Health inspection·November 6, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate staffing for Certified Nursing Assistants in two units within the facility. This failure applied to three of three (R1, R2, R3) residents reviewed for staffing and has the potential to affect 29 residents currently residing in the two units (Suites North and Suites South). Findings include: Per Facility Census dated 11/4/2024 shows there are currently 29 residents residing in two units, [NAME] Suites North and Suites South-total Census of 152 residents residing in the facility. On 11/4/2024, during the course of this survey, R1, R2, and R3 all resided in the Suites North unit. Facility Assessment Tool 2024 with last review date of 7/10/2024 states in part but not limited to the following: The tool is used to inform staffing decisions to ensure that there is enough staff with appropriate competencies and skill sets necessary to care for its residents needs. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of residents at any given time. Direct care staff: CNAs (Certified Nursing Assistants): 1 CNA per 11 Residents for the day shift, 1 CNA per 11 Residents for the evening shift, and 1 CNA for 13 residents for the night shift. The Daily Schedule dated 10/6/2024-11/3/2024 shows that one CNA worked on Suites South and one CNA worked on Suites North for all shifts, including the day shift, evening shift, and night shift. It is to be noted that on 11/4/2024, Suites North had 14 residents, and Suites South had 15 residents. On 11/4/2024 at 10:05 AM, R1 was interviewed regarding care within the facility. R1 said she feels that the CNAs have too much to do and that they are assigned too many residents for one CNA to take care of. She says sometimes she has to wait for her call light to be answered for an extensive period of time. R1 says the facility staff has never given her a shower, but the hospice staff is the only staff member who has ever provided her with a bed bath. Hospice provides this to residents, however, only once a week. At 10:45 AM, R2 was observed to be lying in bed in a gown sleeping. It is to be noted that R2 had facial hair on the upper lip and chin. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145198 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 145198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Morton Grove 8425 Waukegan Road Morton Grove, IL 60053 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)