Inspection·October 23, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few declined going anywhere to talk in private and stated it could be done right there. R1 stated on Monday R2 was in her room stealing. R1 stated R2 was bent over a box container that had snacks in it under her bed. R1 stated R2 ran from R1's room through the bathroom and jumped onto R2's bed. R1 stated she followed R2 into her room and she punched R2 in the face. R1 stated R2 has stolen stuff from her room before and no one is doing anything about it, R1 stated she took things into her own hands and hit R2 in the nose. R1 stated R2 stays away from her now. R1 stated they offered to give her a different room and she doesn't want to change rooms. R1 stated she keeps the bathroom door to her room closed at all times now. R1 stated if they (facility) would do something about R2 stealing then this would not have happened. R1 stated if the facility would have handled R2 stealing before this then she would not have had to. R1 stated she was told she can't hit people yet staff were glad that she did it because R2 steals from them and other residents. R1 stated she does not go around hitting people and knows not to do that.On 10/23/25 at 8:56 AM, R2 was in her room, awake, laying on her bed. R2 stated she got in a fight because R1 was mad at her. R2 stated she went into R1's room and was going through her stuff to find something to drink. R2 stated snack time was 4 hours away and she wanted something now. R2 stated R1 did not tell her she could go in her room or through her stuff. R2 stated she knows it was wrong. R2 stated she was in R1's room and the janitor saw her. R2 stated when R1 came back to her room she came over to R2's room and punched her in the face. R2 stated she did not get hurt, and she was not upset over being hit. R2 denied any injury. R2 stated she is not afraid of R1 and did not want to change rooms. R2 stated after it happened V1 Administrator, and V2 DON came and talked to her, and she told them what happened. V1 and V2 told her not to do it again. R2 stated the police did not come in and talk to her. R2 stated she doesn't go into other people's room all the time. R2 stated she just so hungry that she wasn't thinking straight and was trying to find something to eat and drink.On 10/23/25 at 9:03 AM, R6 was in her room that she shares with R2 and stated she was in the room when the incident happened. R6 stated R1 came into R2's room and she tried to tell R1 to get out. R1 said she did not care and that she was going to knock R2 out. R6 stated the curtain between her and R2's bed was partially closed so she got up and saw R1 hit R2 in the nose. R6 stated R1 followed R2 through the bathroom and hit R2. R6 stated she heard R2 took something from R1's room. R6 stated other residents have complained about R2 taking things from their rooms but they don't bother her about it because they know she does it. It is a disease that R2 has, and she doesn't know what she is doing. R2 just thinks she is hungry and thirsty and does it. R2 doesn't think to go to the nurse or put her light on and ask for water. R6 stated she tries to help R2 and watch over her because R2 is her friend. R6 stated V1 and V2 came and talked to R2 and then talked to R6 about it later. R6 denied R1 ever coming into their room before or R1 and R2 ever being in a fight before. R6 stated she was not afraid of R1 and was not worried about her coming into their room. R6 stated R2 knows she shouldn't steal, and the staff have talked to her about it before.On 10/23/25 at 9:51 AM, V1 Administrator stated he was on a conference call when the incident happened, and he wanted to make sure it happened. V1 stated he wanted to make sure it wasn't he said she said situation. V2 did not find any injury on either resident. V1 stated he should have reported this and is aware that abuse will be cited for the facility. V1 stated staff should have documented the incident in the chart, that he was not aware that it wasn't documented, and did not know why it wasn't documented. V1 stated they were not saying the incident did not happen.On 10/23/25 at 10:32 AM, V2 Director of Nursing (DON) stated R2 has behaviors and a history of stealing. R2 goes into other resident's rooms all the time. Staff keep redirecting her. When R2 does this it is reported, and we continue to educate her. R2 has had her room moved in the past and occasional room searches are done. R2 is focused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 2 of 5 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 10/23/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on stealing food and soda. V2 stated she hasn't been at the facility very long and was not sure what all has done in the past. V2 stated she was made aware of the incident and talked to R1 and R2. V2 stated R1 told her that she confronted R2 about being in her room. V2 stated R2 did not tell her that R1 hit her, V2 stated R2 admitted going into R1's room but did not recall everything R2 told her. V2 stated she told R2 that it was inappropriate to go in anyone room and touch things. V2 stated the residents were kept away from each other. V2 stated R1 was offered a room change and refused. R1 and R2 have been monitored and stay away from each other. V2 stated she looked into R1 and R2's medical records today and saw that there wasn't any documentation about the incident. V2 stated she put a note in risk management today about the incident. V2 stated the nurse should have documented in the resident's medical records what happened. V2 stated V1 is the abuse coordinator, and he does the reporting and investigation of any allegations of abuse. V2 stated her part is to enter the incident in risk management. V2 stated the police were not notified of the incident and the families were contacted by the administrator.The Minimum Data Set (MDS) dated [DATE] for R1 showed no cognitive impairment. The MDS dated [DATE] for R2 showed no cognitive impairment.The facility's Abuse, Neglect, and exploitation policy (2025) showed, abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Event ID: Facility ID: 146152 If continuation sheet Page 3 of 5 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 10/23/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of abuse between two residents to the state agency when R1 hit R2. This failure affects two of four residents (R1/R2)reviewed for abuse in the sample of six.The findings include:The written Statement from Administrator dated 10/20/25 in an investigation file for R1 & R2 showed, On October 20th, during a conference call around noon, the writer was informed of a confrontation between two residents, R2 and R1 both with a BIMS (Brief Interview of Mental Status) of 15 (no cognitive impairment). R2 reported that she entered R1's room without a clear reason, which R1 found objectionable. Following this, R1 confronted R2 in her own room. R1 claimed that R2 was going through her personal belongings, which did she did not appreciate. At the time of these interviews, there was no evidence or confirmation of physical contact or altercation between the two. The Medical Doctor was notified, and the Power of Attorney (POA) was contacted. A preliminary investigation was initiated, although initially, there was no founded evidence of an altercation, and thus, it was not reported externally. The facility did not have an Initial Report for the resident-to-resident altercation between R1 and R2.On 10/23/25 at 8:34 AM, V3 Registered Nurse (RN) stated on Monday (10/20/25) she was working and R1 and R2 had an altercation. V3 stated she wasn't the nurse for R1 and R2; V4 RN was working in that area. V3 stated she was told R2 was caught in R1's room going through R1's things. Someone told R1 that R2 went into R1's room. R1 and R2' share a bathroom in between their room. R1 went to her room, went through the bathroom to R2's room and punched her in the face. R2 did not go to the hospital. R1 and R2 were separated for the day and monitored. V3 stated when something like this happens the nurse will assess the residents, let management know what happened, and they do the investigation and reporting. In the past the police would be called when something like this happens, but she did not see the police come in this time. On 10/23/24 at 8:40 AM, V5 Certified Nursing Assistant (CNA) stated he was working at the time of the incident between R1 and R2. V5 stated he was in the hall going to get a dressing for V4 RN who was in a room doing a dressing change. V5 stated when he came back with the dressing, V4 told him to get V2 DON because R1 had punched R2. V5 stated the police did not come in for the incident. V5 stated he has never had a problem between R1 and R2 before. V5 stated R1 doesn't have any behaviors and has never hit any residents before. V5 stated R2 has behaviors of going into other residents' rooms and taking things that are not hers. On 10/23/24 at 8:45 AM, R1 was sitting in a wheelchair by the door in the common area waiting to go outside to smoke. R1 declined going anywhere to talk in private and stated it could be done right there. R1 stated on Monday R1 was in her room stealing. R1 stated R2 was bent over a box container that had snacks in it that had been under her bed. R1 stated R1 ran from R2's room through the bathroom and jumped onto R2's bed. R1 stated she followed R2 into her room and she punched R2 in the face. R1 stated R2 has stolen stuff from her room before and no one is doing anything about it, R1 stated she took things into her own hands and hit R2 in the nose. R1 stated R2 stays away from her now. R1 stated they offered to give her a different room and she doesn't want to change rooms. R1 stated she keeps the bathroom door to her room closed at all times now. R1 stated if they (facility) would do something about R2 stealing then this would not have happened. R1 stated if the facility would have handled R2 stealing before this then she would not have had to. R1 stated she was told she can't hit people yet staff were glad that she did it because R2 steals from them and other residents. R1 stated she does not go around hitting people and knows not to do that.On 10/23/25 at 8:56 AM, R2 was in her room, awake, laying on her bed. R2 stated she got in a fight because R1 was mad at her. R2 stated she went into R1's room and was going through her stuff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 4 of 5 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 10/23/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete find something to drink. R2 stated snack time was 4 hours away and she wanted something now. R2 stated R1 did not tell her she could go in her room or through her stuff. R2 stated she knows it was wrong. R2 stated she was in R1's room and the janitor saw her. R2 stated when R1 came back to her room she came over to R2's room and punched her in the face. R2 stated she did not get hurt, and she was not upset over being hit. R2 denied any injury. R2 stated she is not afraid of R1 and did not want to change rooms. R2 stated after it happened V1 Administrator, and V2 DON came and talked to her, and she told them what happened. V1 and V2 told her not to do it again. R2 stated the police did not come in and talk to her. R2 stated she doesn't go into other people's room all the time. R2 stated she just so hungry that she wasn't thinking straight and was trying to find something to eat and drink.On 10/23/25 at 9:51 AM, V1 Administrator stated they did not report the incident between R1 and R2 to Illinois Department of Public Health (IDPH) because we wanted to do a soft investigation to see what happened. V1 stated he was on a conference call when the incident happened and he wanted to make sure it happened. V1 stated he wanted to make sure it wasn't a he said she said situation. V2 did not find any injury on either resident. V1 stated we did not report this and we are supposed to report it within 2 hours but did start an investigation. V1 stated he should have reported this and is aware that abuse will be cited for the facility. The Minimum Data Set (MDS) dated [DATE] for R1 showed no cognitive impairment. The MDS dated [DATE] for R2 showed no cognitive impairment.The facility's Abuse, Neglect, and exploitation policy (2025) showed, abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Reporting/Response: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Event ID: Facility ID: 146152 If continuation sheet Page 5 of 5