Health inspection·June 25, 2025

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 interviews and record reviews the facility failed to protect one (R6) resident from verbal and physical abuse out of nine residents reviewed for abuse in a sample list of 12 residents. R6 was admitted to the facility on [DATE] and has the following medical diagnoses; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Sepsis, Inflammatory Disorders of Scrotum, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Cerebral Infarction, COPD, Muscle Wasting and Atrophy, Lack of Coordination, Type 2 Diabetes, GERD, Heart Failure, Major Depressive Disorder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Tachycardia, HTN, Gout, Muscle Weakness, Malaise, Acquired Absence of Left Leg Above Knee and Nicotine Dependence. R6's Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score 14, cognitively intact. R6's Health Note dated 6/7/25 at 8:37pm documents: Chief Complaint: General Notifications: Vitals: Temperature 97.8, Pulse 78, Blood Pressure 147/76, Respirations 18, Oxygen saturation 92% on room air. Summary: R6 reported to staff being choked by stepdaughter. No markings noted. R6 is stable. Local County Sheriff's Department Report #P2506-0012 dated 6/7/25 at 8:39pm documents on Saturday 6/7/25 at 4:59pm, V16 Deputy Sheriff's Department was dispatched to nursing home [NAME], Illinois, in regard to possible assault. V16 arrived on scene at 7:19pm and was met by V1 Administrator. V1 made V16 aware that R6 had complained about being grabbed and choked by V17 R6's Stepdaughter, during an earlier visit that day. V1 stated that shortly after their visit V6 pulled a staff member aside and explained to them what had happened. V1 said that R6 although elderly, was lucid and could speak for R6's self. V1 escorted R6 into an office where R6 could be interviewed. Upon first seeing R6, V16 noticed R6 to be an elderly man with some considerable physical disabilities. R6 left leg was amputated and R6 was wheelchair bound. R6 was able to give me R6's name and stated that R6 has been living here since December and that R6 was previously at a different nursing home for 6 months prior to that. R6 told V16 that V18 (R6's Wife) and V17 had been at the nursing home to visit R6 at around 4:00pm. R6 stated that during the visit V17 asked R6 for R6's bank card. R6 told V17 that R6 had given it to a friend to hold for safe keeping because R6 had recently lost R6's wallet. R6 said, at around 4:15pm is when V17 and V18 accompanied R6 to the parking lot to smoke a cigarette and say goodbye. R6 said, while in the parking lot, V17 again asked R6 for R6's bank card and claimed R6 owed R17 money. R6 stated that when R6 did not produce R6's bank card, V17 grabbed R6 by R6's shirt collar with one hand and grabbed R6 by the neck with the other. R6 said R6 had a hard time moving when V17 had ahold of him. V17 and V18 then exited the nursing home property in their vehicle. (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 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 06/25/2025 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)