Inspection·July 8, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or before May 14, 2025.R1's Psychiatric Follow up visit note dated June 24, 2025, shows, Patient voiced concern about his electric wheelchair missing. Thought content: Concerned about missing electric wheelchair, no suicidal ideation, no homicidal ideation, no self-harm urges, no aggressive urges, no evidence of delusional thought, no auditory hallucination, no visual hallucination, and no evidence of psychosis.On July 7, 2025, at 10:21 AM, there was an electric wheelchair in R1's room. R1 was sitting in a manual wheelchair. R1 said he did not know whose electric wheelchair was that was in his room. R1 said it doesn't even work. R1 said he doesn't know what happen to his motorized wheelchair when he moved to the current facility. R1 said he heard someone threw it away. R1 said he had been in a motorized wheelchair for years prior to coming to this current facility. R1 said he has to wheel himself backwards in a manual wheelchair because that is the only way his legs will work. R1 said a motorized wheelchair would help him get around much better. On July 7, 2025, at 11:15 AM, V3 Social Services Director said R1's electric wheelchair was in storage. V3 said she thought R1's motorized wheelchair was thrown away when the previous administrator was at the facility and going through the storage shed. V3 said therapy was in touch with the DME company trying to get R1 a new motorized wheelchair. V3 said the request was denied and the therapy department appealed the denial. V3 said the therapy person that was working on the motorized wheelchair request is no longer working for the facility.On July 7, 2025, at 11:25 AM, V4 Maintenance Director said he worked at the facility for three years, when the previous administrator terminated V4. V4 said the previous administrator and V4 placed R1's motorized wheelchair in the shed when R1 was admitted to the facility because there was not enough room in R1's room. V4 said the previous administrator is no longer at the facility and the facility asked V4 to come back to work at the facility. V4 said he was gone from the facility for eight months and when he came back, he began to clean out the facility's storage shed. V4 said he found two motorized wheelchairs in the shed and took a picture of one of them to show R1. V4 said R1 said the motorized wheelchair in the picture was his. V4 said he brought the motorized wheelchair into R1's room and plugged it in to charge, but it would not charge so it does not work. V4 said R1 has been asking for his motorized wheelchair since he was admitted to the facility. On July 7, 2025, at 1:48 PM, V2 Director of Nursing (DON) said she has worked at the facility for the last two months. V2 said that R1's motorized wheelchair was gone before she started working at the facility. V2 said something happened to R1's motorized wheelchair, but she doesn't know what happened to it. V2 said the facility was looking into purchasing a new motorized wheelchair for R1 since they could not find his original one. V2 said R1's motorized wheelchair issue has been brought up in the department heads daily meetings. On July 7, 2025, at 2:18 PM, V5 Business Office Manager said she started working at the facility in January 2025. V5 said R1 transferred to her facility from another facility when it closed. V5 said the facility was trying to replace R1's motorized wheelchair but it was $30,000. V5 said there was several electric wheelchairs in the shed that were donated. V5 said the previous administrator cleaned out the facility's storage shed. V5 said that R1 stays in his wheelchair and does not get into bed due to PTSD from childhood trauma. V5 said the wound care nurse mentioned that R1 would benefit from a different chair due to his wounds on his buttocks and feet. V5 said therapy said R1 would benefit from getting back into his motorized wheelchair so therapy put in a request to get a new motorized wheelchair back in March 2025. V5 said the facility got a denial letter dated April 25, 2025, from the insurance company and that's the last of the communication. V5 said the motorized wheelchair never got followed up since April because the therapist left the facility, and the facility got a new administrator. V5 said the request kind of got brushed aside. V5 said the motorized wheelchair that is currently in R1's room is not R1's. V5 said she believes it is a different (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145222 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 145222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Woodstock 309 McHenry Avenue Woodstock, IL 60098 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident's that got a new motorized wheelchair and donated his old one. V5 said that motorized wheelchairs are customized to each resident. An email communication dated April 7, 2025, between V7 previous physical therapist shows she was made aware that the facility threw out R1's motorized wheelchair.The facility's Resident Rights Policy revised November 2024 shows, The resident has the right to be informed of, and participate in, his or her treatment, including: The right to receive the services and/or items included in the plan of care. The resident has the right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. Event ID: Facility ID: 145222 If continuation sheet Page 3 of 3