Health inspection·February 26, 2026

F 0689 Level of Harm - Actual harm Residents Affected - Few I was doing rounds, between 9 to 10 AM. He was in isolation for COVID. I knocked, no response, so I entered the room. I didn't see him in the bed. So I went around the bed, I noticed his feet and legs sticking out from under the bed. Most of his body was under the bed. I found him in that space under the bed, between the window and the bed. I tried to call his name he did not respond. I called the nurses. They went to the room and took over from there. His bed was not in the lowest position. I don't know if he was high risk for fall. He was unresponsive at the time. On [DATE] at 10:35 AM, V7 (Licensed Practical Nurse, LPN/Rehab Nurse) was asked regarding R1's incident on [DATE]. V7 verbalized, It was V4 (Registered Nurse, RN) who was the nurse on duty for R1. R1 was COVID positive and was placed in a single room for isolation. I just finished passing morning medications and was sitting at the nurses' station, V6 came to me, and said he (R1) was on the floor in his room. It was around 9:15 AM. Myself and V4 responded to his room immediately. We noticed that he was laying between the heater and bed, more on under the bed, unresponsive. We didn't see his chest rising, no eyes opening, no verbalization, no communication. He was under the bed; the bed was not in lowest position. We called code and started CPR (cardiopulmonary resuscitation); he was full code. Oxygen was also administered. Paramedics came and took over. V7 was asked regarding R1's mobility and monitoring. V7 continued, He needs assistance with mobility, he was bedbound, unable to walk. He was not a dialysis patient. He was on isolation for COVID 19. We monitor residents on isolation every hour. Nurses do odd numbered times and CNAs do even numbered times. It was an agency CNA who worked with him (R1) at that time. When agency CNA comes in, I usually ask them if they have worked here before and if they verbalized, they were and know their assignments, I'll just tell them to call me if they have any questions. If they verbalized, they haven't been here, I print the census and I go from room to room and endorse accordingly. To my knowledge, they said he (R1) was last seen at 6:30 AM. V9 (LPN) mentioned during interview on [DATE] at 10:55 AM that R1 was alert, oriented to self and place, needs assistance, can't walk, bedbound. V9 also emphasized that every hour monitoring should be performed to residents on isolation; also making sure fall interventions such as bed in lowest position, side rails up as ordered; should be in place for fall risk residents. R1 is on strict isolation precautions and high risk for fall. On [DATE] at 11:34 AM, V4 was asked regarding R1 and incident on [DATE]. V4 stated, He was alert but spoke different language. He was in isolation, in a private room. He was COVID positive, on complete isolation; door is to be closed. On [DATE], I got reports in the morning that he was sleeping in bed comfortably during night shift and had no issues. I went to pass medications. I passed the medications until 9 AM. I have not physically seen him since I started working for the morning shift. My shift starts at 7 AM. But the CNA (V5) passed trays around 7:30 AM to 8 AM, I assumed she (V5) passed his tray and seen him. Around 9 AM, somebody called code blue, and everybody was rushing to his room. I went there, me and V7. He was on the floor, under the bed, unresponsive, pulseless. We called for help. CPR started. Paramedics were called, came in and took over. He passed away in the facility. For isolation residents, we monitor them every one to two hours for vital signs, making sure they are okay. He had COVID and coughing, unable to walk. I believed the CNA (V5) mentioned that he (R1) was not in his room. I was busy with medication passing that time and not thinking, and since I had another resident going out for an appointment that day and a dialysis patient, I told her (V5) that he (R1) might be in dialysis. I got mixed up with another resident, my mistake, and not thinking. I didn't check him (R1) in his room to verify. Since he was in isolation, he should be monitored every one to two hours. He was not a fall risk resident. For fall risk resident, we always make sure the bed at the lowest position. On [DATE] at 12:01 PM, V11 (RN/Fall Coordinator) was asked regarding R1's monitoring and fall interventions. V11 verbalized, Based on my evaluation he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145198 If continuation sheet Page 2 of 4 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 02/26/2026 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few was a high fall risk. We implemented call light within reach, personal items within reach, no clutter on the floor, reminders to ask for assistance, bed in low position always, changing positions slowly especially when transferring, both quarter length side rails up all the time. He sometimes plays with the bed remote but we have to make sure his bed is in low position. He was alert, oriented, speaks little English. He was able to verbalize needs and wants. R1 was on isolation for COVID 19 positive. In preventing falls on residents on isolation, staff need to do rounds every one hour and check residents' status; make sure all the interventions in the care plan are followed, especially bed position, bedside table and personal items within reach. During change of shift, the outgoing staff should give reports to incoming staff related to residents. R1's care plan documented:1.High risk for falls related to decline in functional status, impaired balance during transitions, impulsivity or poor safety awareness, muscle weakness, syncope and history of falls prior to admission ([DATE]):Intervention: Prefer to keep the bed in the low position for safety. 2. Has an active COVID 19 diagnosis, requires a single room, strict isolation, and contact droplet precautions ([DATE]):Intervention: Monitor resident for change in condition especially with respiratory distress. 3. May need to use 2 1/2 partial bedrails to enhance functional independence and promote skin integrity ([DATE]):Interventions: Would like to utilize (2) partial siderails to define bed parameters; Would like to use (2) partial siderails (2) to prevent potential for injury related to medical condition. On [DATE] at 12:28 PM, V3 (Assistant Director of Nursing/Infection Control Preventionist) stated during interview, For residents on isolation or COVID positive, the doors should be closed; monitoring should be done every hour for COVID residents. We assigned the nurses to do the odd numbers for the hour rounding and CNAs will do the even number hours. We check the residents' condition, if they are having respiratory symptoms, we have to do vital signs, assess resident and notify physician and family regarding change in condition. We also have to check fall mats, call light, bed in lowest position, half side rails to make sure everything is in place for high fall risk residents. On [DATE], he (R1) was in isolation due to being COVID positive. He should be on strict isolation and monitored on an hourly basis. We have an internal policy called routine resident checks which was in service to staff. Staff shifts start at 7 AM to 3:30 PM; 3 PM to 11:30 PM and 11:00 PM to 7:30 AM. For isolation residents, we educated staff to do hourly rounds. They do the documentation for the hourly rounds in the progress notes. A review of R1's progress notes dated [DATE] showed no documentation that he was observed and monitored every hour that started [DATE] when he was placed on isolation precautions. On [DATE] at 10:25 AM, V14 (RN) was asked regarding R1's condition on [DATE] night shift. V14 stated, On [DATE], I was the night nurse for him. He had COVID, he was placed on isolation. He was bedbound, unable to walk. On [DATE], report was given to morning nurse V4. He (R1) had no concern during night shift, with stable vital signs, and took his medications without any problems. I saw him at 6:30 AM and he was in bed, lowest position, sleeping comfortably. No signs of distress were noted. He was in isolation, and we do hourly monitoring on him. We go to his room and check, assess him for any unusual signs. CNAs also do rounds alternating with nurses but I do it every hour. We don't document the hourly observation; we were told not to do documentation. On [DATE] at 2:15 PM, V13 (Medical Director) was interviewed regarding expectation on staff related to monitoring and fall prevention. V13 stated, Facility has a clear protocol for monitoring patients/residents. CNAs and nurses see patients/residents during rounds. Nurses distribute medications and able to see residents. CNAs has protocol for fall residents that they follow. Nurses and CNAs see residents at the beginning of their shift and see residents every two hours to check, especially incontinent residents, regardless if these residents are on isolation or not. Nurses has to check if patients/residents are not in room. When I do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145198 If continuation sheet Page 3 of 4 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 02/26/2026 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete rounds and do not see resident in room, I ask nurses. Nurses should be aware where their residents are. V2 (Director of Nursing) also verbalized during interview on [DATE] at 11:20 AM, After endorsements, nurses need to do the hand off, meaning they need to check the residents physically after endorsements to check. For isolation residents, staff need to check every two hours, odd and even numbers meaning every hour. Staff need to see residents prior to start of shift. R1 was last seen at 6:30 AM. At 9:12 AM, R1 was observed on the floor, unresponsive and not breathing. At 9:58 AM, R1 was pronounced dead. R1's death certificate dated [DATE] recorded Cardiac Arrythmia; Atrial Fibrillation and Cerebrovascular Disease as causes of death. Facility's policy titled Routine Resident Checks dated [DATE], stated in part but not limited to the following:Purpose: Nursing staff will make structured and regularly scheduled routine resident checks to help proactively maintain resident safety, comfort, care needs and well-being. Procedures and Implementation:To promote the safety and well-being of our residents, nursing staff shall make initial rounds upon starting the shift and then routine checks on each unit at least every 2 hours (e.g.8 hour or 12 hour shift) and/ or as often as needed concordant to the resident's needs.Routine resident checks involve entering resident's room and/ or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concern, monitor vital signs as indicated and see if the resident is sleeping, needs toileting assistance, safe and etc. Facility's policy titled, Fall Occurrence dated [DATE] documented in part but not limited to the following:Policy Statement:It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Event ID: Facility ID: 145198 If continuation sheet Page 4 of 4