Health inspection·January 20, 2026

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure residents' non-invasive ventilation machine Continuous Positive Airway Pressure (CPAP) masks fit securely on residents faces to provide the prescribed treatment for their obstructive sleep apnea for 2 of 3 residents (R1, R2) reviewed for respiratory care in the sample of 4.The findings include:1.R1's physician order dated 12/12/25 showed an order for R1 to be placed on CPAP at night when sleeping due to his diagnosis of obstructive sleep apnea. On 1/20/26 at 8:54 AM, R1 was awake, lying in bed. A CPAP machine with attached tubing and face mask was noted on a table by the foot of R1's bed. The CPAP machine and equipment appeared clean and unused. R1 stated he had not used his CPAP at night for months because the mask doesn't fit. It leaks air and blows into my eyes. R1 stated he told nursing and a pulmonology nurse practitioner about his ill-fitting mask, but nothing had been done about it. R1's Health Status note dated 12/10/25 showed R1 was seen and examined by V5 Nurse Practitioner (NP). The note showed, Pulmonary NP to follow for refitting of CPAP for sleep apnea as patient complains of ill-fitting mask.R1's Follow Up Pulmonary note dated 12/17/25 showed R1 was seen and examined by V4 Pulmonary Nurse Practitioner. The note showed R1 requested a new mask for his CPAP machine. The note showed V4 notified facility staff R1 needed a new mask.R1's Health Status note dated 1/14/26 showed R1 still had not received a new mask for his CPAP machine. Facility nursing staff notified V4 Pulmonary Nurse Practitioner that R1 had yet to receive a new mask.On 1/20/26 at 10:00 AM, V4 Pulmonary Nurse Practitioner stated R1 requires the use of CPAP at night due to his sleep apnea. V4 stated in December 2025, facility staffed initially notified her that they could not find the mask to R1's CPAP machine but the facility called back shortly after that to tell me they had found the mask. I wasn't notified until January 14th (2026) that (R1's) mask didn't fit. V4 stated she did not recall R1 telling her that his mask didn't fit on 12/17/25. V4 stated if a CPAP or BiPAP does not fit securely on a resident's face, it can cause the resident to not receive enough oxygen while sleeping which could lead to respiratory distress and/or failure.On 1/20/26 at 11:01 AM, V5 NP stated R1 complained of his CPAP mask not fitting to V5 on 12/10/25. V5 stated, I put in a referral then for him to be refitted for a mask by pulmonology. I don't know why he has not received a new one.2. R2's physician order dated 11/4/24 showed an order for R2 to be placed on CPAP at night when sleeping due to her diagnosis of COPD (chronic obstructive pulmonary disease).On 1/20/26 at 8:48 AM, R2 was seated in a wheelchair in her room. A CPAP machine with the attached tubing and mask was wrapped in a plastic bag, sitting on R2's bedside table. R2 stated she had not used her CPAP at night in a long time because the mask doesn't fit. It's too big. R2 stated, I've been waiting on pulmonology to come fit me for a new mask. I keep asking when they are coming but nothing has happened.R2's Follow Up Pulmonary note dated 12/3/25 showed R2 was seen and examined by V4 Pulmonary Nurse Practitioner. The note showed, Patient reports compliance with CPAP device however is asking to replace her medium sized mask with a small, facility staff notified.R2's Health Status note dated 12/17/25 showed R2 was seen and examined by V5 Nurse Practitioner (NP). Residents Affected - Few Page 1 of 2 145222 145222 01/20/2026 LA Bella of Woodstock 309 McHenry Avenue Woodstock, IL 60098

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The note showed, Patient complained of ill-fitting CPAP mask and not using (CPAP) at night. Patient has lost approximately 50 pounds since the mask was first fitted in 2023 and ordered for pulmonary NP to evaluate regarding CPAP mask refitting to ensure proper seal.On 1/20/26 at 10:00 AM, V4 Pulmonary Nurse Practitioner stated she notified facility nursing staff on 12/3/25 that R2 needed a small CPAP mask so the facility could order the mask. V4 stated, I can't remember which nurse I talked to about this. Once a mask is ordered, the resident should receive the mask within a couple of weeks.On 1/20/26 at 11:01 AM, V5 NP stated, (R2) has a (CPAP) mask that doesn't fit. She has lost weight recently. I put a referral for her to be refitted for a mask when I saw her on December 17th (2025).On 1/20/26 at 8:51 AM, V3 Registered Nurse stated R1 and R2 have been waiting for pulmonary to come fit them for CPAP masks for at least a month. Their masks are too big, so they don't use their CPAP. I have called pulmonary twice about this in the past couple of weeks, but no one has called me back.On 1/20/26 at 2:00 PM, V2 Director of Nursing stated she was not aware that R1 or R2 needed new CPAP masks. The facility's Noninvasive Ventilation policy (undated) showed, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. CPAP or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patient airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose and mouth. Replace equipment immediately when it is broken or malfunctions. 145222 Page 2 of 2