Inspection·December 5, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some influence of drugs or alcohol but admitted she'd had a previous addiction to opioids and benzos (benzodiazepines) of which she was treated for in 2019. V12 stated on 12/2/25, she should have requested to go home that day because I was so tired. V12 stated she did at some point on 12/2/25 start to doze off if I sat down and her head may have bobbed or jerked because she was so tired. V12 stated she took a urine drug test on 12/2/25 that was given to her by V2 Director of Nursing (DON). V12 stated, My urine test was negative, so I went back to work and finished my shift. I was so tired I should have requested to go home after my test came back negative.On 12/5/25 at 11:03 AM, V1 Administrator stated he did receive concerns from V3 CNA, V4 CNA, V9 Housekeeping, V10 Dietary Manager, and V11 CNA about V12 LPN falling asleep at work on 12/2/25 around 10 AM. V1 stated around 11 AM that morning, V1 and V2 DON pulled (V12) in to talk to her. V1 stated, (V12's) eyes were open. We asked her if she needed any help. (V12) said she was just tired. We gave her a cup of coffee. We let her go back to work. She denied she had taken any drugs or alcohol. I kept watching her. Around lunchtime, I saw (V12) nod off and close her eyes. That's when we called our human resources, and they told us to drug test her. V1 stated V2 DON went to a local pharmacy to get a an over the counter (OTC) urine drug test because the facility did not have a contract with a local laboratory to have employees drug tested. V1 Administrator stated V12's OTC urine drug test was negative however V1 could not state exactly what drugs V12's urine was tested for and did not have any written results of V12's urine screen. V1 pulled out his cell phone and showed this surveyor a black and white pictures of an unlabeled and undated specimen cup. The cup showed no written results that identified exactly what was measured or identified from the liquid specimen noted in the cup. When V1 was asked what the facility policy was on what to do if a staff member appears impaired or too tired at work, V1 stated, We would send the staff member home because their productivity would be compromised if they can't stay awake. They wouldn't be able to chart or give medications. When V1 was asked how he could ensure that V12 was able to provide safe cares to residents on 12/2/25 after multiple complaints from staff members, V1 stated, We kept an eye on her. Her drug test was negative. I guess I can't answer that. I should have sent her home, but I left that up to (V2 DON). On 12/5/25 at 12:07 PM, V2 DON stated she received multiple complaints from staff, on 12/2/25, stating V12 LPN was falling asleep at work. V2 DON stated on 12/2/25 around late morning, V2 and V1 Administrator pulled V12 LPN aside to speak with her. V2 stated she found V12 to be awake and alert at that time. V2 stated V12 reported that she was tired. V2 and V1 sent V12 LPN back to work. V2 stated around lunch time she again was notified by staff that V12 continued to fall asleep at work. V2 DON stated she went to a local pharmacy to pick up an OTC urine drug test. V2 returned to the facility and watched V12 LPN take the drug test. When asked exactly what drugs were tested for in V12 LPN's urine drug test, V2 stated, I don't exactly know all of them. I would have to look at the box. I just know the urine test was negative. V2 DON was unable to provide any written test results from V12's urine drug screen completed on 12/2/25. V2 DON stated she sent V12 LPN back to work after her drug screen was negative because I never saw her sleeping or saw her with any behaviors I was concerned about. I would have sent her home if I myself had seen her sleeping. On 12/5/25 at 12:44, V14 Medical Director was asked what he would do if his saw a staff member falling asleep in a facility or the staff member seemed impaired in any way, V14 stated, I would report it immediately to the administrator or DON. When V14 was asked if he would allow a nurse to take care of his residents if he or she appeared impaired for any reason, V14 stated, Absolutely not.The facility's Conduct and Behavior policy (undated) showed, All employees must adhere to accepted professional standards. This includes displaying business conduct and behavior, and exhibiting a high degree of integrity at all times. Conduct that interferes with the safe operation of the (continued on next page) 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 12/05/2025 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 0689 facility, brings discredit to the company, residents or staff, or that is offensive to a resident, family member, visitor, or employee, will not be tolerated and can be grounds for disciplinary action. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146152 If continuation sheet Page 3 of 3