Inspection·April 2, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 4 (R1) residents reviewed for activities of daily living in the sample of 4. Residents Affected - Few The findings include: R1's face sheet shows he is [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, generalized anxiety, and major depression disorder. On 4/2/24 at 9:10 AM, R1 was observed lying in a bariatric bed. He said on 3/28/24 during third shift, V9 (Agency Certified Nursing Assistant/CNA) did not change him during her shift from 10 PM to 6 AM. R1 said he pressed his call light on a few times in the morning and someone answered and said they would come. V8 (CNA) the day shift CNA answered his call light after 6:00 AM to change him. R1 said he was soaked with urine and stool and had not been changed from the night before about 8:30 PM. On 4/2/24 at 9:41 AM, V5 (CNA) said there has been times when she comes in for her shift in the morning and she finds residents who have not been changed. It happened three days ago and its usually agency staff. On 4/2/24 at 11:54 AM, V8 (CNA) said she was R1's CNA on 3/29/24, during day shift at 6:00 AM. When she came in R1's call light was on. He said he needed to be changed. He said he was aggravated with one of the rentals )that's what he calls the agency staff.) R1 was soaked with urine and stool, I had to change the complete bed because it was soiled. R1 is alert and oriented when he voids, he is a heavy wetter. When a resident is soaked it usually means they have not been changed. I had a couple of residents that shift who were soaked. V9 did not give her report in the morning. V8 said, Agency staff they just leave when their shift is over. Residents should be checked and changed every two hours for incontinence care. On 4/2/24 at 1:38 PM, V2 (ADON) said R1 has reported to her concerns with agency staff. A previous time he did report not being changed during a shift and it was true. We try to keep him with our regular staff because he does not like agency staff. R1's current care plan dated through April 2024 shows he is always incontinent of bladder and bowel with interventions for staff to check me for incontinence episodes every two hours. The facility's 2nd floor Assignment Sheet for night shows V9's assignment including R1's room. (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: 145511 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 145511 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lombard 2100 South Finley Road Lombard, IL 60148 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)