Inspection·July 1, 2025

F 0697 Level of Harm - Actual harm Residents Affected - Few R1's June 2025 eMAR (electronic Medication Administration Record) showed on 6/30/25, R1 received a dose of hydrocodone-acetaminophen at 5:00 PM and subsequently received a dose of her PRN (as needed) oxycodone-acetaminophen at 6:57 PM when she reported her pain level at a 5. (This pain medication was administered within 2 hours of the previous pain medication.) R1's next dose of pain medication documented was on 7/1/25 at 4:36 AM when she received a dose of her PRN pain medication oxycodone-acetaminophen. On 7/1/25 at 10:30 AM, R1 was lying in her bed with a long hinged brace to her left leg. R1 was rubbing and holding her upper leg and wincing in pain. R1 said she rated her pain at a 10 out of 10. R1 said she has breaks in her leg and she is not doing good . I'm hurting so bad. I need to get out. I need something. On 7/1/25 at 10:36 AM, V4 RN (Registered Nurse) said she has been really busy this morning with a resident who is one on one at the nursing station. V4 said she was taking R1's scheduled hydrocodone-acetaminophen scheduled to be administered at 7:00 AM into R1 right now (3.5 hours after the scheduled administration time). V4 said a CNA (Certified Nursing Assistant) came up to her and told her R1 needed something for pain. V4 said she just got the word now regarding R1's pain so she headed down to see her. On 7/1/25 at 2:30 PM, V2 DON (Director of Nursing) said after reviewing R1's medication administration record, [R1] should not have been given the 6:57 PM dose of oxycodone with a pain level of 5. I would have expected them to give her Tylenol, reposition her, use distraction, or see what else we can do to make it better at that point. It was too soon to give another narcotic pain medication. That is probably why she slept through until the morning after that and didn't need another dose until the morning. This morning with the delayed medication pass she should have pulled an aide to sit with the resident at the nurses station and passed her medications instead of being so far behind. The facility's policy and procedure implemented 3/2025 showed, Pain Management . Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences . The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated . c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: . c. Fidgeting, increased or recurring restlessness d. facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) e. Behaviors such as: resisting care . irritability, depressed mood . Pain Management and Treatment: 1. Based upon evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individuals resident's pain beginning at admission . 7. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain . h. Opioid treatment for acute pain, subacute pain, and chronic pain will be prescribed and dosed in accordance with current professional standards of practice and manufacturers guidelines to optimize their effectiveness and minimize their adverse consequences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 2 of 3 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 07/01/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure medications were administered within their scheduled timeframe for 1 of 1 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's facesheet showed she was admitted to the facility 9/18/19 with diagnoses to include transient cerebral ischemic attack, pseudobulbar affect, disorders of bone density and structure, major depressive disorder, spastic hemiplegia, insomnia, bipolar disorder, hyperlipidemia, mood disorder, and anxiety disorder. On 7/1/25 at 10:36 AM, V4 RN (Registered Nurse) was administering medications to R1. V4 said, These are [R1's] scheduled morning medications. V4 said she has been really busy this morning with a resident who is 1 on 1 at the nursing station. R1's July 2025 eMAR (electronic Medication Administration Record) showed medications scheduled to be administered at 7:00 AM to include dicyclomine 10 mg (milligrams) TID (three times a day), gabapentin 600 mg TID, Hydrocodone-Acetaminaphen 10-325 mg TID, and Metformin HCL 1000 MG BID (two times a day). These medications were administered at 10:36 AM (2.5 hours outside of the allowable medication administration time). The next dose of dicyclomine, gabapentin, and Hydrocodone-Acetaminophen were scheduled to be administered at 12:00 PM (only 1.5 hours after the morning medications were administered.) On 7/1/25 at 2:30 PM, V2 DON (Director of Nursing) said after reviewing R1's medication administration record,This morning with the delayed medication pass [V4] should have pulled an aide to sit with the resident at the nurses station and passed her medications instead of being so far behind. Medications can be passed 1 hour before and 1 hour after the scheduled administration time. It would be too soon to give these medications again at the next scheduled administration time. The facility's policy and procedure revised 11/2024 showed, Medication Administration . Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 3 of 3