Inspection·July 14, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's funds were safeguarded and free from misappropriation. This applies to 2 of 3 residents (R4, R5) reviewed for misappropriation in the sample of 5. The findings include:(1.) R4's Minimum Data Set (MDS) dated [DATE], shows that R4 is cognitively intact.On 7/14/25 at 9:06 AM, R4's bedside drawer had a latch attached, allowing the top drawer to be locked by a pad lock. There was not a pad lock on the drawer at this time. The back panel of R4's bedside drawer was originally fastened with nails. However, at this time, the back panel of R4's bedside drawer was still half off, allowing access into R4's bedside drawer through the back. On 7/14/25 at 9:06 AM, R4 said after returning from a day out on pass with family on a Saturday in June, R4 noticed that R4's bedside drawer had been pulled away from the wall and a plastic shoebox containing compact discs and a compact disc player was on the floor behind the bedside drawer. R4 thought nothing of it that evening and asked staff to help pick up the items and move the bedside drawer back to the wall. The next morning, R4 noticed that the bag where R4 keeps R4's money in the top, locked drawer had been ripped in half and all of R4's money, except for approximately $25 in bills, was gone. R4 said there was approximately between $200 and $300 in the bag. R4 spoke with V10 (Social Services Director), V13 (Business Office Manager), and V1 (Administrator) about the incident the Monday after it happened and R4 requested the facility not to contact the local police or R4's husband. R4 said she doesn't exactly recall when the money could have been taken but indicated that whoever took it knew that R4 likes to sit outside while at the facility and that R4 had left the faciity on 6/21/25 to visit family. R4 typically carries R4's key to the lock in R4's purse, which is on R4 at all times. R4 said approximately three years prior, R4 had two separate instances where someone took money from R4's purse while R4 was sleeping. Ever since then, R4 had requested and been locking away R4's money in the top drawer of R4's bedside drawers using a padlock to keep it locked. R4 said only a handful of employees at the facility knew R4 had money in the top drawer. R4's Resident Sign In/Out Sheet shows that R4 signed out of the facility on 6/21/25 at 12:00 PM and returned the same day at 7:44 PM. R4's Progress Note dated 6/23/25, written by V10 (Social Services Director) states R4 informed V10 of the missing money and that V1 (Administrator) was made aware. On 7/14/25 at 11:02 AM, V13 (Business Office Manager) said she started working at the facility on January 27th, 2025. Since V13 has worked at the facility, V13 has known R4 to always keep R4's money in the top drawer of R4's bedside drawers, locked with a lock and key. V13 said R4's husband gives R4 spending money once a month and R4 keeps the money in the locked top drawer. V13 also corroborated that multiple certified nursing assistants knew where R4 kept R4's money. After the incident, V13 spoke with R4 who entrusted R4 to hold onto the remaining money as well as all of the loose change that was in R4's top drawer. On 7/14/25 at 10:26 AM, V1 said it's difficult to remove the back panel of the bedside drawer and whoever did it must have had a tool to remove the back. (2.) R5's MDS dated [DATE], shows R5 is cognitively intact.On Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 145222 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 07/14/2025 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)