Inspection·April 8, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place, and failed to identify and implement a system to ensure bed and chair alarms are functioning. These failures apply to 1 of 3 residents (R1) reviewed for falls in the sample of 4. The findings include: R1's face sheet printed on 4/8/25 showed R1 has diagnoses including but not limited to schizophrenia, anxiety disorder, dementia without behaviors, extrapyramidal & movement disorder, bipolar disorder, and unsteadiness on feet. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and has experienced 2 falls without injury and 1 fall with injury. R1's fall risk assessment dated [DATE] (prior to R1's most recent fall) showed R1 is a high fall risk. R1's care plan dated 4/22/24 showed, (R1's) review shows risk for falls. Risk Factors include behaviorimpulsive without regard for safety, cognitive Impairment- does not understand limits, gait/balance problems . The facility's fall investigation dated 4/6/25 showed, (R1) experienced a fall resulting in a laceration to the right middle forehead. The incident occurred around 5:25AM on April 6, 2025. (R1) is known to be at risk for falls, and a bed alarm was in use to enhance her safety .Additional Notes: During the incident, it was noted that the bed alarm did not activate as expected .The facility is currently conducting a thorough review of this equipment to ensure its functionality and reliability. We are committed to maintaining the highest standards of safety and care, which includes regular checks and maintenance of all safety devices. R1's electronic medical record showed no physician's orders for a bed/chair alarm, no routine documentation of bed/chair alarm checks to ensure functionality, and no care plan documentation of bed/chair alarms being utilized for R1. On 4/8/25 at 10:00AM, V3 (Maintenance) was inspecting R1's bed alarm control box. V3 stated he does not have any routine checks he does of bed alarms and that today was the first time he was asked to look at R1's bed alarm to check its functionality. (2 days after R1's fall) (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: 146152 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 146152 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Rochelle 1021 Caron Road Rochelle, IL 61068 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)