Inspection·July 20, 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 3 of 4 residents (R2, R3, and R4) reviewed for activities of daily (ADL) care in a sample of 4. Residents Affected - Few The Findings Include: 1. R2 is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. MDS also indicates that R2 is dependent on toilet hygiene. On 7/19/24 at 9:45 AM, R2 stated, I was changed at 5:00 AM today. I am a little wet now. On 7/19/24 at 10:05 AM, per the surveyor's request, V5 (Certified Nursing Assistant/CNA) checked on R2 for incontinence and found R2 with a urine-soaked diaper and urine smell in the room. On 7/19/24 at 10:05 AM, V5 stated, I started my shift at 6:00 AM, and I didn't change her today. We should check residents every two hours for incontinent care. A review of R2's incontinent care plan documents R2's preference to check on her for incontinent episodes every two hours. R2 also prefers assistance to wash, rinse, and dry her perineum. 2. R3 is an [AGE] year-old female admitted on [DATE] having mild cognitive impairment as per the MDS dated [DATE]. MDS also indicates that R3 is dependent on toilet hygiene. On 7/19/24 at 10:00 AM, R3 stated, They changed me at 4:30 AM. I might be wet now. Upon the surveyor's request, V4 (Registered Nurse/RN) checked on R3 for incontinence. R3 was found with a urine-soaked incontinent brief (urine smell in room) with mild blackish discoloration to brief. On 7/19/24 at 10:03 PM, V4 stated that they should check on residents every two hours to offer incontinent care. 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 an [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R4 is dependent on toilet hygiene. On 7/19/24 at 10:10 AM, V7 (RN) checked on R4 as per the surveyor's request, and R4 was observed with a double diaper soaked in urine, even the outer layer. (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 07/20/2024 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)