Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
La Bella of Woodstock
WOODSTOCK, IL · 115 certified beds · Last Life Safety survey June 4, 2025
CMS Certification Number 145222 · first certified November 1970
Ownership
Independently operated (no chain recorded by CMS) · For profit - Individual
- Ownership changed September 1, 2023 (change of ownership)to HIGHLIGHT HEALTHCARE OF WOODSTOCK, LLC from CROSSROADS CARE CENTER OF WOODSTOCK, LLC
Position within IL
53 citations — more than 98% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 19 citations; the earlier surveys in the window averaged 17. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
13 of the 53 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
20 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 53 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 53 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 13, 2023 | 8 |
| May 15, 2024 | 26 |
| June 4, 2025 | 19 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0271 | Have exits that are accessible at all times. | 3 | 2025-06-04 |
| K-0293 | Have properly located and lighted "Exit" signs. | 3 | 2025-06-04 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-06-04 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-06-04 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-06-04 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-06-04 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-06-04 |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | 2 | 2025-06-04 |
What the citations cover
- Emergency Preparedness Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 12
- Smoke Deficiencies 10
- Egress Deficiencies 10
- Other 8
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 12 |
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 10 |
| Miscellaneous Deficiencies | 7 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 4, 2025 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 4, 2025) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (July 4, 2025) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (July 4, 2025) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (July 4, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 4, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 16, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 21, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 24, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 4, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (July 4, 2025) |
May 15, 2024 — 26 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 31, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (May 31, 2024) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (May 31, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (May 31, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (May 31, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (May 31, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (May 31, 2024) |
April 13, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (May 19, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.