatives, and care plan for side rails for two of two residents reviewed.
F0758 - The facility failed to complete quarterly psychotropic medication assessments, identify targeted behaviors and nonpharmacological interventions, limit PRN psychotropic medication orders, obtain consent, and rule out underlying causes for three of five residents reviewed.
F0801 - The facility failed to employ a clinically qualified Director of Food and Nutrition Services.
F0812 - The facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS food, failed to prevent physical cross-contamination, and failed to maintain sanitary food storage equipment.
F0881 - The facility failed to obtain a culture to ensure appropriate antibiotic use for one of two residents reviewed for antibiotic stewardship.
F0883 - The facility failed to offer and administer pneumonia vaccine as recommended for two of five residents reviewed for vaccinations.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 74
Residents affected: 1
Residents affected: 2
Inspection Report — Jul 10, 2023
Complaint Investigation
Date: Jul 10, 2023
Visit Reason
This complaint investigation was conducted following an alleged complaint of mental abuse reported on 07/05/2023. The facility investigated the allegation and determined it to be unfounded.
Complaint Details
Complaint # not explicitly stated in the document; investigation of alleged mental abuse on 07/05/2023 found the complaint unfounded.
Findings
The facility failed to notify the resident's representative of an abuse allegation involving one resident and failed to ensure medications were available and administered as ordered for four residents due to pharmacy and supply issues.
Deficiencies (2)
F0607 (no Illinois section number) - The facility failed to follow their policy to report an allegation of abuse to the resident's representative for one of five residents reviewed.
F0755 (no Illinois section number) - The facility failed to ensure medications were available and administered as ordered for four residents due to unavailability and lack of pharmacy notification.
Report Facts
Residents affected: 1
Residents affected: 4
Inspection Report — May 17, 2023
Date: May 17, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a Statement of Deficiencies for Hawthorne Inn of Danville dated 05/17/2023.
Findings
The facility was found to have deficiencies related to medical records access, care plan meetings, and medication administration and accounting.
Deficiencies (3)
F0573 - The facility failed to timely respond to a written request for medical records for two of three residents reviewed.
F0657 - The facility failed to have quarterly care plan meetings involving the resident or resident representative for three of six residents reviewed.
F0755 - The facility failed to accurately account for controlled medications for two of three residents reviewed for medications.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Inspection Report — Mar 23, 2023
Date: Mar 23, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
Two deficiencies were cited related to resident privacy during G-tube medication administration and improper administration technique causing potential harm to one resident.
Deficiencies (2)
F0583 (Keep residents' personal and medical records private and confidential) - The facility failed to ensure that a resident was afforded privacy during G-Tube medication administration, exposing the resident's bare abdomen and feeding tube to a roommate and potentially passersby.
F0693 (Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube) - The facility failed to provide safe Gastrostomy tube medication administration, as a nurse repeatedly forced medication and flush through a clogged G-tube, contrary to standard practice.
Report Facts
Residents affected: 1
Residents reviewed: 26
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