La Bella of Rochelle

Inspectors wroteBased on interview and record review the facility failed to prevent a resident to resident abuse for two residents (R4 & R5) reviewed for abuse on the sample list of 11. This facility failure resulted in R4 sustaining a thoracic fracture and being sent to the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate a resident-to-resident sexual abuse allegation involving a resident (R1) with impaired cognitive abilities. This applies to two of five residents (R1 & R2) reviewed for abuse in the sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to have interventions in place to protect a cognitively impaired resident from potential abuse. This applies to one of five residents (R1) reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's power of attorney - POA of the residents fall for 1 of 3 residents (R1) reviewed for notification in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a complete assessment was done and documented after a residents fall for 1 of 3 residents (R1) reviewed for falls and assessments in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident to resident abuse did not occur for one of 5 residents (R1) reviewed for abuse in the sample of five. This failure contributed to R1 experiencing a fracture and increased pain in his right foot.

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were documented as administered on the Medication Administration Record (MAR) after administration for 1 of 5 residents (R4) reviewed for medication administration in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and gallbladder drain for 1 of 3 residents (R1) reviewed for infection control in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure post fall assessments, to include vital signs, head to toe assessment and fall follow up, were completed for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fall interventions were in place for 1 of 3 residents (R1) reviewed for safety in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to prevent the misappropriation of resident medications by staff. This applies to 1 of 3 residents (R5) reviewed for misappropriation in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure the safety of residents by allowing a nurse with witnessed behavior changes outside her norm to provide cares to residents. This failure had the potential to affect all 25 residents (R1-R25) V12 Licensed Practical Nurse (LPN) cared for on 12/2/25.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident (R1) received a physical therapy evaluation per physician's order. This failure affects 1 of 2 residents (R1) reviewed for physical therapy in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to prevent abuse between two residents when R1 hit R2, This failure applies to two of four residents (R1/R2) reviewed for abuse in the sample of six.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a fractured leg received scheduled pain control medication for 1 of 1 residents (R1) reviewed for pain in the sample of 3. This failure resulted in R1 experiencing pain rated at a 10 out of 10.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were allowed to smoke for 17 of 19 residents (R1 and R3-R18) reviewed for resident rights in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents (R1 & R2) were free from physical abuse for two residents reviewed for abuse in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to employee a qualified dietary staff member to oversee the operations of the kitchen. The facility failed to ensure residents' nutritional assessments were completed, in-person, by a qualified dietary staff member. These failures have the potential to affect all 51 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide sufficient dietary staff to carry out the necessary functions of the food service. The facility failed to ensure dietary staff had the required certifications to provide food service to residents. These failures have the potential to affect all 51 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a breakfast menu was followed. This failure has the potential to affect all 51 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the prescribed wound treatment was provided to a resident with stage 4 pressure ulcer. This applies to 1 of 3 (R4) residents reviewed for wounds in the sample of 5.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to provide medical records to a resident's guardian/power of attorney for healthcare (POA) upon verbal and written request for 1 of 3 residents (R1) reviewed for the right to access medical records in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a pressure injury was identified prior to becoming a stage three. This failure resulted in R31 developing a stage three pressure injury to his left ischium that had light serous drainage. This applies to 1 of 1 residents (R31) reviewed for pressure injuries in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure supplements were served and failed to obtain weekly weights for four of eight residents (R18, R24, R5, R34) reviewed for nutrition in the sample of 18. This failure resulted in R18 experiencing a significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to offer the influenza vaccine at the start of influenza season for two of nine residents (R40, R4) reviewed for Influenza Vaccines in the sample of 18. This failure contributed to the facility experiencing an Influenza Outbreak and the hospitalization of R40 and R4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dish machine was plumbed per code to prevent cross-contamination. This has the potential to effect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to track and trend resident illnesses failed to ensure the required PPE (Personal Protective Equipment) was worn when providing care to a resident on enhanced barrier precautions (EBP), and failed to ensure EBP signs were posted outside of residents' rooms. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's advanced directive to be a full code was ordered for 1 of 18 residents (R103) reviewed for advanced directives in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is dependent on staff for Activities of Daily Living (ADLs) received incontinence care in a timely manner for 1 of 18 residents (R33) reviewed for ADLs in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a cholecystostomy drain had a dressing order in place and failed to ensure ace wraps were applied for treatment of lower extremity edema as ordered for 2 of 18 residents (R40 and R103) reviewed for quality of care in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for two of 18 residents (R28, R31) reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were available and administered as ordered and failed to ensure residents were supervised while administering medications for 2 of 18 residents (R23, R49) reviewed for pharmacy services in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure monthly pharmacy recommendations were carried out. This applies to 1 of 5 residents (R31) reviewed for drug regimen reviews in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition for three of 18 residents (R28, R4, R19) reviewed for safe equipment in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to protect a resident from mental abuse for one of four residents (R1) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility has a fulltime Director of Nursing (DON). This failure affects all residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's representative had access to the resident's medical records to 1 of 3 residents (R1) reviewed for medical record in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate a bruise with an unknown origin to 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to document the residents reason for discharge and failed to obtain physician documentation before discharging a resident for 2 of 3 (R10, R9) residents reviewed for discharge in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's guardian and the Ombudsman of a resident's involuntary discharge for 1 of 3 residents (R10) reviewed for discharge in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to allow a resident to return to the facility after a hospital stay and failed to document the reason for the refusal for 1 of 3 residents (R10) reviewed for discharge in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to implement discharge planning for 1 of 3 residents (R9) reviewed for discharge in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's discharge summary was complete for 1 of 3 residents (R9) reviewed for discharge in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to assess and identify a change in condition for a resident after a fall. This failure resulted in a delay in identifying and obtaining treatment for R2's right hip fracture. This applies to 1 of 4 residents (R2) reviewed for injuries in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care for a resident (R1) with a recent urinary tract infection. This applies to 1 of 3 residents reviewed for infections in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with severe cognitive impairment, poor safety awareness and a history of elopement was supervised in the facility courtyard after the door alarm did not sound and R4 exited the building. This applies to 1 of 3 residents (R4) reviewed for safety and supervision in the sample of 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' medications were delivered by individuals who have the skills, knowledge and proper licensure for 8 of 14 residents (R1-R6, R13 and R14) reviewed for medication administration in the sample of 14.

Inspectors wroteBased on interview and record review the facility failed to treat a resident's pain as ordered by the physician. This applies to one of three residents (R1) in the sample of three reviewed for pain. This failure resulted in R1 saying that being without his pain medications affects him both physically and emotionally. R1 said he was feeling shaky and nauseated.

Inspectors wroteBased on interview and record review the facility failed to timely reorder a controlled substance pain medication that the pharmacy required a new prescription from the physician. This failure resulted in a delay in obtaining a prescription from the physician and the resident missing up to 12 doses of this medication. This applies to one of three residents (R1) in the sample of three reviewed for pain medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident at high risk for elopement did not leave the facility unsupervised for 1 of 3 residents (R1) reviewed for elopement in the sample of 14. This failure resulted in an Immediate Jeopardy. The facility failed to ensure resident safety by timely and accurate documentation of resident monitoring for 14 of 14 residents (R1-14) reviewed for frequent monitoring (15-minute checks) in the sample of 14.

Inspectors wroteBased on interview and record review the facility failed to have interventions in place to mitigate the growth and spread of legionella and failed to maintain logs of interventions. This has the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were provided influenza and pneumococcal immunizations as required. This applies to 3 of 3 residents in the sample (R46, R51, R20) reviewed for immunization in the sample 16 and 2 residents outside of the sample (R21, R54).

Inspectors wroteBased on interview and record review the facility failed to ensure residents were provided COVID vaccinations as required. This applies to 3 of 3 residents in the sample (R46, R51, R20) reviewed for COVID immunization in the sample 16, and 2 residents outside of the sample (R21, R54).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident corridor had a section of handrail in place. This applies to 6 of 6 residents (R35, R46, R33, R10, R1, R40) reviewed for handrails in the sample of 16 and 8 residents (R37, R2, R34, R9, R54, R48, R12, R24) outside of the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a window covering or provide a window covering in good repair for 3 of 4 residents (R35, R40 & R46) reviewed for privacy in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 2 residents (R45) reviewed for abuse in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound care as ordered by the wound care physician, failed to identify a wound on a resident's foot, and failed to document details regarding a resident's death. This applies to 2 of 3 residents (R46, R10) reviewed for non-pressure wound care in the sample of 16 and 1 resident (R56) outside of the sample reviewed for death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's respiratory care equipment was stored and administered in a manner to prevent cross contamination for 1 of 2 residents (R1) reviewed for respiratory care in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to date a vial of insulin when it was opened for 1 of 1 resident (R14) reviewed for insulin.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve all menu items to a resident on a puree diet. This applies to 1 of 1 resident (R22) reviewed for puree diet in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wash and sanitize food preparation equipment in between food items for 1 of 1 resident (R22) reviewed for puree diet in the sample of 16.

Inspectors wroteBased on interview and record review the facility failed to thoroughly assess a resident (R1) following an injury of unknown origin. This failure resulted in a delay in identifying and obtaining medical treatment for a clavicle fracture. This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to immediately report an injury of unknown origin to the Abuse Coordinator/Administrator for 1 of 3 residents (R1) reviewed for injuries of unknown origin in the sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify a resident's family/contact person regarding two falls and the resident being sent to a local hospital for evaluation for 1 of 3 residents (R5) reviewed for resident injury in the sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident on anticoagulant therapy was sent out to a local hospital for evaluation after having a fall with a head injury for 1 of 3 residents (R5) reviewed for resident injury in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a locked medication cart or in a locked medication room for 2 (R4 & R8) of 11 residents reviewed in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to obtain physician orders to ensure a resident received his pain medication. This failure resulted in R1 missing 41 days and 123 potential doses and experiencing uncontrolled pain. This applies to 1 of 3 residents (R1) reviewed for pain in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's medical care was being overseen by a primary care physician. This applies to 1 of 3 residents (R1) reviewed for physician services in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident's medical record was complete with documentation from outside services the resident was receiving. This applies to 1 of 3 residents (R1) reviewed for medical records in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff who tested positive for Covid-19 were not allowed to work, and failed to ensure testing was completed for all staff and residents when a positive case was identified. This failure has the potential to affect all the residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to monitor and assess a non-pressure wound for 1 of 2 residents (R1) reviewed for wounds in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize appropriate personal protective equipment (PPE) in COVID positive resident rooms, failed to utilize PPE during a facility-wide COVID-19 outbreak, failed to display isolation precaution signage outside resident rooms for residents currently on transmission-based precautions (TBP), and failed to monitor residents who are COVID-19 positive. These failures apply to 9 of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9) reviewed for COVID-19 infection in the sample of 11 and has the potential to affect all residents.

Inspectors wroteBased on observation, interview and record review the facility failed to complete a dressing change as ordered by a Physician and failed to have off-loading interventions in place. The facility also failed to obtain an order for dressing changes on a resident upon admission, and failed to assess and document on a resident's wounds. This applies to 2 of 3 residents (R1 and R3) reviewed for pressure wounds in a sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a resident with a physician's order for 24/7 observation. This applies to one of four residents (R11) reviewed for safety/supervision in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to permit a resident to return to the facility after an acute hospitalization for 1 of 3 residents (R1) reviewed for discharge.

Inspectors wroteBased on interview and record review the facility failed to provide consistent ongoing monitoring of oxygen saturation for a resident with a history of respiratory failure for 1 of 3 residents (R3) reviewed for respiratory care. This failure resulted in R3 experiencing respiratory distress requiring hospitalization and mechanical ventilation for breathing on 8/19/23 and on 8/31/23.

Inspectors wroteBased on interview and record review the facility failed to complete a fall investigation and failed to put new interventions in place for fall prevention for a resident with a history of falls for 1 of 3 residents (R2) reviewed for safety and supervision.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents on CPAP (Continuous Positive Airway Pressure) had equipment that was maintained and face masks they could wear and tolerate. The facility also failed to maintain a clean oxygen concentrator filter for 1 of 1 resident (R9) reviewed for oxygen in the sample of 15 and one resident (R23) outside of the sample.

Inspectors wroteBased on observation, interview and record review the facility failed to provide initial assessments, treatments and preventative measures for two of four residents (R108 & R20) reviewed for pressure in the sample of 15. This failure resulted in a resident (R108) with a DTI (deep tissue injury) not being provided any offloading to her heels or treatment to her left heel after being seen by a wound care physician on 7/14/23.

Inspectors wroteBased on observation, interview and record review the facility failed to serve all items listed on the menu. This applies to all 55 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to cool leftovers in a safe manner to prevent food bourne illness. This applies to all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively manage flies throughout the facility. This applies to all 55 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to sanitize the blood glucose meter between the residents to prevent the spread of infections. This applies to 9 residents (R9, R12, R15, R20, R23, R28, R29, R50, R108) in the sample of 15 and 5 residents (R16, R18, R24, R25, R26) outside the sample reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident shower room was maintained in a safe condition. This failure affects 11 residents (R25, R12, R35, R27, R4, R30, R11, R3, R28, R6, R20) that use the specific shower room.

Inspectors wroteBased on interview and record review the facility failed to ensure resident advanced directives were consistent throughout the medical chart for 1 of 3 residents (R20) reviewed for advanced directives in the sample of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of theft to the state agency for 1 of 1 residents (R29) reviewed for abuse in the sample of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an allegation of theft was thoroughly investigation for 1 of 1 residents (R29) reviewed for abuse in the sample of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was safe when a sling for a mechanical lift was applied and when the resident was up her motorized wheelchair for 1 of 5 residents (R108) reviewed for safety and supervision in the sample of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pain management was provided for a resident in pain from his hemorrhoids for 1 of 2 residents (R105) reviewed for pain in the sample of 15.