F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure neurological assessments were
performed after an unwitnessed fall for 1 of 3 residents (R1) reviewed for falls in the sample of 3.
Residents Affected - Few
The findings include:
R1's face sheet printed on 2/4/25 showed diagnoses including but not limited to right lower leg amputation,
dementia, and urinary retention. R1's facility assessment dated [DATE] showed no severe cognitive
impairment and requires staff supervision or touching assistance with toileting.
The facility Serious Injury Incident Report dated 2/3/25 showed R1 was found on the bathroom floor the
morning of 2/2/25. R1 was bleeding on the forehead, was sent to the local hospital, and received sutures.
On 2/4/25 at 9:35 AM, R1 was lying on his bed and his daughter (V7) was present. R1 had a bandage on
his right forehead and dark bruising on top of each of his hands. R1 had a right-side prosthetic (mechanic
leg attachment) and an indwelling catheter. R1 stated he got up by himself and went to the bathroom. R1
said he fell and hit his head somewhere in his room. R1 was slightly confused and could not recall the time
or location of the fall.
On 2/4/25 at 9:35 AM, V7 (R1's daughter) stated R1 has fallen in the past and is known to get up without
waiting for staff assistance. V7 stated he can wheel himself to the bathroom. R1 knows he should not be
getting up alone, but he is just so determined he can still do it by himself.
On 2/4/25 at 11:08 AM, V3 (LPN-Licensed Practical Nurse) stated she was working the morning R1 fell. V3
said she was at the nurses station sometime between 3:30 or 3:40 AM when she heard R1 yelling help,
help from his room. V3 said her and another aide (V4) went to the room and found R1 on the floor next to
the toilet. V3 said the wheelchair was tipped over and he was bleeding from his head. V3 said R1 was able
to move his extremities, she did vital signs, and asked if he had pain. V3 said she did not know what to do
next, so she called over to the other unit and had to ask another nurse where to send R1. V3 said R1 was
transferred into bed by V4 and V5 (CNA-Certified Nurse Aides). V3 said R1 was sent to the local
emergency room the same day.
On 2/4/25 at 11:46 AM, V4 (CNA) said she was working the morning R1 fell. V4 said she heard R1 yelling
from his room and went in with V3 (LPN). V4 said she thought it was sometime around midnight but was not
certain. V4 said R1 was on the floor next to the toilet and bleeding from his head. V4 said R1 was
transferred to the bed by herself and V5.
(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
02/04/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
On 2/4/25 at 1:42 PM, V5 (CNA) said R1 fell in his bathroom sometime around 3:00 to 4:00 AM. V5 said he
was bleeding from his head, and she helped transfer him back to the bed.
R1's local emergency room notes dated 2/2/25 at 5:01 AM showed a laceration of the forehead, left and
right hand contusions and neck muscle strain.
Residents Affected - Few
R1's progress notes dated 2/2/25 showed he was found on the floor bleeding from the head. The note
showed a head-to-toe assessment was done, range of motion, and no pain. The note showed R1 appeared
to need sutures, so he was sent to the ER. The noted was written at 6:33 AM (approximately three hours
after the fall).
R1's event report dated 2/2/25 at 6:27 AM was reviewed and the entire neurological check list section was
blank. The report only documented his vital signs as of 6:27 AM. (approximately three hours after the fall).
On 2/4/25 at 2:01 PM, V2 (Director of Nurses) stated, We do not have any neurological assessments
following R1's fall. It was an oversight on the nurse's part (V3). We use a lot of agency nurses and
unfortunately, they don't always know what to do after a resident falls. V2 said the time line of events is
confusing since all the documentation was done after R1 had been sent out. V2 said any resident that has
an unwitnessed fall should have neurological checks started immediately and continue every 15 minutes,
every half hour, every hour etc. for at least 72 hours. V2 said head to toe assessments are not the same as
neurological assessments. V2 stated proper neurological assessment are important to ensure there are no
sudden change in condition or pressure building up inside the head. V2 said it is a standard nursing care,
especially with a head injury.
The facility was unable to supply any neurological checks performed on R1 following the unwitnessed fall
on 2/2/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146193
If continuation sheet
Page 2 of 2
