Inspection·October 2, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to provide feeding assistance for a resident with a dysphagia diagnosis, requiring 1 to 1 feeding assistance. This applies to 1 of 4 (R1) residents reviewed for feeding assistance reviewed for safety supervision in the sample of 7. The findings include: On 10/2/2024 at 12:18PM, R1 was observed at lunch with a mechanical soft tray and thickened liquids in front of him. R1 was observed reaching for and drinking the thickened liquids on the tray. V6 Activity Director was observed sitting at the end of the lunch table R1 was eating at. On 10/2/2024 at 12:20PM, V6 said she was not qualified to feed residents. On 10/2/2024 at 12:15PM, V5 Certified Nursing Assistant (CNA) said R1 had refused lunch. V5 said she left [R1's] tray in front of him at the lunch table. On 10/2/2024 at 1:39PM, V2 Director of Nursing (DON) said resident's requiring 1:1 feeding assistance should be helped by a CNA, nurse, or speech therapy. V2 said a tray should not be left in front of a resident requiring 1:1 feeding assistance without staff present. R1's admission Record dated 10/2/2024 lists a medical diagnosis of Dysphagia, Oropharyngeal Phase. R1's Order Summary Report dated 10/2/2024 lists Regular Diet Mechanical Soft texture, Nectar Thick Liquid Consistency, allow thin water and ice chips between meals. 1:1 assistance, active as of 9/27/2024. 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: 145638 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 145638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Bloomingdale 165 South Bloomingdale Road Bloomingdale, IL 60108 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)