F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Potential for
minimal harm
Based on interview and record review, the facility failed to develop their abuse prevention policy to include a
definition of abuse to include abuse facilitated or enabled by the use of technology. This failure has the
potential to affect all seventy residents residing in the facility.
Residents Affected - Many
Findings include:
The facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated August
2024, does not include a prohibition of abuse facilitated or enabled by the use of technology.
On 3/26/25 at 12:59 PM, V1, Administrator, acknowledged and confirmed the abuse prevention policy dated
August 2024 was the most recent revision and did not include the prohibition of abuse utilizing technology
such as video recording of residents in compromising situations.
On 3/26/25 at 4:15 PM, V6, [NAME] President of Clinical Operations, stated she could put the prohibition
against the use of technology into the facility policy right now.
The facility's Resident Roster dated 3/25/25 documents 70 residents residing in the facility.
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:
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
03/26/2025
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review, the facility failed to implement a plan of care to reduce
resident intrusion of privacy and resulting in aggression. This failure has the potential to affect two residents
(R1 and R2) out of three reviewed for allegations of abuse on the sample list of three.
Findings include:
On 3/25/25 at 11:05 AM, V1, Administrator, stated there had been an incident between R1 and R2 on
3/21/25 when R2 wandered into R1's room, R1 had gotten out of bed to redirect R2 out of his room, and
both residents ended up falling to the floor with R2 landing on top of R1.
R2's Nursing Progress Note dated 3/20/25 documents R2 had exited his bathroom in the wrong direction
on this date, entering the adjoining room of R1 and upsetting R1. This same note documents an
interdisciplinary team review of this incident and formulated a plan of care to place a sign in the bathroom
to indicate to R2 which bathroom door to exit to go into his own room.
On 3/25/25 at 2:30 PM, there was not any sign in the adjoining bathroom between R1's and R2's room to
indicate to R2 which bathroom door to exit to return to his own room rather than R1's room.
On 3/26/25 at 1:45 PM, V2, Director of Nursing, stated she had participated in the interdisciplinary team
review and the team did decide to place a sign in the bathroom between R1's and R2's rooms to indicate
which direction R2's room was from the bathroom. V2 stated the sign did not get placed and then this other
incident happened between R1 and R2 when R2 wandered into R1's room during the night. V2 continued to
state the facility did install a locking doorknob cover on the bathroom door leading to R1's room so that
bathroom door could not be opened from inside the bathroom. V2 stated when R1 uses the bathroom he
has to leave the door open so he can return to his own room when he is finished.
On 3/25/25 at 1:50 PM, V6, [NAME] President of Clinical Operations, was instructing V2 to resolve off R2's
care plan for the doorknob cover and implement placement of the sign according to the interdisciplinary
team decision. V2 then stated there wasn't any reason the facility couldn't do both the sign and the
doorknob.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146085
If continuation sheet
Page 2 of 2
