Inspection·August 6, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility will assess to determine if the bed rail meets the definition of a restraint. A bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently.The facility's policy titled, Restraint Policy dated 3/2025 showed, Physical Restrain refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to .Using bed rails to keep the resident from voluntarily getting out of bed . Event ID: Facility ID: 145222 If continuation sheet Page 2 of 4 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 08/06/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 2 residents (R8,R11) had fall prevention measures in place. This applies to 2 of 3 resident's reviewed for fall prevention in the sample of 11.The findings include:1) R8's electronic face sheet printed on 8/6/25 showed R8 has diagnoses including but not limited to metabolic encephalopathy, schizoaffective disorder, anxiety disorder, restlessness and agitation, and major depressive disorder.R8's facility assessment dated [DATE] showed R8 has severe cognitive impairment, has not had any falls since admission to the facility, and does not utilize alarms while in her bed or chair.R8's fall risk assessment dated [DATE] showed R8 is a high fall risk.The facility's Incident Report Log as of 8/5/25 showed R8 has experienced 11 falls within the past 3 months at the facility.On 8/5/25 at 12:53PM, R8 was in her bed laying on her right-side sleeping. R8's alarm clip was hanging on the mattress next to her bed on the floor and was not clipped to R8. V12 (Licensed Practical Nurse) stated, (R8) is a very high fall risk. She needs the mattress next to her bed at all times and she also has orders for a bed and chair alarm. When she is in bed, she has a pressure pad alarm and when she is up in her chair she uses the clip alarm. (V12 confirmed R8 has orders for both alarms). V12 went into R8's room with surveyor and confirmed R8 did not have the alarm clipped to her nor did she have a pressure pad alarm underneath her. V12 stated, It's not beneficial if the clip isn't connected because it won't alert staff that she's trying to get up. During the same observation, R8's call light was draped over the back of the head of her bed where R8 was unable to reach it. V12 stated R8 rarely uses her call light but she should have it available in case she needs something.On 8/6/25 at 2:23PM, V3 (Director of Nursing) stated, I was informed before dinner yesterday that (R8) has apparently been removing her clip alarm on her own. We switched her over to a pressure alarm last night so that she can't unclip her alarm, but she will probably just pull this one out from under her. I don't know how else to prevent falls for her. If there is an order for staff to be putting a clip alarm on, then that's what they should have been doing but I'm pretty sure she took it off herself. (Surveyor was unable to find any documentation relating to R8 removing her clip alarm aside from an 8/5/25 entry after surveyor observed R8 in bed without the alarm clipped on her and staff were interviewed).The facility's policy titled, Fall Risk assessment dated 08/2025 showed, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents .5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice .2) R11's electronic face sheet printed on 8/6/25 showed R11 has diagnoses including but not limited to chronic respiratory failure, heart failure, unsteadiness on feet, and history of falls.R11's facility assessment dated [DATE] showed R11 has moderate cognitive impairment and does not utilize alarms or bed rails.R11's care plan revised on 10/11/23 showed, (R11) is at risk for falls related to dementia and limited physical mobility .bed alarm placed on bed, floor mat next to bed .R11's physician's orders dated 1/30/23 showed, Bed alarm placement.On 8/6/25 at 12:12PM, V12 was in R11's room and told him she would have staff assist him to bed. Surveyor observed R11 transfer himself to his bed without staff assistance. V12 went back into R11's room, assisted him to lay down, put his side rail down, and left the room. Surveyor went into R11's room, visualized his pressure alarm on his bed and the alarm box was not blinking indicating the alarm was functioning. On 8/6/25 at 12:17PM, V13 (Certified Nursing Assistant) stated, (R11) doesn't use a bed alarm. His bed alarm must be as needed. The nurse didn't tell us if he needed it. I don't even really know him that well (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145222 If continuation sheet Page 3 of 4 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 08/06/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete so can't tell you much. Surveyor went into R11's room with V13 who verified that R11's bed alarm was not turned on or functioning). V13 stated, All residents that are at risk for falls should have their preventative measures in place at all times to hopefully prevent them from falling.On 8/6/25 at 2:10PM, V12 stated, According to (R11's) orders, he does use a bed alarm, but I didn't know that. Surveyor went into R11's room with V12 who confirmed R11's bed alarm was not on and turned it on in front of surveyor. The bed alarm then beeped which V12 indicated that meant the alarm has been turned on and was blinking to show functionality.On 8/6/25 at 2:23PM, V3 (Director of Nursing) stated, I don't think (R11) uses an alarm at all. I guess if he has an order he should have had it on to prevent falls, but I don't think he is a high fall risk. He hasn't had a fall recently, but I know he self-transfers from the chair to the bed which I suppose could put him at risk for falls if he isn't supposed to be doing it alone.The facility's policy titled, Fall Prevention Program dated 11/2024 showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .3. The nurse will indicate the residents fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .6. High risk protocols .c. provide additional interventions as directed by the resident's assessment . Event ID: Facility ID: 145222 If continuation sheet Page 4 of 4