Inspection·March 11, 2025

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. Residents Affected - Few This applies to 2 of 4 residents (R4 and R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R4 is an [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R4 is dependent on toilet hygiene. On 3/7/25 at 10:05 AM, R4 stated, They changed me this morning at around 4:30 AM. I want to be changed now. The CNA is supposed to come and change me. On 3/7/25 at 10:10 AM, V5 (CNA) stated, I started 6:00 AM today and am on my way to change R4. We should provide incontinent care to dependent residents every two hours. I was passing breakfast trays. On 3/7/25 at 10:10 AM, R4 was observed with a urine-soaked incontinent brief with brownish discoloration. A review of R4's incontinent care plan documented that the staff checks the resident for incontinent episodes every two hours and as needed and assists the resident in washing, rinsing, and drying her perineum. 2. R5 is an [AGE] year-old female admitted on [DATE] with cognition severely impaired as per the MDS dated [DATE]. MDS also documents that R5 is dependent on toilet hygiene. On 3/7/25 at 10:15 AM, R5 was observed in her bed with her daughter (V9) at the bedside. On 3/7/25 at 10:15 AM, observed V6 (CNA) checking on R5 for incontinence and observed R5 with urine and feces-soaked brief, with dark brown discoloration. V6 stated that R5 is not her resident and she is just helping out another aide. A review of R5's incontinent care plan documented that the staff checks the resident for incontinent episodes every two hours and as needed and assists the resident in washing, rinsing, and drying her perineum. (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 3 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 03/11/2025 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)