Inspection·November 26, 2024

F 0550 shift to evening shift on 3/5/2024 and she wasn't aware (R2) didn't want to be an evening shower. Level of Harm - Minimal harm or potential for actual harm The Resident Rights Policy revised 2/2021 documents employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be supported by the facility in exercising his or her rights, be informed of, and participate in his or her care planning or treatment and participate in decision-making regarding his or her care. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145651 If continuation sheet Page 2 of 6 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 145651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Alton 3490 Humbert Road Alton, IL 62002 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents received a shower. The facility also failed to document residents who received a shower for 4 of 4 residents (R2, R4, R1, R3) reviewed for Activities of Daily Living care for dependent residents in a sample of 4. Residents Affected - Some Finding include: 1. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a diagnosis of need for assistance with personal care. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has no cognitive deficits and needs substantial/maximal assistance with showering/bathing. R2's Undated Care Plan documents R2 has an activities of daily living (ADL) self-care performance deficit related to limited mobility, with interventions documenting to use a mechanical lift for transfers. R2 currently requires assistance with ADL's such as personal hygiene and bathing with extensive help from one staff member. R2 is on a restorative grooming program as R2 is unable to bathe/groom self independently related to weakness with interventions to encourage R2 to participate in dressing and grooming with substantial/max assistance as tolerated. R2's care plan undated documents R2 has expressed personal and lifestyle preferences, including R2's bathing routine preference is day shift and preferred bathing type is a shower. R2's Bath and Skin Report Sheet, dated November 2024 documents R2 is to receive a shower on Tuesdays and Fridays evenings. Shower sheet documents shower were to be given on 11/1/2024, 11/5/2024, 11/08/2024, 11/12/2024, 11/15/2024, 11/19/2024, 11/22/2024 with no documentation of a shower given or refused. R2's Documentation Survey Report v2, dated November 2024 documents R2 was showered on 11/6/2024, 11/16/2024 and 11/20/2024. No other showers documented for the month of November 2024. R2's progress notes dated November 2024 showed no documentation R2 was showered or that R2 refused a shower. On 11/26/2024 at 8:51 AM R2 sitting up in bed with dryness noted to her face and hair is matted and oily. R2 stated she has not had a shower in about 4 weeks or had her hair washed. R2 stated she has an appointment to go to today and feels like she is not ready to go due to smelling from not having a shower. R2 stated about a week ago her shower schedule was changed from days to evenings, and she does not want to take showers in the evenings due to having to use a mechanical lift. R2 stated the medications she takes in the evening make her tired and she does not feel safe using the mechanical lift after taking them. 2. R4's Undated Face Sheet, documents he was admitted to the facility on [DATE] with no diagnosis regarding need for assistance with personal care. R4's Quarterly MDS, dated [DATE], documents Brief Interview of Mental Status (BIMS) 10/15: moderately cognitively impaired. Shower and personal hygiene: substantial/maximal assistance. Lower extremities impairment on both sides. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145651 If continuation sheet Page 3 of 6 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 145651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Alton 3490 Humbert Road Alton, IL 62002 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R4's Undated Care Plan, documents resident is an ADL self-care performance deficit r/t (related to) limited mobility, left BKA (below the knee amputation.) and right BKA. Goal: none documented. Interventions/tasks: bathing: extensive - total x1. Review of R4's Bath and Skin Report Sheet, dated November 2024 documents he is to be showered on Mondays and Thursdays in the PM. According to the shower sheet, the dates R4 should have been showered are 11/4/2024, 11/7/2024, 11/11/2024, 11/14/2024, 11/18/2024, 11/21/2024 and 11/25/2024. The form showed no documentation R4 was showered on these days. R4's Documentation Survey Report v2, dated November 2024 showed on 11/15/2024 staff documented codes 98 which means resident refused and 97 not applicable. R4's Progress Notes, dated November 2024 showed no documentation R4 was showered or that he refused a showered. On 11/26/2024 at 11:55 AM R4 stated they don't shower me here and I don't know why. R4 stated they also don't shave him and he prefers to be shaved but he can't shave himself because he has a scab on his upper right cheek and he doesn't want to accidentally rip it off, he would allow staff to shave him but no one has offered that service. During the interview observation made of resident, he had long facial hair and oily/greasy hair and there was white flakes on his t shirt from dry skin on his arms. Observation during the interview showed R4 is a bilateral amputee and uses a wheelchair for mobility device. 3. R1's Undated Face Sheet, documents admission date 7/31/2023 with diagnosis of need for assistance with personal care. R1's quarterly MDS, dated [DATE] documents BIMS 11/15 moderately cognitively impaired. Shower: substantial/maximal assistance and personal hygiene: dependent. R1's Care Plan initiated on 7/31/2023 documents resident has an ADL self-care performance deficit need and participation may vary r/t (related to) needing assistance with personal care. Goals: resident will maintain current level of ADL function, resident free from complications related to ADL deficit and resident will be kept clean and comfortable. Interventions: ADL care: resident may need assistance x1 or x2 for ADL care. Bathing specifically was not addressed on the care plan. Review of R1's Bath and Skin Report Sheet, dated November 2024 documents he is to be showered on Wednesdays and Saturdays in the PM. According to the shower sheet, the dates R1 should have been showered are 11/2/2024, 11/6/2024, 11/9/2024, 11/13/2024, 11/16/2024, 11/20/2024 and 11/23/2024. The form showed no documentation R1 was showered on these days. Review of R1's Documentation Survey Report v2, dated November 2024, documents he was showered on 11/14/2024 and 11/17/2024. R1's Progress Notes, dated November 2024 showed no documentation R1 was showered or that he refused a shower. On 11/26/2024 at 11:15 AM V11, CNA observed giving R1 a bed bath and stated she will shave him as well. Observation of R1 at that time showed his fingernails had dark substance under them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145651 If continuation sheet Page 4 of 6 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 145651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Alton 3490 Humbert Road Alton, IL 62002 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/26/2024 at 11:45 AM R1 stated, I don't get showered or cleaned up very often, this is the most clean I have been since I was admitted to the facility this year. No staff offer to give me a shower or shave me, it has to have been weeks since I've received a shower or been shaved. I can't shower and shave myself anymore. 4. R3's Undated Face Sheet documents R3 was admitted to the facility on [DATE] and has a diagnosis of Heart failure, Chronic Kidney Disease, Dementia, Aphasia, Hypertension, and Hypothyroidism. R3's MDS dated [DATE], documents R3 is cognitively impaired and needs substantial/maximal assistance with showering/bathing. R3's Undated Care Plan documents R3 has an ADL self-care performance deficit and needs and participation may vary. Interventions include R3 may need assistance with one or two staff members for ADL care. R3 participates in restorative nursing programs including dressing and grooming. R3 has expressed personal and lifestyle preferences including bathing type preference as showering. R3's Bath and Skin Report Sheet, documents R3 is to receive a shower on Monday and Thursday evenings. Shower sheet documents shower were to be given on 11/04/2024, 11/07/2024, 11/11/2024, 11/14/2024, 11/18/2024, 11/21/2024, and 11/25/2024, with no documentation of a shower given or refused. R3's Documentation Survey Report v2, dated November 2024 documents a shower was given on 11/14/2024. No other showers were documented as given or refused. R3's Progress Notes, dated November 2024 showed no documentation R3 was showered or that R2 refused a shower. On 11/26/2024 at 9:28 AM V5, CNA stated no residents are complaining of not being showered. V5 stated when she showers a resident, she documents it in the shower book located at the nurse's station. On 11/26/2024 at 9:45 AM V6, CNA stated when she showers a resident, she documents it in the shower book located at the nurse's station. On 11/26/2024 at 9:52 AM V7, CNA stated residents are showered every day, most residents are showered twice a week and resident specific shower days are documented in the hall shower book that is located at the nurse's station. V7 stated she documents when she gives a resident a shower on the resident's shower sheet in the hall shower book. On 11/26/2024 at 9:53 AM V9, Licensed Practical Nurse (LPN) stated certain residents refuse showers and when they do, she expects the CNA to report the refusal so she can go talk to the resident about the shower as well. CNAs are expected to document when they give a resident a shower in the hall shower books that are located at the nurse's station. Hospice CNAs document in the hospice book when they shower a resident. V9 stated (R2) refuses showers unless staff offer them to her as the exact time she wants to take them. (R2) is a night shower due staffing. (R1), (R3) and (R4) do not refuse showers to her knowledge. The Facility's Activities of Daily Living (ADLs), Supporting, revised March 2018, documents residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145651 If continuation sheet Page 5 of 6 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 145651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Alton 3490 Humbert Road Alton, IL 62002 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 0677 Level of Harm - Minimal harm or potential for actual harm care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support with assistance with hygiene (bathing, dressing, grooming and oral care.) Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145651 If continuation sheet Page 6 of 6