Inspection·February 28, 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 observations, interviews, and record reviews, the facility failed to provide residents with grooming and incontinent/hygeine care for residents who require assistance with ADLs (Activities of Daily Living) Residents Affected - Few This applies to 3 of 3 residents (R14, R43, and R46) reviewed for ADL cares in a sample of 31. The Findings include: 1. R14 is a [AGE] year-old male admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R14 is dependent on shower/bath and toileting hygiene and requires substantial/maximal assistance with personal hygiene. On 02/25/25 at 10:24 AM, R14 was observed in his bed with long, dirty fingernails with a black substance underneath the nail tip and a broken right middle fingernail. On 02/25/25 at 10:29 AM, V17 (Staffing Coordinator/Certified Nursing Assistant/CNA) stated that the CNAs are supposed to clean and trim R14's fingernails. On 2/26/25 at 12:20 PM, V2 (Director of Nursing/DON) stated that the CNAs or nurses can provide nail care/trimming. V2 also stated that they could check and offer nail trimming and grooming during shower days. A review of the facility presented Nail Care policy revised on 8/16/24 documents: 1.Nursing staff shall check the residents for nail care, which includes cleaning and regular trimming 4.Trimmed and smooth nails prevent the resident from accidentally scratching and injuring their skin . 2. R43 is a [AGE] year-old male with mild cognitive impairment as per MDS dated [DATE]. The MDS also documents that R43 is dependent on shower/bath and toileting hygiene. On 2/25/25 at 11:56 AM, R43 was observed in his bed with a strong odor of urine. On 2/25/25 at 12:00 PM, V18 (Registered Nurse/RN) checked on R43 for incontinence. R43 was observed with a urine-soaked incontinent brief and an intense urine smell. On 2/26/25 at 12:20 PM, V2 (DON) added that incontinent care should be offered at least every two hours. A review of R43's Activities of Daily Living (ADL) care plan documents that R43 is dependent on staff for toileting hygiene and requires 1-2 staff assistance for all toileting needs, including adjusting clothes, providing appropriate cleaning, and providing perineal care. A review of the facility presented incontinent and perineal care policy revised on 7/31/24 documents: 1.Do rounds at least every 2 hours to check for incontinence during the shift 3. On 02/25/25 at 12:00 PM, observed R46 sitting on her bed with her nightgown on. Alert and oriented. Observed R46 had stubbles on her chin area, about half cm long and thick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 2 of 17 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 02/28/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm On 02/26/25 at 10:08 AM, observed R46 had stubbles on her chin. R46 stated, CNA (Certified Nursing Assistant) will shave her today. V25 (RN - Registered Nurse) stated, R46 can shave on her own. On 02/27/25 at 12:45 PM, observed R46 sitting on her bed and eating lunch. Observed that there is a lot of hair on her chin area, about ½ to ¾ cm long. R46 stated, facility staff will shave it today. Residents Affected - Few On 02/27/25 at 12:55 PM, V22 (LPN-Licensed Practical Nurse) stated, anytime the CNAs (Certified Nursing Assistant) shower the residents, they will take care of their nails, facial hair etc. It is supposed to be done during their shower. V22 (LPN) stated, sometimes when agency staff is working, they do not pay attention to such details. On 02/27/25 at 12:59 PM, V21 (LPN) stated, it is undignified for females to be left with facial hair. It should be shaved during shower. If resident refuses, the CNAs inform the nurse & it is documented in the progress notes and care-plan. On 2/27/25 at 2:00 PM, V2 (DON) stated, facial hair, whether for males or females, should be shaved /trimmed during their shower. It is part of the resident's ADL (activities of daily living) care. If the resident refuses to be groomed regarding their facial hair, the nurse would document it in the progress notes. V2 stated, facility do not have a policy specific to the facial hair grooming. R46's Care Plan dated 1/13/25 showed R46 needed assist with ADLs. R46's MDS (Minimum Data Set) dated 1/21/25 GG showed R46 needed substantial assist for upper body dressing & shower & bathing. R46's Progress Notes did not include any note stating that R46 refused to be groomed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 3 of 17 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 02/28/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure blood glucose testing was performed as accurately as possible and failed to follow up on resident concerns with characteristics of urinary output. Residents Affected - Few This applies to 4 of 4 residents (R26, R96, R98, R157) reviewed for quality of nursing care in a sample of 31. The findings include: 1. On 2/26/25 at 11:47 AM, V16 (Agency RN) wiped R26's index finger her right hand with an alcohol pad and pricked the finger with a lancet and squeezed R26's finger. Instead of using a gauze, V16 wiped away the first drop of blood with an alcohol wipe without it letting it dry. Then she squeezed R26's finger a second time and tested the second drop of blood. The glucometer machine read R26's blood glucose as 583 MG/DL. On 2/26/25 at 12:30 PM, V16 went back to R26 and rechecked her blood sugar. V16 again wiped R26's ring finger of her left hand with an alcohol pad and pricked the finger with a lancet and squeezed it. V16 wiped away the first drop of blood with the alcohol pad, and again without letting it air-dry, squeezed the finger and tested the second drop of blood. R26's blood glucose read 495 MG/DL. On 2/26/25 at 2:05 PM, V2 stated she was unaware that by wiping away the first drop of blood with an alcohol wipe that hasn't air-dried, the alcohol can affect blood glucose readings. R26's face sheet shows a diagnosis of type 2 diabetes mellitus with hyperglycemia. R26's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. Call MD if blood sugar is below 75 or above 400. R26's care plan (1/13/2025) shows: Focus: (R26) is at risk for fluctuating blood sugars due to diabetes mellitus, receives glucose monitoring, insulin and Metformin. Under the Procedures section of the facility's Diabetes management policy (revised 7/26/2024), it showed 5. Blood Glucose Check clean the selected fingertip with alcohol pad and allow it to dry completely obtain a blood sample using a lancet 2. On 2/26/25 at 11:22 AM, V14 (Agency RN/Registered Nurse) wiped R157's right middle finger with an alcohol pad and pricked it with a lancet. V14 wiped away the first drop of blood with an alcohol pad and without letting it air-dry, V14 took the second drop of blood and tested it. R157's blood glucose reading was 129 MG/DL (Milligrams/Deciliter). R157's face sheet shows a diagnosis of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye. R157's POS (Physician Order Sheet) shows an order: Blood glucose 3 times a day before meals. Call MD (Medical Doctor) if blood sugar is below (70) or above (400). R157's care plan (2/14/25) shows: Focus: (R157) is at risk for fluctuating blood sugars due to diabetes mellitus. Interventions: Blood sugar check per physician's order. 3. On 2/26/25 at 11:28 AM, V14 wiped R96's right middle finger with an alcohol pad, pricked it with a lancet, then squeezed R96's finger. V14 wiped away the first drop of blood with an alcohol pad and instead of waiting for the alcohol to air-dry, She squeezed R96's finger ad tested the second drop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 4 of 17 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 02/28/2025 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 0684 of blood. The machine read R96's blood glucose as 155 MG/DL. Level of Harm - Minimal harm or potential for actual harm R96's face sheet shows a diagnosis of type 2 diabetes mellitus without complications. R96's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. Call MD if blood sugar is below 70 or above 350. R96's care plan (2/11/25) shows: Focus: (R96) is at risk for fluctuating blood sugars due to diabetes mellitus. Interventions: Blood sugar check per physician's order. Residents Affected - Few 4. On 02/26/2025 at 10:00 AM, R98 said he was in pain and had discomfort in his penis, especially when his urine passed through, and he was scared to drink any water so as to avoid the discomfort. R98 said this has been happening for a few days and he reported it already to some staff members but nothing had been done. R98 repeatedly said that he thinks he is going to die. A review of the urinary catheter output nursing document showed that R98 had decreased urinary output ranging from 300 ml (milliliters) to 450 ml for the whole day from 02/24/2025 to 02/26/2025. On 02/26/2024 at 10:40 AM, V7 (Certified Nursing Assistant) emptied R98's indwelling urinary Foley catheter (IFC) drainage bag and nephrostomy drainage bag. R98's IFC drainage totaled approximately 50 ml of concentrated, cloudy, and foul-smelling urine that had blood in it. The 100 ml of drainage from the nephrostomy tube was a muddy brown color, and it was also cloudy and foul-smelling. V7 checked R98's temperature at 09:50 AM, which showed his temperature was elevated at 99.7 degrees Fahrenheit. V7 said R98's urinary drainage was cloudy the day before on 02/25/2025, and she reported to V21 (Licensed Practical Nurse). On 02/26/25 at 11:25 AM, V24 (Fall Nurse) said she called R98's Nurse Practitioner and received an order for a urine culture and blood lab work. V24 then changed R98's indwelling catheter tubing. V24 said she was covering the unit and did not realize she needed to assess R98 completely. R98's urinalysis with culture and sensitivities was not collected until the next day on 2/27/25, and the nephrostomy drainage sample was not collected until the day after that on 2/28/2025. R98's preliminary urinalysis report showed abnormal results of turbid urine of orange color, with the presence of protein (300 milligram/deciliter), a large amount of blood, and positive for nitrites, leukocyte large, and bacteria many (reference ranges are negative); also with red blood cells more than 900 (reference range is 0-5), white blood cells 15 (reference range 0-5), and hyaline casts 6 (reference range is 0-3). The final urine cultures/sensitivities were not ready by the end of the survey. On 02/27/2024 at 10:00 AM, V21 said the staff should monitor, document, and follow up with the physician regarding any change in the resident's conditions. The EMR (Electronic Medical Record) showed R98 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, calculous of kidney, hematuria, obstructive and reflex uropathy, covid 19, diabetes type 2, acute and chronic respiratory failure with hypoxia and with a foley catheter and nephrostomy drainage tubing. R98's Minimum Data Set, dated [DATE] showed R98 cognitively moderately intact, and the care plan dated 01/18/2025 showed R98 needed monitoring for signs of elevated temperature, raised inflammatory markers, purulent urine output, pain, and burning and stinging when passing urine. On 02/28/2025 at 9:26 AM, V28 (R98's Physician) said he was unaware of R98's issue and the facility might be following up with the nurse practitioner. V28 said that if R98 has a low-grade fever, decreased urinary output, and other symptoms, the best practice is to do bloodwork and urine labs and expedite his appointment with the urologist. V28 said R98 was admitted with a indwelling catheter and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 5 of 17 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 02/28/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nephrostomy tube. V28 said that, to his best knowledge, R98 had both tubes because of an obstruction and didn't know the details, so the urologist might decide to keep or remove at least one of the tubes when R98 goes for the follow-up. The facility's Urinary Catheter Care revised policy dated 08/24/2025, in part, stated check the urine for unusual appearances, report the complaints of residents may have tenderness or pain in the urethral area, observe for the signs and symptoms of urinary tract infection or urinary retention and report to the physician or supervisor immediately . Event ID: Facility ID: 145638 If continuation sheet Page 6 of 17 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 02/28/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/26/25 at 9:27 AM, R14 was observed in his bed with a call light on the floor, floor paddings folded and leaned towards the wall (not on the floor at bedside), and an entry door name tag with no yellow star with the resident's name (indicative of a fall risk). R14 has severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 2/26/25 at 9:27 AM, V29 (Certified Nursing Assistant/CNA) stated that R14 is on fall precautions and floor padding should be on the side of the bed, and the call light should be accessible to the resident. On 2/26/25 at 12:20 PM, V2 (Director of Nursing/DON) stated the floor padding should be in place, and the call light should be accessible to the resident to call. The resident's name board should have a yellow star to reflect his high risk for falls. A review of the fall risk assessment dated [DATE] documented that R14 is at high risk for falls and the fall incident log documented that R14 had a fall he sustained on 1/26/25 with no injury. A review of the fall care plan interventions includes: providing floor mats/floor pads at my bedside, applying a yellow star sign that indicates high fall risk in his name tag by the door, and a call light within reach. A review of the facility presented Fall Occurrence policy revised on 7/26/24 documents: 1. Those identified as high risk for falls will be provided with fall interventions . Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls for residents with recent histories of falls. This applies to 2 of 2 residents reviewed (R14, R100) for fall and injury in a sample of 31. The findings include: 1. R100's admission Record showed he admitted to the facility on [DATE] with multiple diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis afftecting the left side, adjustment disorder, insominia, encephalitis, encephalomyelitis, impaired cognition, and muscle weakness. R100's fall care plan said he was at high risk for falls. The care plan included the following interventions Bed/Chair alarm to alert staff when resident attempts to get out of bed unassisted so staff can assist resident and prevent fall initiated on 12/14/2025 and Please provide me with wing mattress whenever available initiated on 1/17/2025. On 2/25/2025 at 10:05 AM, R100 was in bed on a regular mattress. R100 did not have a wing mattress (a fall prevention mattress with a boundary perimeter) in place. R100's sensory fall alarm pad was hanging on the left side bedrail, not underneath him. R100's wife said she was concerned for his safety because he had recently fallen out of bed twice. On 2/27/2025 at 9:30 AM, V2 (DON) said she expected R100's fall interventions to be obtained and implemented, including his fall sensory alarm pad and specialty fall mattress. V2 said wing mattresses are ordered from an outside equipment company and delivered within two days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 7 of 17 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 02/28/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm On 2/27/2025 at 10:30 AM, V24 (Fall Nurse) said she followed up regarding R100's specialty mattress and the facility was now putting it in place. R100's Fall Incident report dated 12/20/2024 said R100 had an unwitnessed fall from his bed, and a second Fall Incident report dated 1/13/2025 said R100 had another unwitnessed fall from his bed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 8 of 17 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 02/28/2025 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 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to to ensure urinary catheter tubing and drainage bags were positiond in a manner to prevent infection. Residents Affected - Few This applies to 3 out of 4 (R358, R96, and R95) residents reviewed for urinary catheters in a sample of 31. The findings include: 1. On 2/26/2025 at 10:40 AM, R358 was in bed and he was wearing pants. R358's urinary catheter drainage tubing came out from underneath the waistband of his pants, and then was over his pants (above the level of his bladder). R358's catheter drainage bag had been placed on top of his bed and the tubing and drainage bag contained urine. V7 (Certified Nurse Assistant/CNA) said she would provide catheter care to R358. R358's catheter tubing securement device was ripped and detached from the tubing and the tubing was not secured. After V7 completed R358's care, she again brought his catheter tubing up from his front waistband and then over his pants. R358's care plan said he required the use of a Foley catheter for acute urinary retention related to hydronephrosis and benign prostatic hyperplasia with lower urinary tract symptoms. R358's care plan interventions included catheter care every shift per facility policy protocol. On 2/27/2025 at 9:50 AM, V2 (Director of Nursing/DON) said residents with urinary catheters should be checked every shift to ensure securement devices are properly in place securing the tubing. V2 said catheter tubing should never be positioned underneath and over a resident's pants waistband, it should go underneath their pant leg. V2 said drainage bags should be placed below the bladder to prevent urine backflow into the bladder. The facility's policy titled Urinary Catheteter Care dated 8/19/2024, said The purpose of this procedure is to prevent catheter-associated urinary tract infections. b. Maintain Unobstructed Urine Flow i. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks .iii. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) . 2. On 2/26/2025 at 10:05 AM, R96 was in bed. V6 (CNA) said he would provide catheter care to R96. R96's urinary catheter tubing was looped underneath his right upper leg. R96's catheter tubing was not secured because the securement device was wrapped around the tubing and not attached to his leg. R96's urinary catheter tubing and drainage bag contained urine. R96's care plan said he required the use of an indwelling catheter for obstructive uropathy. R96's care plan interventions included positioning the catheter bag and tubing below the level of the bladder and for staff to check the catheter tubing for kinks. 3. On 2/26/2025 at 10:25 AM, R95 was in bed. V6 (CNA) said he would provide catheter care to R95. R95's urinary catheter tubing was not secured because the securement device was not attached to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 9 of 17 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 02/28/2025 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 right upper leg. R95's urinary catheter's tubing and drainage bag contained urine with sediment. Level of Harm - Minimal harm or potential for actual harm R95's Order Summary Report dated 2/27/2025 said she required the use of an indwelling catheter for obstructive uropathy. R95's report included orders for catheter care every shift and to monitor urinary tract infections. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 10 of 17 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 02/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow and serve the posted menu for residents. Residents Affected - Some This applies to all 18 residents (R8, R11, R18, R14, R41, R54, R55, R57, R59, R62, R70, R76, R82, R96, R357, R360, R361, R362) who receive non-vegetarian mechanical soft and puree regular diets, and 1 resident (R22) who receives a vegetarian pureed diet from the facility kitchen. The findings include: The facility's Week-At-A-Glance menu provided on 2/25/2025 showed a roasted pork loin was to be served for lunch on Tuesday (2/25/2025). On 2/25/2025 at 12:00 PM, V11 (Dietary Server) said the menu's main entree for lunch was roasted pork loin. At 12:30 PM R14 was served mechanical soft beef, not pork. V11 said residents with a mechanical soft diet were being served beef but could have pork. V11 said she was unsure why mechanical beef was prepared instead of pork. V11 said the pork loin was soft enough to be served for residents with a mechanical soft diet. V26 (Dietary Server) said the dietary department was not provided with the facility's updated list of residents receiving mechanical soft diets to ensure enough food could be prepared in advance. The facility's posted Menu on 2/26/2025 for breakfast also said a sausage patty was to be served. On 2/26/2025 at 8:15 AM, V11 said the breakfast menu included sausage patties. At 8:20 AM, R360 was served mechanical soft ham, not a sausage patty. V11 said she was unsure why mechanical ham was prepared but possibly because there was not enough sausage patties available. V11 said the sausage patty could be cut up into small cube sizes and be served to residents with a mechanical soft diet. At 8:35 AM, R361 was served a pureed meal, which had pureed eggs, bread, and a light whitish-tan colored meal item. V11 was asked what the unidentified puree item was served. V11 said it was not sausage but was unsure what was prepared because the container was not labeled. V11 was asked to serve the surveyor a puree sample tasting plate. The unidentified light whitish-tan item tasted like poultry and not sausage or ham. At 8:45 AM, breakfast observation was continued on the other unit. R54 and R41 were also served mechanical soft ham and not a sausage patty. R18 was served a pureed meal, which also included the same light whitish-tan puree meal item. V12 (Dietary Server) was asked to serve the surveyor a pureed sample for tasting. The served sample meal had the same poultry item and no sausage. V12 was asked about the served item but was unable to say what was being served. On 2/26/2025 at 12:05 PM, R22 was served a puree meal for lunch. R22's lunch meal ticket dated 2/26/2025 said R22 was to be served a Puree Vegetarian Burger. R22's served meal did not have a puree vegetarian burger as indicated in his meal ticket. V11 (Dietary Server) said she served a puree meal as requested by the CNA (Certified Nurse Assistant). V11 said she was not informed the meal was a puree vegetarian meal. V11 also said she was not provided with a puree vegetarian burger to serve R22. Then R361 was served a puree meal, which had puree bread, mashed potatoes, and green peas. R361's lunch meal ticket dated 2/26/2025 said R361 was to be served a double portion of Puree Crispy Chicken Thigh. R361's meal did not have a puree crispy chicken thigh as indicated in his meal ticket. V11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 11 of 17 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 02/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was asked to serve the surveyor a pureed tasting sample. The served sample meal had puree bread, mashed potatoes, and green peas. The sample meal did not have puree chicken. V4 (Dietary Manager) was present during the observations for R22, R361, and the puree meal taste sampling . V4 said R22 was supposed to receive a puree vegetarian burger and R361 a puree crispy chicken thigh. On 2/27/2025 at 11:10 AM, V4 (Dietary Manager) was interviewed regarding menus. V4 said menus should be followed but at times he makes the decision to substitute items. V4 said the facility had enough pork loin, sausage patties, and crispy chicken to serve residents. V4 said the puree sausage patty was substituted because he felt the quality and appearance was poor. V4 said he was unsure what was served on 2/26/2025 as a substitute for the puree sausage patty. V4 was unable to say why the sausage patty was also a substitute for residents receiving mechanical soft diets. V4 said dietary servers serve what is requested from the staff and if a resident has specific food items, they need to be made aware to ensure the resident receives it. On 2/28/2025 at 9:00 AM, V23 (Registered Dietician) said menu substitutions needed to be done prior to meal preparation to ensure the items are of equal nutrition. V23 said on 2/25/2025 residents with mechanical soft diets were to be served mechanical roasted pork loin for lunch. V23 said she did not approve any substitutions for the pork loin and was unsure what was served for residents with mechanical soft diets. V23 said on 2/26/2025 residents with mechanical soft diets were to be served a mechanical ground sausage patty for breakfast. V23 said she was unsure why it was changed to mechanical ham. V23 said V4 (Dietary Manager) informed her during the meal service that the puree sausage was changed to puree ham because of the poor quality appearance of puree sausage. V23 said she was unsure what the served unidentified light whitish-tan puree meal item was that was served for breakfast. V23 said sausage patties can be pureed and mechanically chopped. V23 said she was unsure why R22 did not receive his vegetarian burger which was selected for his lunch menu in advance. V23 said she was also unsure why R361 did not receive his double portion of puree chicken. V23 said she was unsure if the puree food containers were labeled with the food items to ensure servers were serving all the menu items. V23 said residents should be served what is indicated in their meal tickets. The facility's Diet Type Report dated 2/27/2025 said R54, R70, R41, R59, R82, R360, R357, R96, R362, R57, R14, and R76 were receiving non-vegetarian regular mechanical soft diets. The report also said R361, R62, R55, R11, R8, and R18 were receiving non-vegetarian regular puree diets. The facility's policy titled Menus dated 10/2019, said Policy Statement It is the center policy that menus are planned in advanced, and to meet the nutritional needs of the residents/patients, will be developed utilizing an established national guideline .6. Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal .8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. The facility's policy titled Kitchen dated 8/16/2024, said 8. Menu a. All food items in the menu and recipe will be followed. In the event that change is needed, the dietician may be consulted first to approve the change and ensure that the change is appropriate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 12 of 17 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 02/28/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 2/26/25 at 11:47 AM, V16 (Agency RN) took R26's blood sugar with a glucometer in her room. She then brought the glucometer to her medication cart. Instead of wiping down the surface of the glucometer and disinfecting it, she simply wrapped it in a bleach wipe and left it to air dry. At 12:30 PM, V16 went back to R26 and rechecked her blood sugar. Again V16 brought the glucometer to her medication cart and just wrapped it with a bleach wipe. Residents Affected - Some R26's face sheet shows a diagnosis of type 2 diabetes mellitus with hyperglycemia. R26's POS (Physician Order Sheet) shows an order: Blood glucose check 4 times a day before meals and at bedtime. On 2/26/25 at 2:10 PM, V2 (DON) said, the nurse should wipe the surface first, then either wrap it with the bleach wipe or keep it wet continuously for however long the manufacturer's recommendations says. Facility's policy titled: Glucose Meter Cleaning (7/30/24) shows: Policy Statement-To ensure safe, convenient and proper cleaning and disinfection of blood glucose meters in accordance to CDC (Centers for Disease Control and Prevention) guidelines and manufacturer's instructions to help prevent device exposure to blood borne pathogens. Procedures: 3. Place equipment on a clean surface. 4. Clean and disinfect glucose meter with EPA-approved disinfectant including Clorox Healthcare Bleach Germicidal Wipes/Microkill Wipes/ Microdot Wipes/Avert Wipes before after each resident use. 5. Staff must keep glucometer with the disinfectant wipe for a minimum of 60 seconds The label on the back of the container and manufactures guidelines for the Clorox Healthcare Bleach Germicidal Wipes showed: Cleaning Procedure: Blood and other body fluids must be thoroughly cleaned from surfaces and other objects before applying this product. Contact Time: Allow surfaces to remain wet for 1 minute, let air dry. For all other organisms, see directions for contact times. 7. On 2/26/25 at 11:22 AM, V14 (Agency RN/Registered Nurse) took R157's blood sugar in her room with a glucometer that is used for all residents. She then brought the glucometer to her medication cart. Instead of wiping the surface of the glucometer first, she wrapped it in a Clorox Healhcare Bleach Germicidal Wipe and left it to air dry. R157's face sheet shows a diagnosis of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye. R157's POS shows an order: Blood glucose 3 times a day before meals. 8. On 2/26/25 at 11:28 AM, V14 stated that R96 was Covid positive. V14 took R96's blood sugar in his room with a glucometer. She then brought the glucometer back out of the room and to her medication cart. Instead of wiping down the surface of the glucometer, she wrapped it in a bleach wipe and left it to air dry. R96's face sheet shows a diagnosis of type 2 diabetes mellitus without complications. R96's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. 9. On 2/26/25 at 11:34 AM, V15 (LPN-Licensed Practical Nurse) took R48's blood sugar with a glucometer. She then brought the glucometer to her medication cart. Instead of thoroughly wiping down the surface of the glucometer, she wrapped it in a bleach wipe and left it to air dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 13 of 17 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 02/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm R48's face sheet shows a diagnosis of type 2 diabetes mellitus without complications. R48's POS shows an order: Blood glucose check 4 times a day before meals and at bedtime. 10. R98 is a [AGE] year-old male with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, and hematuria with nephrostomy drainage tubing and foley catheter. Residents Affected - Some On 02/26/2025, at 10:40 AM, observed not having enhanced barrier precaution (EBP) signage on R98's door, and V7 (Certified Nursing Assistant) drained R98's nephrostomy and urinary catheter bag. At 11:25 AM, V24 (Registered Nurse) changed R98's indwelling urinary catheter drainage bag. V7 and V24 provided direct care to R98 without using gowns per their enhanced barrier precaution policy. 11. R21 is a [AGE] year-old male with diagnoses including stenosis of the anus and rectum with a colostomy bag, anemia, and protein-calorie malnutrition. On 02/26/2025 at 10:10 AM, observed not having enhanced precaution signage on R98's door, and V7 (Certified Nursing Assistant) provided incontinence care to R98. V7 provided direct care to R21 without wearing a gown. On 02/26/2025 at 11:40 AM, V7 and V24 said they should have worn full PPEs (Personal Protective Equipment) while providing direct care to R98 and R21. 12. R359 is a [AGE] year-old female on isolation for Covid 19 positive result with diagnoses including acute gastroenteropathy due to other small round viruses, infectious gastroenteritis, and colitis. On 02/27/2025 at 10:30 AM, observed V21(Licensed Practical Nurse) administering medications without using a facial shield. R359's care plan, dated 02/25/2025, states that staff will wear a mask and face shield or goggles while providing care while in close contact with the resident. 13. R53 is a [AGE] year-old female on isolation for Covid 19 positive result with diagnoses including end-stage renal disease and chronic obstructive pulmonary disease. On 02/27/2025 at 10:30 AM, V21(Licensed Practical Nurse) was observed administering medications without a facial shield. On 02/27/2025, at 10:55 AM, V21 said she forgot to wear a face shield, which she should have. On 02/27/2025 at 2:30 PM, V5 (Infection Control Nurse) said, All staff should adhere to infection control protocol and policies. Based on observation, interview, and record review, the facility failed to follow its respiratory testing policy for the management of its COVID-19 outbreak. The facility also failed to follow infection control practices for residents on transmission-based and enhanced-barrier precautions and failed to thoroughly disinfect glucometers. This applies to 13 of 13 residents (R23, R53, R307, R96, R32, R359, R103, R358, R48, R157, R26, R21, and R98) reviewed for infection control in a sample of 31. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 14 of 17 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 02/28/2025 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 0880 The findings include: Level of Harm - Minimal harm or potential for actual harm 1. On 2/25/2025 at 9:30 AM, the facility's main entrance had signage indicating that the facility had a COVID-19 outbreak and the transmission rate for respiratory infections was high in the facility's county. Residents Affected - Some On 2/25/2025 at 11:25 AM, V5 (Infection Preventionist/IP Nurse) said the facility's COVID-19 outbreak started on 2/22/2025. V5 said the facility had three cases of confirmed facility COVID-19 cases. V5 said R96 and R307 tested positive on 2/22/2025, and R23 had just now tested positive. On 2/25/2025 at 11:55 AM, R32 was wearing a hospital gown in the dining room with other residents. R32 said she felt ill because she had a sore throat. R32 said she asked the nurse to test her for COVID-19 early in the morning. R32 said her rapid COVID test was negative but she still felt ill. R32 said the facility then tested her roommate (R23) because she was also having respiratory symptoms. R32 said she was then removed from her room because R23 tested positive for COVID. R32 said that the staff had not returned to explain to her what was going to occur with her room situation. On 2/26/2024 at 8:50 AM, R32 was in bed and said her throat was still sore. 2. On 2/25/2025 at 11:45 AM, R23 was in her room receiving 3 liters of oxygen via nasal cannula. R23 said she had been feeling ill and was without an appetite for a few days and thought she had a sinus infection. R23 said overnight she felt short of breath and was placed on oxygen. R23 said the nurse tested R32 and then her for COVID-19 early in the morning. R23 said she tested positive for COVID-19. On 2/26/2025 at 12:40 PM, V5 (IP Nurse) said the facility now had two additional confirmed resident cases (R359 and R53) and one staff member V8 (Registered Nurse/RN). V5 said the facility was only testing symptomatic residents for COVID-19. V5 said she had informed V13 (IP Local Health Department) and received guidance, including a link for Preventing and Controlling ARI [Acute Respiratory Infection] Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Nursing Care. On 2/26/2025 at 2:50 PM, V13 (IP Local Health Department) confirmed that the facility received guidance resources on managing respiratory outbreaks, including COVID-19, on 2/06/2025. V13 said that based on the current transmission rates in the county, facilities are to be testing for both COVID-19 and Influenza for residents showing respiratory symptoms. On 2/27/2025 at 9:50 AM, V3 (Regional Nurse Consultant) said the facility should be following their COVID-19 policies. V3 said infection control policies are developed based on CDC (Centers for Disease Control and Prevention) and Health Department regulations and guidelines. V3 said V5 has now retested R32 for both COVID and Influenza. V3 said she has also instructed V5 to now test R23, R359, R53, R96, and R307 for influenza. R32's Order for Respiratory nasal swab panel showed it was obtained on 2/26/2025 at 5:55 PM. The facility's document titled COVID-19 Residents Cases Tracker showed R307 and R96 were tested on [DATE]; and R23, R359, and R53 were tested on [DATE] only for COVID-19. The document titled Preventing and Controlling ARI Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Nursing Care from IDPH (Illinois Department of Public Health), showed This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 15 of 17 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 02/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some guidance replaces previous COVID-19 disease-specific guidance. It is based on the CDC's guidance for the control of respiratory illnesses, including COVID-19, influenza, and other respiratory illnesses, in healthcare settings . Testing COVID-19, influenza, RSV, and other viral respiratory illnesses all have similar and overlapping symptoms. When an outbreak of acute respiratory illness is suspected, testing to determine the etiology of the disease is essential to determine the appropriate precautions needed to control the outbreak and if indicated, to implement timely treatment and chemoprophylaxis .Specimens for acute respiratory outbreaks should be collected immediately after the onset of illness .Test any resident with symptoms of COVID-19 or influenza for both viruses. The facility's policy titled Covid 19 and Influenza Virus Cocirculation policy dated 7/16/2024, said The following practices recommended by CDC should be considered when COVID 19 and Influenza viruses are found to be co-circulation based upon local public health surveillance data and testing at local healthcare facilities .2. Test any symptomatic resident for both Covid and Influenza viruses. Obtain respiratory specimens for influenza and Covid 19 testing .Test for COVID 19 by nucleic acid detection OR by COVID 19 antigen detection assay .Because antigen detection assay have lower sensitivity than nucleic acid detection assays for detecting Covid 19 in upper respiratory tract specimen, a negative Covid 19 antigen detection assay result in a symptomatic person does not exclude Covid 19 infection and should be confirmed . 3. On 2/25/2025 at 10:50 AM, R96's room door had signage for transmission-based precautions instructing everyone entering the room that N95 PLUS EYE PROTECTION AND CONTACT PRECAUTIONS were required. V10 (Physical Therapist) was observed exiting R96's room without eye protection. V10 said she just finished providing therapy services to R96. V10 said she did not don a face shield because she used her personal prescription eyeglasses as PPE (personal protective equipment). On 2/26/2025 at 9:15 AM, V6 (Certified Nurse Assistant/CNA) was observed exiting R96's room with a surgical mask, not an N95 mask. V6 said he forgot to don an N95 mask before entering R96's room. R96's Order Summary report had an order for Isolation- Droplet/Contact Reason: Active COVID initiated on 2/22/2025. 4. On 2/26/2025 at 9:20 AM, R103's room door had signage for enhanced-barrier precautions (EBP) instructing providers are required to don gloves and a gown when providing high-contact activities. V6 (CNA) transferred R103 from her wheelchair to her bed by supporting her right upper arm. V6 was not wearing a gown. R103 had a right upper arm intravenous midline and sacral wounds. R103's care plan said she was on EBP because of the potential spread of infection (initiated on 2/14/2025). The care plan said EBP interventions were required because high-contact activities provided the opportunities for transfer of [multi-drug resistant organisms] to staff hands and clothing. 5. On 2/25/2025 at 10:40 AM, R358's room door had a signage for EBP. V7 (CNA) entered R358's room with gloves and proceeded to provide him with urinary catheter care. V7 did not don a gown. R358's care plan said she was on EBP because of the potential spread of infection (initiated on 2/25/2025). The care plan interventions said precautions should be taken when being provided with high-contact activities including device care such as urinary catheters. On 2/26/2025 at 12:40 PM, V5 (IP Nurse) said staff were expected to don proper PPE when providing care to residents under transmission-base and enhanced-barrier precautions to prevent the spread of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 16 of 17 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 02/28/2025 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 0880 infections and protect other residents and staff. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Enhanced Barrier Precautions dated 7/26/2024, said The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug resistant organisms in the nursing homes. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 17 of 17