La Bella of Woodstock

Inspectors wroteBased on Interview and record review the facility failed to safely transfer a resident. This failure resulted in R3 sustaining an ankle fracture that required surgical repair. This applies to one of three residents (R3) reviewed for safety in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to identify a resident's pressure injury prior to an advanced stage. This failure resulted in R1 being identified with a DTI (Deep Tissue Injury) to his bilateral buttocks on 5/20/26. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in a sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure a psychotropic medication order was transcribed to the medication administration record. This failure resulted in R1 not receiving the medication for the purpose of managing R1's behaviors and improving his quality of life. This applies to 1 of 1 resident (R1) reviewed for significant medication errors in the sample of 9.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that dietary staff change their gloves during food service after coming in contact with potentially dirty objects/areas to prevent cross contamination. This has the potential to affect all 73 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered, at ordered times for 2 of 3 residents (R1, R3) reviewed for medication administration in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered, at ordered times for 4 of 7 residents (R4, R5, R6 and R2) reviewed for medication administration in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow R6's Menu Preferences for 1 of 8 residents (R6) reviewed for dietary in the sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's environmental noise was at a comfortable level. This applies to 3 of 3 residents (R5-R7) reviewed for resident rights in the sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent resident to resident abuse for 4 of 4 residents (R1,R2,R3,R4) reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review that facility failed to have fall prevention interventions in place for a resident at risk for fall. This applies to 1 of 3 residents (R4) reviewed for safety and supervision in the sample of 7. This failure resulted in R1 slipping out of his high back wheelchair and sustaining a left femur fracture.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of verbal and mental abuse for 2 of 5 residents (R1 and R2) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received timely medical treatment of a fractured leg that was sustained from a fall for 1 of 3 residents (R4) reviewed for quality of care in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who receives continuous oxygen was provided oxygen services during transportation to an outpatient procedure. This applies to 1 of 3 residents (R3) reviewed for oxygen services in the sample of 9.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wore a beard guard/net while handling/serving food. This has the potential to affect all 73 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had privacy during personal activities of daily living for 1 of 4 residents (R2) reviewed for resident rights in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene after touching their face/nose and handling resident food for 1 of 4 residents (R4) reviewed for infection control in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from misappropriation for one of four residents (R2) reviewed for misappropriation in the sample of four. This past noncompliance occurred from August 14, 2025-August 14, 2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R11) was free from restraints. This applies to 1 of 1 resident's reviewed for restraints in the sample of 11.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to have evidence that R4's alleged allegations were thoroughly investigated for 1 of 6 residents (R4) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure R1 did not leave the facility unsupervised, this applies to 1 of 6 residents (R1) reviewed for supervision in the sample of 6.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the state agency. This applies to 3 of 3 residents (R1, R4, R5) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of misappropriation were thoroughly investigated. This applies to 3 of 3 residents (R1, R4, R5) reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was transferred safely using a mechanical lift for 1 of 3 residents (R1) reviewed for safety in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's needs were accommodated by not assisting a resident with obtaining a replacement motorized wheelchair for one of five residents (R1) reviewed for accommodation of needs in the sample of five.

Inspectors wroteBased on interview and record review the facility failed to ensure an as needed psychotropic medication order had a stop date for 4 of 5 residents (R49,R175,R16,R54) reviewed for chemical restraints in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity while being fed for 1 of 20 residents (R41) reviewed for resident rights in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents fingernails were clean and trimmed for 2 of 20 residents (R47, R27) reviewed for Activities of Daily Living care in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with congestive heart failure (CHF) had weights done as ordered for 1 of 2 residents (R14) reviewed for quality of care in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident at risk for pressure injuries for 1 of 2 residents (R54) reviewed for pressure injuries in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to identify and assess a resident's contracted left hand. The facility also failed to ensure a resident's wheelchair was the appropriate fit to allow him to sit comfortably in the chair. This applies to 1 of 6 residents (R37) reviewed for range of motion and mobility in a sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietitian's recommendations were implemented and failed to ensure a dietary supplement was given to a resident. This applies to 2 of 5 residents (R23 and R27) reviewed for weight loss in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to follow dialysis recommendations for daily weights for 1 of 2 residents (R27) reviewed for dialysis in the sample of 20.

Inspectors wrote3. On 06/02/25 at 1:32 PM, V10 CNA-Certified Nursing Assistant emptied R47's indwelling urinary catheter bag. V10 CNA did not wear a gown when emptying the urinary collection bag. R47's room door had a sign that showed, Enhanced Barrier Precautions. Staff must wear gloves and a gown when providing care for a resident with a urinary catheter. On 06/04/25 at 10:05 AM, V2 DON-Director of Nursing said, residents with indwelling urinary catheters are on EBP-Enhanced Barrier Precautions. There is a chance of being splashed by urine when emptying the urinary catheter bag, gloves and a gown should be worn. We also provide face shields to protect the staff's eyes. The facility's Enhanced Barrier Precautions dated 04/2024 shows, Implementation of Enhanced Barrier Precautions: Make gowns and gloves available immediately near or outside of the resident's room. Note: [...]

Inspectors wroteBased on interview and record review the facility failed to have documentation that residents received or refused the pneumococcal vaccine for 2 of 5 residents (R11 and R28) reviewed for immunizations in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to administer medications at the scheduled times for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of mental abuse for 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. This failure resulted in R1 suffering undue, ongoing anxiety and contributed to his leaving the facility and made R2 feel badly.

Inspectors wroteBased on interview and record review the facility failed to ensure an incident of verbal abuse was reported to the state agency. This applies to 2 of 3 residents (R1000, R1001) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal abuse from another resident. This applies to 2 of 4 residents (R5 and R6) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of resident to resident verbal abuse was immediately reported to the administrator, and reported to the state agency. This applies to 2 of 4 residents (R5 and R6) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident that was on an oral anticoagulant medication (blood thinner) was free from physical abuse. This applies to 2 of 3 residents (R12, R13) reviewed for abuse in the sample of 15. This failure resulted in R12 complaining of 5/10 sharp pain to right parietal and temporal area during head examination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietitian recommendations for an increased tube feeding order were carried out. This failure resulted in R8 experiencing a significant weight loss of 13.9% in 6 months. This applies to 1 of 3 residents (R8) reviewed for weight loss in the sample of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a resident who wanders and has physical aggressive behaviors towards others. This applies to 2 of 15 residents (R12, R13) reviewed for safety in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received their medications. This applies to 1 of 1 resident (R2) reviewed for medications in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated with respect and dignity for 7 of 9 residents (R1, R3, R4, R6, R7, R8, R9) reviewed for resident rights in the sample of 9.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot liquids are served in a safe manner and failed to ensure 1 of 7 residents (R1) in the sample of 7 reviewed for safety and supervision was supervised and assisted while drinking hot coffee. These failures resulted in R1 spilling coffee on herself and sustaining second degree burns to her thighs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was allowed to stay in there room. This failure applies to 1 of 7 residents (R1) reviewed for room transfers in a sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal abuse which applies to 1 of 7 residents (R1) reviewed for verbal abuse in a sample of 7.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the facility designee and failed to report an allegation of abuse to the State Agency in a timely manner which applies to 1 of 7 residents (R1) reviewed abuse notification in a sample of 7.

Inspectors wroteBased on interview and record review the facility failed to initiate an investigation after an allegation of abuse and failed to remove an alleged perpetrator from the building following an allegation of abuse for 1 of 7 residents (R1) reviewed for abuse investigations in a sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure five residents with norovirus-like symptoms (R7, R8, R11, R13, R15) were isolated to prevent cross contamination during the facility norovirus outbreak. This has the potential to affect all 76 residents residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure facility-initiated discharge documentation was included in the resident's medical record for 1 of 5 residents (R1) reviewed for resident discharge documentation in a sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an exit door with an audible alarm was in functional order and alerting staff when opened, and failed to ensure a resident with severe cognitive impairment and increased confusion was appropriately assessed and supervised to prevent elopement for 1 of 3 residents (R1) reviewed for elopement in the sample of 13. The Immediate Jeopardy began on 10/22/24 when R1 could not be located in the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 11/8/24 at 8:20 AM. This surveyor confirmed by observation, interview, and record review that the immediacy was removed on 11/8/24, but noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R3) was free of physical abuse by a resident (R4) with known aggressive and verbal behaviors. This failure resulted in R3 not feeling safe in the facility. This applies to 3 of 3 residents (R3, R4, R5) reviewed for abuse in the sample of 11. This failure resulted in R3 experiencing pain and fearfulness.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate supervision was in place for a resident on pass to the community for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 16.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ankle brace and hand splint for residents with limited range of motion. This applies to 2 of 3 residents (R1, R6) reviewed for splints/devices in the sample of 7.

Inspectors wroteI. Based on observation, interview and record review the facility failed to ensure female residents were protected from sexual abuse by male residents. This resulted in R4 placing his penis on R11's knee and telling her to touch it on 5/26/24, and R18 touching R21's breast on 7/5/24, R17's breast on 7/5/24 and R1's breast on 7/7/24. This applies to 6 of 14 residents (R1, R4, R11, R17, R18, R21) reviewed for sexual abuse in the sample of 22. The Immediate Jeopardy began on 5/26/24 when R4 placed his penis on R11's leg and told her to touch it. V1 (Assistant Administrator), V2 (Director of Nursing) and V20 (Corporate Nurse) were notified of the Immediate Jeopardy on 7/10/24 at 11:35 AM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision for R12, a severely cognitively impaired resident and failed to provide progressive intentions to address R12's exit seeking behavior. This failure resulted in R12 exiting the building on 6/27/24 around 4:15 PM, walking across a small gravel area to the end of a driveway (approximately 75 feet) and attempting to step onto the street, a two lane highway with a speed limit of 30 mph. This applies to 1 of 3 residents (R12) reviewed for safety and supervision in the sample of 22. The Immediate Jeopardy began on 6/24/24 when R12 first exited the facility without staff supervision. V20 (Corporate Nurse), V1 (Assistant Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/10/24 at 11:50 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the facility was administered in a manner to protect the health and well-being of the residents who reside in the facility. This applies to 7 of 22 residents (R1, R4, R11, R12, R17, R17, R21) reviewed for administration in the sample of 22.

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse Policy by not ensuring that staff reported an allegation of sexual abuse to the Administrator and by not investigating an allegation of sexual abuse. This applies to 4 of 14 residents (R4, R11, R18 and R22) reviewed for abuse in the sample of 22.

Inspectors wroteBased on interview and record review the facility failed to ensure that staff report an allegation of resident to resident sexual abuse to the Administrator or designee. This applies to 2 of 14 residents (R22 and R18) reviewed for abuse in the sample of 22.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of resident to resident sexual abuse. This applies to 1 of 14 residents (R11 and R4) reviewed for abuse in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's safety when in bed and failed to put interventions in place to protect a resident from injury. This failure resulted in R27 sustaining a fractured right ankle on 3/2/24. The facility also failed to ensure a resident ordered to have nectar thick liquids was not given thin liquids, failed to assess a resident for safety when smoking, and failed to ensure that medical equipment was not plugged into power strips in 3 resident rooms. This applies to 6 of 18 residents (R27, R30, R75, R38, R4 & R17) reviewed for safety and supervision in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's code status was assessed and documented for 1 of 18 residents (R75) reviewed for advanced directives in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a male resident did not expose his private areas to female residents while outside on the smoking patio. This applies to 2 of 18 residents (R8 & R279) reviewed for abuse in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Physician Ordered treatments for 2 of 18 residents (R50, R179) reviewed for physician orders in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure treatment orders were administered as ordered for 1 of 18 residents (R28) reviewed for quality of care in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents wore their prescribed orthotic devices (splints) and failed to ensure residents were provided with a restorative program for 3 of 3 residents reviewed for range of motion in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with insidious weight loss received a dietary intervention of ice cream with lunch for 1 of 6 residents (R71) reviewed for nutrition in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oxygen humidifier bottle was changed every 72 hours for 1 of 5 residents (R30) reviewed for respiratory care in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident on Transmission Based Precautions had signage outside his room to indicate the isolation precautions for 1 of 18 residents (R28) reviewed for infection prevention in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse Policy by not ensuring that staff report an allegation of sexual abuse to the Administrator and by not investigating an allegation of sexual abuse. This applies to 2 of 18 residents (R27 & R279) reviewed for abuse in a sample of 18.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of sexual abuse to the administrator and to the State Agency. This applies to 2 of 18 residents (R27 & R279) reviewed for abuse in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of sexual abuse. This applies to 2 of 18 residents (R27 & R279) reviewed for abuse in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the alarms on 2 of 7 exit doors were functional. This applies to 3 of 3 residents (R5, R8, R9) reviewed for elopement risk in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to honor a resident's right to have a visitor by informing a visitor that visiting hours ended at 8:00 PM. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal and mental abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review the facility staff failed to immediately report an allegation of abuse to the administrator and the State Survey Agency for 1 of 5 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review the facility staff failed to investigate an allegation of abuse and protect the resident from further abuse while the investigation is in progress for 1 of 5 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation and interview the facility failed to ensure residents' shower was maintained comfortable and homelike for 4 of 11 residents (R1, R2, R5, and R8) reviewed for safe, clean, comfortable homelike environment in the sample of eleven.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep an indwelling urinary catheter bag below the level of the bladder, clean the end to the drain on the catheter bag, and ensure a secure device was in place for 3 of 3 residents (R59, R22, & R6) reviewed for catheters in the sample of 19. This failure resulted in R59 sustaining trauma to the tip of his penis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with contractures or who were at risks of developing contractures received range of motion for 5 of 6 residents (R27, R22, R56, R23 and R59) reviewed for range of motion in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were being answered in a timely manner for 2 of 2 residents (R7 & R67) reviewed for dignity in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received a bath/shower weekly and complete cleansing of a resident's peri-area was done after an incontinence episode for 2 of 2 residents (R25 & R23) reviewed for activities of daily living in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident with seizure-like activity when the resident was outside smoking. The facility also failed to transfer a resident to a shower chair in a safe manner. This applies to 2 of 9 residents (R46, R25) reviewed for safety and supervision in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was administered as prescribed. This applies to 1 of 2 residents (R57) reviewed for oxygen use in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent care in a manner to prevent infection and failed to clean urine from the floor and from a non-skid pad to prevent cross contamination for 3 of 3 residents (R27, R23 and R22) reviewed for infection control in the sample of 19.