Health inspection·October 21, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses, including chronic congestive heart failure, chronic kidney disease stage 3, diabetes type 2, legal blindness, and urinary tract infection. R3's MDS, dated [DATE], showed R3 had moderately impaired cognition and required assistance with ADLs, including substantial assistance with eating, oral hygiene, and personal hygiene and supervision with bathing and sitting up in bed, dependent on staff assistance for toileting, dressing and transfer. According to the facility's schedule, R3 was scheduled to receive a shower on September 17, 20, 24, 26, and October 1, 4, 8, 11, 15, and 18. However, R3 received a shower per POC documentation on September 27 and 28 and October 4, 8, and 13, 2024, not as often as scheduled, twice per week. On October 19, 2024, at 3:00 PM, R3's daughter stated she wanted R3 to receive her bathes twice per week as scheduled. 4. R7's EMR showed R7 was admitted to the facility on [DATE], with multiple diagnoses, including nontraumatic intracerebral hemorrhage, unsteadiness on feet, diabetes type 2, depression, ischemic cardiomyopathy, and chronic kidney disease stage 3. R7's MDS dated [DATE], showed R7 had moderate cognitive impairment, and required assistance with ADLs including set up assistance with eating, oral hygiene, upper body dressing, Supervision/light touch with bed mobility, personal hygiene, toilet hygiene, and lower body dressing, and partial assistance with bathing. Per R7's POC documentation for the past 30 days, R7 received a shower on September 27, and October 13, 2024, less than the minimum of 7 days apart. 5. R8's EMR showed R8 was admitted to the facility on [DATE], with multiple diagnoses, including unspecified atrial fibrillation, vascular dementia, obstructive and reflux uropathy, and cognitive communication deficit. R8's MDS, dated [DATE], showed R8 was severely cognitively impaired and required assistance with ADLs, including supervision with eating and oral hygiene, partial assistance with upper body dressing and bed mobility, and substantial assistance with lower body dressing, bathing, and transfer. R8's shower documentation from September 22, 2024, through October 20, 2024, showed R8 received a shower on October 10, 17, and 18, 2024. There was no documented shower given from September 22, 2024, until October 10, 2024. On October 19, 2024, at 5:36 PM, V2 (Director of Nursing) stated residents are scheduled to receive a shower twice per week and if the resident refuses the shower, staff is to document the refusal. The Facility's policy title Shower and Hygiene dated August 19, 2024, showed It is the policy of the facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin.Procedures .1 Administer the shower once weekly and/or as often as necessary. Any resident who needs hygienic care will be provided to promote hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 2 of 4 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 10/21/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not follow their policy for Urinary Catheter Care and failed to document the assessment of symptoms for residents with indwelling urinary catheters who developed UTIs (Urinary Tract Infections) This applies to 3 of 4 residents (R1, R2 and R8) reviewed for indwelling urinary catheter care and UTI in the sample of 8. The findings include: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], and discharged from the facility on October 8, 2024. R2 was admitted with multiple diagnoses: metabolic encephalopathy, unspecified psychosis, type 2 diabetes with chronic kidney disease, neuromuscular dysfunction of the bladder, unspecified dementia, pressure ulcer to the ankle, and acute and chronic respiratory failure. R2's MDS (Minimum Data Set) dated September 24, 2024, showed R2 was moderately cognitively impaired, and required assistance with ADLs (Activities of daily Living) including substantial assistance with eating, oral hygiene, personal hygiene, dressing, and bed mobility and dependent on staff for bathing and toileting. R2 had an indwelling urinary catheter and was incontinent of bowel. R2's hospital record dated October 8, 2024, showed R2 arrived at the local hospital emergency department from the facility at 7:35 PM. R2's emergency department record showed R2 arrived lethargic, altered mental status with possible UTI. R2's laboratory reports dated October 8, 2024, at 9:05 PM, showed R2's urine was orange in color, extra turbid, with blood and many bacteria present. R2's symptoms documented in the emergency room note showed that R2 was lethargic and non-verbal, skin was slightly warm, clammy, and shaky. R2's hospital admitting diagnosis was a urinary tract infection with indwelling urethral catheter. On October 19, 2024, at 5:54 PM, V14 (RN) stated he was the regular evening shift nurse assigned to R2 and had been the nurse who sent R2 to the hospital on October 8, 2024. V14 stated that R2 was sent to the hospital after R2's daughter insisted that R2 be transferred. V14 stated that R2 was very lethargic and not taking in oral fluids. V14 stated he told R2's daughter he would contact R2's physician and obtain an order for IV (Intravenous fluids) and obtain a urine sample. V14 stated the daughter was told it may take a day for the initial urine results and the culture would take an additional 48-72 hours for results and the daughter insisted R2 to be sent to the hospital for evaluation and treatment. V14 stated he did not recall what the urine output in the drainage bag looked like, but there was not much in the drainage bag. There was no description of R2's urinary output, color, clarity, or unusual appearance in R2's EMR. 2. R8's EMR (Electronic Medical Record) showed R8 was admitted to the facility on [DATE], with multiple diagnoses including unspecified atrial fibrillation, vascular dementia, obstructive and reflux uropathy and cognitive communication deficit. R8's MDS (Minimum Data Set) dated September 4, 2024, showed R8 was severely cognitively impaired, and required assistance with ADLs including supervision with eating and oral hygiene, partial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 3 of 4 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 10/21/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance with upper body dressing and bed mobility, and substantial assistance with lower body dressing, bathing, and transfer. R8's progress note of October 14, 2024, showed R8 had urine lab results called to the physician for notification due to the presence of bacteria noted in the urine lab result. R8's EMR showed there was no assessment of symptoms, including urine color, turbidity, or presence of pain, or evaluation for fever in R8's progress notes. R8's physician ordered Cipro 500 mg twice daily for 7 days as an antibiotic to treat UTI. R8's progress notes did not contain a description of R8's urine output except for the amount drained from the bag. R8's progress notes do not contain an assessment of R8's response to treatment of the UTI. R8's urine lab results dated October 10, 2024, showed urine described as cloudy. 3. R1's EMR showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic diastolic congestive heart failure, chronic kidney disease stage 3B, dry eye syndrome, type 2 diabetes without complication, malignant neoplasm of the prostrate, other obstructive and reflux uropathy and dementia, unspecified. R1's MDS, dated [DATE], showed R1 with moderate cognitive impairment and required assistance with ADLs, including substantial assistance with oral hygiene, upper body dressing and bed mobility, set up assistance with eating, and dependent on staff for toileting, bathing, lower body dressing and transfer. R1 had a suprapubic indwelling urinary catheter in place. On September 3, 2024, the hospice NP (Nurse Practitioner) wrote a progress note with orders to change the antibiotic order from Macrobid to Cipro for 14 days for a UTI. R1's progress notes did not include an assessment by facility staff and no lab results indicative of a UTI to indicate why the medication was changed or what symptoms of UTI R1 was exhibiting. R1's progress notes did not contain documentation of R1's response to treatment for a UTI. On October 19, 2024, at 3:19 PM, V2 (Director of Nursing) stated it is the expectation for nursing staff to monitor urinary output from indwelling urinary catheters and document color, clarity or any unusual appearance or change in the output. The facility policy titled Urinary Catheter Care, dated August 19, 2024, showed Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections .General Guidelines . 2a. Input/output i. Observe the resident's urine level for noticeable increases or decreases .ii. Maintain an accurate record of the resident's daily output .Complications .1b Check the urine for unusual appearance (i.e. color, blood, etc.) .e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately .Documentation .4. Character of urine such as color (straw colored, dark, or red), clarity (cloudy, solid particles, or blood) and odor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 4 of 4