Inspection·April 11, 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 observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 4 of 5 residents (R1, R3, R4, and R5) reviewed for activities of daily (ADL) care in a sample of 9. Residents Affected - Some The Findings Include: 1. R1 is a [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R1 is dependent on toilet hygiene. On 4/9/24 at 9:22 AM, R1 was observed with V5 (Certified Nursing Assistant/CNA) and R1 was observed with an inner liner inside an incontinent brief soaked with urine and feces. V5 stated on 4/9/24 at 9:22AM, I started my shift at 6:00 AM, and I checked her around 6:20 AM, and R1 was dry then. We are supposed to check residents for incontinence every two hours. A review of R1's incontinent care plan documents R1's preference to check on her for incontinent episodes every two hours. R1 also prefers assistance to wash, rinse, and dry her perineum. 2. R3 is an [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R3 is dependent on toilet hygiene. On 4/9/24 at 9:35 AM, R3 was observed with V4 (CNA) and R3 was observed with a urine-soaked inner pad inside the incontinent brief. On 4/9/24 at 9:35 AM, V4 stated that R3's preference for an inner pad is care planned, and she will change R3 even though she was not assigned CNA for R3. A review of R3's incontinent care plan documents R3's preference to check on her for incontinent episodes every two hours. R3 also prefers assistance in washing, rinsing, and drying her perineum. 3. R4 is a [AGE] year-old female admitted on [DATE]. As per the MDS dated [DATE], her cognition is intact. The MDS also indicates that R4 is dependent on toilet hygiene. R4 was observed on 4/9/24 at 9:42AM in her bed with a double-layered incontinent brief with inner padding soaked with urine. R4 stated on 4/9/24 that the staff changed her earlier, at around 5:50 AM. Later, V4 provided care and R4 was compliant with incontinent care without refusal. A review of R4's incontinent care plan documents R4's preference to check on her for incontinent episodes every two hours. R4 also prefers assistance in washing, rinsing, and drying her perineum. 4. R5 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the MDS dated [DATE]. MDS also indicates that R5 dependent on toilet hygiene. R5 was observed in her room on 4/9/24 at 9:50AM and stated that the last time she was provided personal care was around midnight. On 4/9/24 (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 04/11/2024 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)