Inspection·April 14, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm The facility's Pressure Injury Prevention Guidelines Policy states, To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is he policy of this facility to implement evidence based interventions for all residents who are assessed at risk or who have a pressure injury present compliance with interventions will be documented in the medical record for residents who have a pressure injury present: treatment of medications administration records . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 2 of 4 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 04/14/2025 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)

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide physical therapy treatments for a resident admitted for skilled services. This applies to 1 of 3 (R1) residents reviewed for rehab services in the sample of 5. Residents Affected - Few The findings include: R1's face sheet shows he is a [AGE] year old male admitted on [DATE], with diagnoses including embolism and thrombosis of the lower extremities, chronic atrial fibrillation, diabetes mellitus, hypertension, COPD, CHF, and peripheral vascular disease. On 4/14/25 at 8:46 AM, R1 was observed sitting in his wheelchair with mechanical lift sling under him. R1 said they transfer him using the mechanical lift. R1 said his right leg is weak and he can stand but is not ambulating. R1 said get me the hell out of here. R1 said he's been here for about one month and is not receiving physical therapy five days a week. R1 said he has Medicare A they cover 120 days of skilled care. R1 said he came to the facility after having a blood clot in his right leg and was walking prior to his hospitalization. R1 said he came to facility to receive therapy so he can go home. On 4/14/25 at 10:24 AM, V2 (DON) said physical therapy staff are usually here every day because we have residents who should have therapy daily. R1 is supposed to be receiving therapy daily, R1 reported concerns about therapy and she spoke with V9 (Director of Therapy). V9 reported he is not always cooperative. On 4/14/25 at 12:02 PM, V10 (Physical Therapist) said today is her first time at the facility and works as prn (as needed) and she is not familiar with the residents. V10 said V9 can answer questions and asked to call him to assist with any questions. V9 was interviewed he said residents should receive therapy as ordered. V9 said R1 should be receiving therapy five days a week and he did his therapy on 4/11/25 (Friday). R1 was able to stand but not able to ambulate, he was a max assist with transfers and recommended the staff use the mechanical lift for transfers for safety. V9 said he did not want to answer if R1 was receiving his therapy five days a week without reviewing his medical records. V9 said there were multiple times when therapy staff were a no call no show and residents did not receive therapy on those days. On 4/14/25 at 12:13 PM, V10 reviewed R1's therapy notes and confirmed he did not receive physical therapy five days a week. V10 said there has been staffing issues with this facility and that's why she is here today. R1's Physician Order Sheets dated April 2025 shows orders for Physical Therapy(PT)/Occupational Therapy (OT) evaluation .I certify skilled nursing services (SNF) are required to be given on an inpatient SNF basis of this residents need for skilled care on a continuing basis for the condition, for which he was receiving inpatient hospital services prior to his transfer .skilled services PT/OT. R1's Physical Therapy Evaluation and Plan of Treatment Certification Period: 3/20/25-4/29/25 shows his plan of treatment for physical therapy is 5 times a week to improve strength, balance, actively tolerance and safety, independence with transfers, bed mobility and ambulation following recent hospitalization following abdominal aneurysm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 3 of 4 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 04/14/2025 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)

F 0825 R1's Physical Therapy Service Log for March 20, 2025 and April 12, 2025 (3 weeks) shows he received three therapy sessions per week (two physical therapy treatments were not provided). 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: 146152 If continuation sheet Page 4 of 4