Inspection·September 30, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician prescribed medication was obtained and administered for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 5. The findings include: R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including: adult failure to thrive, urinary retention, unspecified dementia, and protein calorie malnutrition. R1's nursing progress notes show he was sent to a local emergency room on 9/11/24 for increased weakness, confusion and having amber colored urine in his indwelling Foley catheter. Nursing progress notes show R1 returned from the hospital on 9/12/24 at 2:30 PM and was diagnosed with a urinary tract infection (UTI). R1's 9/12/24 After Visit Summary from a local community hospital shows his discharge medications to include levofloxacin (Levaquin) (an antibiotic) 500 mg. (milligrams) to be taken daily for 5 days for a UTI. R1's Physician Order Report for 9/1/24-9/26/24 shows an order for R1 to begin levofloxacin 500 mg to be given daily for 5 days beginning 9/12/24 between 3:00-6:00 PM. R1's Medication Administration Record from 9/12/24-9/26/24 shows he did not receive his scheduled levofloxacin on 9/12/24 or 9/13/24 with the reason coded as Not Administered: Drug/Item unavailable. On 9/26/24 at 12:01 PM, V12 (Licensed Practical Nurse) said the facility has an onsite medication distribution system called stat safe which has numerous medications available they can access. V12 said she was not aware that R1 missed 2 days of his antibiotic and she would have called the pharmacy to see where the medication was. On 9/26/24 at 12:20 PM, V7 (Registered Nurse) said she noticed a few days later that R1 had missed 2 doses of his antibiotic and if she was the nurse who was scheduled to have given the antibiotic, she would have called the pharmacy to find out where the medication was or obtain it from the state safe and given it. V7 said the facility pharmacy can be slow at delivering medications. On 9/26/24 at 1:33 PM, V6 (Pharmacist) said they received the order for R1's levofloxacin on 9/12/24 at 2:57 PM and delivered it to the facility on 9/13/24 at 2:10 AM. V6 said the consequence of R1 missing the doses of antibiotics could result in worsening systems of his infection or becoming (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146193 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)