Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
interview and record review the facility repeatedly failed to provide showers as scheduled for three of three
dependent residents (R2, R3, R4) reviewed for showers in the sample list of five.
Residents Affected - Few
Findings include:
1. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical
diagnoses; Atrial Fibrillation, Chronic Pulmonary Embolism, Abnormalities of Gait and Mobility,
Unsteadiness on Feet, Weakness and Presence of Orthopedic Joint Implants.
R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS)
score 15, cognitively intact, needs substantial assistance with shower/bathe self, and Activities of Daily
Living (ADL).
R2's Care Plan dated 9/12/24 documents R2 will receive scheduled showers. Interventions: Staff will
encourage resident to take showers per shower schedule. R2 has an Activities of Daily Living (ADL)
self-care performance deficit related too decreased strength and mobility.
R2's Shower Schedule documents R2 to receive showers on Tuesday and Fridays during the day shift.
R2's Bath and Skin Report Sheet dated December 2024 and January 2025 documents R2 received a
shower on 12/31/24.
On 1/9/24 at 9:38am R2 stated that R2 rarely gets a shower and had only one or two last month. R2 stated
R2 is supposed to get them on Tuesday and Fridays. R2 stated staff will come and tell R2 that it's R2's
shower day and then never come back. R2 stated that R2 does needs staff assistance when taking a
shower. R2 stated R2 usually just washes up at the sink in R2's room, which doesn't really get R2 clean all
over.
2. R3's Facility Census documents R3 was admitted to the facility on [DATE] and has the following medical
diagnoses; Acute Respiratory Failure, Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to
Excess Calories, Unsteadiness on Feet, Pulmonary Hypertension, Acute Respiratory Failure with Hypoxia,
Muscle Wasting and Atrophy, Right Heart Failure, Abnormalities of Gait and Mobility, Shortness of Breath,
Personal History of Transient Ischemic (TIA) Attack and Lack of Coordination.
R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS)
score 13 cognitively intact, needs substantial assistance with shower/bathe self, and Activities of Daily
Living (ADL).
(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:
146085
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
146085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
LA Bella at Clifton
1190 E 2900 North Road
Clifton, IL 60927
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
R3's Care Plan dated 10/29/24 documents R3 has an Activities of Daily Living (ADL) self-care performance
deficit needs and participation may very related too activity intolerance, fatigue, impaired balance, and
limited mobility. Intervention: Bathing: R3 needs assist of 1-2 based on fatigue, weightbearing, weakness.
R3's Shower Schedule documents R3 to receive showers on Sunday and Thursdays during the day shift.
Residents Affected - Few
R3's Bath and Skin Report Sheet dated December 2024 and January 2025 documents R3 received a
shower on 12/12/24, 12/21/24 and 1/2/25.
On 1/9/24 at 10:04am R3 said, that R3 does not get two showers a week. R3 said, that R3 might get one
shower a week. R3 said, that R3 is scheduled to get a shower on Sunday and Thursdays and doesn't
understand why staff doesn't give R3 a shower. R3 said, R3 is dependent on staff's assistance when
getting a shower, R3 is unable to shower R3's self.
3. R4's Facility Census documents R4 was admitted to the facility on [DATE] and has the following medical
diagnoses; Fracture of Sternum, Chronic Diastolic (Congestive) Heart Failure, Unsteadiness on Feet,
Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Chronic Venous Hypertension (Idiopathic)
with Inflammation of Bilateral Lower Extremities, Obesity and Anxiety Disorder.
R4's Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS)
score 14 cognitively intact, needs substantial assistance with shower/bathe self, and Activities of Daily
Living (ADL).
R4's Care Plan dated 10/25/24 documents R4 has an Activities of Daily Living (ADL) self-performance
deficit related too sternum fracture, impaired mobility, and weakness. Intervention: Bathing/Showering: R4
requires assist of 1 staff member with bathing/showering.
R4's Shower Schedule documents R4 to receive showers on Monday and Thursdays during the day shift.
R4's Bath and Skin Report Sheet dated December 2024 and January 2025 documents R4 received a
shower on 12/6/24, 12/30/24 and 1/6/25.
On 1/9/24 at 10:20am R4 said, R4 is dependent on staff to get a shower, R4 is not able to self-shower. R4
said, that R4 has only been living in the facility a couple of months and does not every get two showers a
week. R4 stated that R4 is supposed to get showers on Monday and Thursdays and is lucky to get one
shower every other week.
On 1/9/25 at 1:45pm V2 (Director of Nursing) said all residents are scheduled 2 showers a week and
should be getting them. V2 said, after a shower is given, the Certified Nursing Assistant should be
documenting it on the resident's bath and skin report sheet. V2 said, if a resident refuses a shower, it
should be documented that they refused. V2 acknowledged that R2, R3 and R4 did not receive their 2
scheduled showers as ordered.
Facilities Bath, Shower/Tub Policy no date documents: The purpose of this procedure to promote
cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.
Documentation: 1. The date and time the shower/bath was performed. 2. The name and title of the
individual (s) who assisted the resident with the shower/bath. 5. If the resident refused the shower/bath, the
reason (s) why and the intervention taken. 6. The signature and title of the person recording the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146085
If continuation sheet
Page 2 of 3
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
146085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
LA Bella at Clifton
1190 E 2900 North Road
Clifton, IL 60927
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
data.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146085
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the January 9, 2025 survey of LA BELLA AT CLIFTON?
This was a inspection survey of LA BELLA AT CLIFTON on January 9, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LA BELLA AT CLIFTON on January 9, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.