Health inspection·April 23, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review the facility failed to ensure the right to be free from physical abuse for three (R1, R2, &R3) of four residents reviewed for abuse from a sample list of four residents. Findings include: 1.) The facility provided incident report dated 4/19/25 documents that an altercation between R1 and R3 occurred in the dining room at approximately 6:00 AM. V14, Dietary Aid's, written statement dated 4/19/25 documents that V14, Dietary Aid, heard R1 and R3 screaming in the dining room at approximately 6:00 AM. R3 had blocked R1 in the dining room and was cursing at her. R1 complained that R3 kicked her. R1's Minimum Data Set, dated dated 3/26/25 documents that R1 is cognitively intact. On 4/21/25 at 11:45 AM, R1 stated that R3 bothers her and that R3 hit her left knee a few days ago and caused her pain. On 4/21/25 at 12:00 PM, V3, R1's Family Member, stated that the facility notified her on 4/19/25 that R3 had hit R1's leg and that R1 confirmed that R3 had kicked her in the knee. 2.) The facility provided incident report dated 4/19/25 documents that at approximately 6:30 PM, R2 and R3 approached the exit door on the B hall and R3 pushed R2, resulting in a right knee skin tear. V7, Certified Nursing Assistant (CNA), stated that he observed R3 raise both hands, place them on R2's back and pushed R2 to the ground. R2's minimum data set documents that R2 is severely cognitively impaired. R2's progress notes dated 4/19/25 documents that V7, CNA, observed R3 push R2 to the floor. On 4/23/25 at 11:01 AM, V12( Licensed Practical Nurse (LPN)) removed R2's right knee dressing where a quarter-sized skin tear was observed. R2 winced in pain as V12 (LPN) moved R2's over the wound and above the knee. On 4/23/25 at 11:05 AM, R2 stated as the bandage was removed, That's my knee that hurts. (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 4 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 04/23/2025 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)