Health inspection·July 19, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents were free from abuse for 3 of 5 residents (R2, R3 and R4) reviewed for abuse on the sample list of 5. The findings include: 1. R1's Minimum Data Set assessment dated [DATE] documents R1 admitted to the facility on [DATE], has severely impaired cognition, requires supervision with walking in her room and corridors and has had physical and verbal behaviors directed towards other. R2's Minimum Data Set Assessment (MDS) dated [DATE] documents R1's cognition is intact. On 7/19/23 at 12:00 PM, R2 said that R2 was just sitting in the dining room and out of the blue, [R1] came up to R2 and punched her in the left eye and started shaking her walker. R2 stated, It hurt really bad. She makes me nervous when she is around me because I don't know what she is going to do. On 7/19/23 at 11:03 AM, V5 (Certified Nursing Assistant) said that V5 witnessed the altercation between R1 and R2. V5 stated, I was in the dining room getting everyone ready for lunch. I had the music on and was singing and dancing with [R2]. [R1] came in like I was playing [Heavy Metal Rock Band], all mosh pit style and smacked her on the cheek and then started shaking her walker. V5 said that R1 was not provoked by anything, and that R1 just walked into the dining room. V5 said that R1 does have behaviors so she just lets her do her own thing. V5 said that R1 can be aggressive and mean at times. V5 said that recently R1 has been wandering into other resident rooms and stealing their belongings. R2's Final Abuse Allegation Investigation Report dated 6/26/23 shows, Investigation showed that [R2] was noted to be sitting in the dining area in her wheelchair. [R1] was ambulating around the dining area, and stopped at [R2's] table, moved a few items on the table around, and [R2] requested her to stop. [R1] then made contact to [R2's] arm using her open hand . On 7/19/23 at 1:00 PM, V1 (Administrator) said that it was substantiated that the situation between R1 and R2 happened. V1 said that in the final report, he mistyped, and it should have said cheek and not arm. R2's Nursing Notes dated 6/21/23 at 12:45 PM shows, It was reported to this nurse that a different resident came up and struck her in the face (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 3 Event ID: 146084 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 146084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Morrison 500 North Jackson Street Morrison, IL 61270 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)