Health inspection·January 27, 2026

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure grievances were recorded, investigated, summarized, confirmed or not confirmed for 2 of 3 residents (R1,R11) reviewed for grievances in the sample of 15. The findings include:On 01/26/2026 at 10:00AM, R1 was lying in bed on her back. R1's left, and right arms were contracted close to the body. At 2:33PM, R11 was lying in bed on her back. R1's MDS-Minimum Data Set, dated [DATE] shows, R1 is cognitively intact, with impairment to left and right upper and left and right lower extremities. R1 needs extensive assistance from staff to total dependence on staff for all ADLs-Activities of Daily Living. R11's MDS dated [DATE] shows, R11 is cognitively intact, with upper extremity impairment on both sides, lower extremity impairment on both sides. R11 needs partial assist, extensive assist, and is also dependent on staff for ADLs. R1 and R11 need to be supervised when eating. On 01/26/26 at 10:00AM, R1 said, (V5 CNA-Certified Nursing Assistant) refused to get me up a week ago from last Friday (01/16/2026). (V5) told me I had to do it her way or not at all. (V5 CNA) left me for the second shift to get out of bed. I reported the interaction to (V2 DON-Director of Nursing). I also reported the incident to the Ombudsman. I did not fill out a grievance form. I have Cerebral Palsy; I cannot use my hand to write.at least not legibly. I would need the staff to fill out the form; I can sign my name. Documents have a tendency to disappear around here. I prefer to complain to the Ombudsman. On 01/26/2026 at 10:23 AM, V2 DON-Director of Nursing said, I do not have any reports about (V5 CNA). On 01/26/2026 at 10:50AM, V5 CNA said, (R1) likes to get up after lunch. I did not have enough time to get her up and give (R2) a shower before my shift ended. (R1) was upset. The next time I was assigned to (R1), she told me she had talked to (V2 DON) and I was not to help her anymore. I stopped and walked out of the room. On 1/26/25 at 2:33PM, R11 said, (V5 CNA) does not follow the rules. One of the nurses reported her for leaving my roommate hanging alone in the room in a full body mechanical sling lift. (V5 CNA) got written up. I reported the incident to (V2 DON). Last Thursday (01/22/2026) I stayed in bed. I was not going to let (V5 CNA) help me. The next day I let (V5 CNA) help me get out of bed and into my wheelchair. I should not have. I explained how to position the chair and myself, but (V5 CNA) had to do it her way. (V5 CNA) ended up having to leave me in the sling while she left the room to go get help. (V5 CNA) claimed she did not have enough training. It is not training, (V5 CNA) needs to follow directions. I do not know anything about a grievance form. It is easier to tell (V2 DON). On 01/27/26 at 9:14AM, V1 Administrator said, (R1) reported (V5 CNA) is 'bad'. I did not know about (R11's) grievance with (V5 CNA). On 01/27/2026 at 9:45AM, V13 CNA said, I have had a lot of complaints about (V5 CNA). The residents have complained about the way (V5 CNA) speaks to them. (V5 CNA) has been using the full body mechanical sling lift without a second staff member present. (V5 CNA) got into a political argument with one of the residents. I reported my concerns to (V11 Human Resource Director).: On 01/27/2026 at 10:03AM, V11 Human Page 1 of 3 145222 145222 01/27/2026 LA Bella of Woodstock 309 McHenry Avenue Woodstock, IL 60098

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resource Director said, I have not had any complaints from the residents about (V5 CNA). I received feedback from (V13 CNA). (V13) is (V5's CNA) trainer. There was no need to bring the issues to the Administrator, it was nothing he needed to know about. If the issue is about patient care, it is reported to the Administrator or DON. A resident can go to any manager, speak to any nurse, and file a grievance. We have a grievance form. I will listen to the resident's grievance then follow up with social services to do a written grievance. On 01/27/2026 at 10:22AM, V12 RN-Registered Nurse said, I have no personal knowledge of any resident complaints. The resident file their grievances with the Social Service Director. On 01/27/2026 at 10:44AM, V9 Social Service Director said, The person the resident reports the grievance to needs to be the person that fills out a grievance form. Grievance Forms are available in the office and the nurse's stations. The staff should fill out the form and report to me. If the resident reports a grievance to the CNA or the nurse, the nurse should fill out the grievance form with the resident there. I will do the investigation. I may ask another staff to assist me with the investigation. I also bring the grievances to the morning meeting with administration and the entire management team. The Administrator is required to sign off on every grievance. I have not had any reported issues about (V5 CNA). On 01/26/26 at 11:07AM, V6 Ombudsman said, I encourage the resident to first report their grievances to the facility staff prior to contacting The Ombudsman's Office or The State Agency. However, the residents feel when they report their grievances to the staff, nothing ever gets resolved. The staff are in a better position to resolve the resident's grievances than I am. On 01/26/2026 the facility's Grievance Log dated, December 2025 and January 2026 does not show, R1 and R11's concerns with V5 CNA. The facility's undated Grievance/Concern Report form shows, this form shall be utilized to provide written documentation of any grievance or concern expressed or filed by a resident or resident representative and to record the follow-up action taken and results thereof. 145222 Page 2 of 3 145222 01/27/2026 LA Bella of Woodstock 309 McHenry Avenue Woodstock, IL 60098

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review the facility failed to provide R3, a resident assessed to have a high level of pain, with pain medication for 1 of 5 residents reviewed for pain in the sample of 15. This failure allowed R3's pain from a traumatic rib fracture go untreated in the facility from 1:00PM to 6:49PM. The findings include: On 01/26/2026 at 11:30AM, On 01/26/2026 R3 was not in the facility. On 01/26/2026 at 9:23AM, R3 said, I fell at home. I was discharged from the hospital with multiple rib fractures. I was using intravenous hydromorphone in the hospital to control the pain. I was admitted to the facility for rehabilitation and pain control. I had pain 20 out of 10. I waited 7.5 hours to get a pain pill. The facility had pain medication available but something about the rules would not allow them to treat me. I was in a lot of pain. I could not even open the door to the room I hurt so bad. I called my friend to pick me up and left. The nurse said I was leaving against their will. What WILL? I had no idea what their will was, no one saw me. V3 RN-Registered Nurse said, (R3) arrived at the facility during medication pass. I needed to finish the medication pass before putting in (R3's) orders. (R3's) admission gave me resident number 30. This hall is a challenge, admitting a new resident makes it more difficult. I did not put (R3's) orders in fast enough. We did not have (R3's) pain medication on hand. It took quite a few hours for (R3) to get treatment for the pain. The medication was provided on the second shift around 7:30PM. The physician was called at 7:00PM, shift change. (R3) left the facility against medical advice. On 01/27/2026 at 11:11AM, V4 NP-Nurse Practitioner said, I assessed (R3) on 01/19/2026 at 4:21PM, (R3) rated the pain 9/10. (R3) had multiple left rib fractures. The fractures extended from rib number 6 to rib number 9. (R3's) number one diagnosis was Rib Fracture; R3's second diagnosis was, Pain. I was notified around 6:00PM, the facility did not have (R3's) pain medications available. If I would have been notified sooner, I would have provided an alternative pain medication immediately. On 01/27/2026 at 3:48PM, V12 RN said, Zero is no pain, 10 is the worst pain ever. R3's Vital Sign Record shows, Pain: on 01/19/2026 at 1:00PM, 8/10, at 5:44PM, 8/10. R3's Medication Administration Record dated January 19, 2026 shows, R3 was provided with her first dose of pain medication at 6:49PM. The facility's Pain Management policy dated 10/01/2025 shows, Acute Pain refers to pain that is usually sudden in onset.caused by injury, trauma, or medical treatments.Policy Explanation: to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage Pain. Residents Affected - Few 145222 Page 3 of 3