Inspection Reports for
Hawthorne Inn of Rochelle
2201 Flagg Rd, Rochelle, IL, 61068
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 3
Date: Sep 23, 2025
Visit Reason
Annual licensure survey conducted to assess compliance with personnel requirements, food service sanitation, and physical plant regulations.
Findings
The facility was found to have insufficient staffing on the 3rd shift with only one caregiver for 44 residents, food service sanitation violations including debris in steam table pans and freezer shelves, and failure to maintain acceptable evacuation capability documentation per NFPA Life Safety Code.
Deficiencies (3)
Failed to have sufficient staff on 3rd shift to meet 24 hour scheduled and unscheduled needs of residents and ability to intervene in a crisis.
Failed to meet Food Service Sanitation Code due to buildup of debris on freezer shelf and debris in steam table pans.
Failed to comply with NFPA Life Safety Code by not maintaining documentation demonstrating acceptable evacuation capability with evacuation time of 13 minutes or less.
Report Facts
Resident census: 44
Resident falls on 3rd shift: 16
Residents requiring evacuation assistance: 4
Evacuation time: 0.5
Evacuation time: 13
Previous residents during drills: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Manager | Interviewed regarding staffing on 3rd shift |
| E3 | Personal Assistant | Interviewed regarding staffing sufficiency and ability to call for help |
Inspection Report
Deficiencies: 2
Date: Aug 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to wound care and medical record accuracy at the Hawthorne Inn of Danville nursing home.
Findings
The facility failed to prevent cross contamination during wound care and did not implement all physician-ordered treatments for pressure ulcers. Additionally, the facility failed to maintain complete and accurate medical records for one resident regarding skin assessments and bruising documentation.
Deficiencies (2)
F 0686: The facility failed to prevent cross contamination during wound care and did not implement all physician orders for pressure ulcer treatment for one resident. Hand hygiene and glove changes were not performed as required during wound dressing changes.
F 0842: The facility failed to ensure medical records were complete and accurate for one resident, lacking documentation of skin assessments and bruising on admission and during the stay.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V10 | Registered Nurse | Named in wound care deficiency related to failure to perform hand hygiene and glove changes. |
| V8 | Registered Nurse | Confirmed wound care orders and procedures. |
| V2 | Director of Nursing | Responsible for entering physician orders into EMR and involved in medical record documentation issues. |
| V29 | Nurse Practitioner | Provided progress notes related to resident's hospitalization and bruising. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication errors and incomplete medical records at the nursing home.
Complaint Details
The complaint investigation focused on medication errors and medical record inaccuracies affecting one resident (R1). The investigation substantiated failures in timely medication order clarification, medication delivery, administration, and medical record accuracy.
Findings
The facility failed to obtain complete physician orders for medications on admission, resulting in delayed and missed medication administration for one resident (R1). 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 a resident, resulting in incomplete medication instructions.
F0755: The facility pharmacy repeatedly failed to provide medications in a timely manner, causing delays in medication administration for one resident.
F0760: The facility failed to prevent significant medication errors by not clarifying incomplete hospital medication orders timely and delayed obtaining medications from the pharmacy, resulting in multiple missed doses.
F0842: The facility failed to maintain complete and accurate medical records, including inconsistent code status documentation and incomplete POLST forms for one resident.
Report Facts
Residents reviewed for medications: 8
Sample list size: 12
Missed doses of Fosinopril: 6
Medication start delay for Fosinopril: 4
Medication start delay for Metoprolol: 1
Medication start delay for Mirtazapine: 3
Hospital stay duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in medication error findings and interview regarding medication delays |
| V7 | Physician | Clarified medication orders and involved in medication error report |
| V8 | Nurse Practitioner | Clarified medication orders, acknowledged delays in medication administration |
| V18 | Corporate Nurse Consultant | Interviewed regarding pharmacy and nursing delays in medication provision |
| V32 | Registered Nurse | Documented medication administration and omissions |
| V33 | Family Member | Reported concerns about medication administration |
| V25 | Social Service Director | Documented inaccurate discharge note and confirmed medical record issues |
| V4 | Resident Service Director | Confirmed incomplete POLST form and medical record discrepancies |
| V27 | Physician | Provided statements on medication order review and standard of practice |
| V6 | Registered Nurse | Documented medication not administered due to pharmacy unavailability |
Inspection Report
Routine
Deficiencies: 4
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, pain management, medication administration, antibiotic stewardship, and overall facility operations.
Findings
The facility was found deficient in preventing resident falls due to inadequate use of blind spot mirrors, ineffective pain management for residents, failure to provide medications as ordered due to unavailability, and inadequate implementation of antibiotic stewardship including failure to meet UTI symptom criteria and obtain/review urine cultures.
Deficiencies (4)
F 0689: The facility failed to prevent a fall by not using a blind spot mirror before opening a door, resulting in one resident being bumped and falling.
F 0697: The facility failed to effectively manage pain, assess pain, and notify providers for two residents, resulting in one resident experiencing severe pain affecting daily activities.
F 0755: The facility failed to ensure medications were available and administered as ordered for four residents, and failed to notify pharmacy or providers of missed doses.
F 0881: The facility failed to implement antibiotic stewardship by not ensuring UTI symptom criteria were met and not obtaining or reviewing urine cultures for four residents treated for UTIs.
Report Facts
Residents reviewed: 28
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 4
Medication doses missed: 8
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V12 | Dietary Aide | Named in fall incident for failing to use blind spot mirror before opening door |
| V13 | Certified Nursing Assistant | Witnessed fall incident involving resident R58 |
| V5 | Registered Nurse | Provided statements regarding fall incident |
| V1 | Administrator | Provided statements regarding use of blind spot mirror |
| V17 | Nurse Practitioner | Evaluated resident R167 for pain and provided orders |
| V2 | Director of Nursing | Provided statements regarding pain assessment and medication procedures |
| V16 | Registered Nurse | Documented missed medication doses and provided statements about medication availability |
| V24 | Registered Nurse | Provided statements about medication backup supply and missed doses |
| V10 | Infection Preventionist | Provided statements regarding antibiotic stewardship and UTI criteria |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 7, 2024
Visit Reason
Annual Survey conducted on 10/07/2024 to assess 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 to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations during the annual survey.
Inspection Report
Routine
Capacity: 74
Deficiencies: 10
Date: Apr 17, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including resident assessments, medication administration, care planning, food and nutrition services, and infection control.
Findings
The facility had multiple deficiencies including failure to timely complete and transmit Minimum Data Set (MDS) assessments, inadequate feeding tube care, lack of physician orders for oxygen use, incomplete side rail assessments and consents, improper psychotropic medication management, unqualified dietary manager, unsafe food handling and storage practices, failure to monitor antibiotic use properly, and failure to offer and administer recommended pneumonia vaccinations.
Deficiencies (10)
F0638: Facility failed to timely complete Minimum Data Set (MDS) assessments for 4 of 18 residents reviewed.
F0640: Facility failed to timely transmit Minimum Data Set (MDS) assessment for one resident reviewed.
F0693: Facility failed to ensure residents received the ordered amount of enteral feeding for 2 residents reviewed.
F0695: Facility failed to obtain physician orders and care plan for oxygen administration for one resident reviewed.
F0700: Facility failed to accurately assess, obtain consent, document alternative interventions, and care plan for side rail use for two residents reviewed.
F0758: Facility failed to complete quarterly psychotropic medication assessments, document targeted behaviors and nonpharmacological interventions, limit PRN psychotropic medication orders, and obtain consent for psychotropic medication use for three residents reviewed.
F0801: Facility failed to employ a clinically qualified Director of Food and Nutrition Services.
F0812: Facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label time/temperature control for safety (TCS) food, and failed to maintain sanitary food storage equipment.
F0881: Facility failed to obtain a culture to ensure appropriate antibiotic use for one resident reviewed.
F0883: Facility failed to offer and administer pneumonia vaccine as recommended for two residents reviewed.
Report Facts
Residents reviewed for MDS assessments: 36
Residents affected by MDS completion deficiency: 4
Residents affected by MDS transmission deficiency: 1
Residents affected by feeding tube deficiency: 2
Residents affected by oxygen order deficiency: 1
Residents affected by side rail deficiency: 2
Residents affected by psychotropic medication deficiency: 3
Facility resident capacity: 74
Residents affected by dietary manager deficiency: 74
Residents affected by food safety deficiencies: 74
Residents affected by antibiotic stewardship deficiency: 1
Residents affected by vaccination deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Confirmed MDS assessment deficiencies, oxygen order deficiency, side rail assessment deficiencies, psychotropic medication management issues, and antibiotic stewardship issues. |
| V10 | MDS/Care Plan Coordinator | Confirmed untimely MDS assessments and side rail assessment deficiencies. |
| V16 | Dietary Manager | Reported not being a clinically qualified dietary manager and acknowledged food safety deficiencies. |
| V9 | Registered Nurse/Infection Preventionist | Attempted to obtain pneumonia vaccine consent and confirmed vaccination deficiencies. |
| V7 | Registered Nurse | Admitted to forgetting to start feeding tube pump for resident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 10, 2023
Visit Reason
The inspection was conducted following an alleged complaint of mental abuse involving a resident at the facility.
Complaint Details
The complaint investigation was triggered by an allegation of mental abuse involving a resident. The facility's investigation found the allegation unfounded but failed to notify the resident's representative as required.
Findings
The facility failed to notify the resident's representative of an abuse allegation as required by policy. Additionally, the facility failed to ensure medications were available and administered as ordered for four residents due to pharmacy supply issues, with no documentation of appropriate notifications to physicians or family members.
Deficiencies (2)
F 0607: The facility failed to follow its policy to notify the resident's representative of an alleged abuse involving one resident. The final report did not document notification to the resident's family.
F 0755: The facility failed to ensure medications were available and administered as ordered for four residents. There was no documentation that the pharmacy or physicians were notified of missed doses, and family notification was lacking for one resident.
Report Facts
Residents reviewed for abuse: 5
Residents reviewed for medications: 6
Residents affected by medication deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 Administrator | Administrator | Provided statements regarding abuse allegation and reporting |
| V2 Director of Nursing | Director of Nursing | Provided statements regarding abuse allegation reporting and medication policies |
| V13 Social Services Director | Social Services Director | Responsible for notifying resident's representative of abuse allegations |
| V19 Licensed Practical Nurse | Licensed Practical Nurse | Provided information about medication supply issues for resident R6 |
Inspection Report
Deficiencies: 3
Date: May 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations related to medical records access, care plan meetings, and pharmaceutical services in the nursing home.
Findings
The facility failed to timely respond to medical records requests for two residents, did not conduct quarterly care plan meetings for three residents, and failed to accurately account for controlled medications for two residents.
Deficiencies (3)
F 0573: The facility failed to timely respond to a written request for medical records for two residents, with one request delayed by a month and another not yet released due to incomplete paperwork.
F 0657: The facility failed to have quarterly care plan meetings involving the resident or representative for three residents, with documentation showing no meetings held or offered since 2020 for one resident.
F 0755: The facility failed to accurately account for controlled medications for two residents, with discrepancies between medication administration records and narcotic records.
Report Facts
Residents reviewed for medical records requests: 3
Residents reviewed for care plan meetings: 6
Residents reviewed for medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator | Provided information on medical records requests and follow-up |
| V2 | Director of Nursing | Documented care plan meeting notes and involved in care plan review |
| V5 | Assistant Director of Nursing | Confirmed medication administration and narcotic record discrepancies |
| V15 | MDS/Care Plan Coordinator | Provided information on care plan meetings and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident privacy during Gastrostomy Tube medication administration and failure to provide safe Gastrostomy tube medication administration according to standard practice and physician orders.
Complaint Details
The complaint investigation substantiated failures related to resident privacy and safe medication administration via Gastrostomy tube for resident R50.
Findings
The facility failed to maintain resident privacy during G-Tube medication administration and failed to safely administer medication through the Gastrostomy tube, including improper force applied to the syringe plunger causing potential harm. These failures affected one resident (R50) out of the sample reviewed.
Deficiencies (2)
F 0583: The facility failed to ensure a resident was afforded privacy during Gastrostomy Tube medication administration, leaving the resident's bare abdomen and feeding tube exposed to the roommate and anyone outside the window.
F 0693: The facility failed to provide safe Gastrostomy tube medication administration according to standard practice and physician orders, including repeatedly forcing the syringe plunger to advance medication and flush, which is not appropriate.
Report Facts
Residents reviewed for privacy: 26
Residents affected: 1
Residents reviewed for Gastrostomy tube medication administration: 26
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | LPN (V11) involved in failure to maintain privacy and improper G-tube medication administration | |
| Assistant Director of Nursing (ADON) | ADON (V3) observed and commented on the failures in privacy and medication administration | |
| Director of Nursing | Director of Nursing (V2) stated that the LPN should not have forced the syringe plunger and planned in-services |
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