Inspection·May 22, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Coreg medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:14 (9:14 PM), more than four hours after the scheduled administration time. 2. On May 21, 2025 at 11:12 AM, R2 was lying in bed in her room. R2 said V6 (RN) arrived at the facility at approximately 5:45 PM on May 17, 2025. R2 said, She got here and just sat at the desk and didn't even bother to check on us. I had to go up to her at the desk and tell her I needed my blood sugar checked. I had to go to the desk to get my Gabapentin (pain medication) because she hadn't passed medications, and no one had filled in for her when she was late getting here. I was not having a lot of pain, but it's just the idea that we like to get our medications on time, and that was not happening. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, sciatica, atrial fibrillation, chronic kidney disease, left eye cataract, pressure ulcer of the left heel, presence of cardiac pacemaker, depression, heart failure, pulmonary hypertension, anemia, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, oral hygiene, dressing, and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering. R2 is occasionally incontinent of bowel and bladder. R2's care plan for pain/discomfort initiated on July 22, 2024 shows multiple interventions initiated on April 4, 2023 including, provide analgesic as ordered. The EMR shows the following order for R2 dated September 14, 2024: Gabapentin 100 mg. Give 2 capsules by mouth three times a day for pain. R2's May 2025 MAR shows R2's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. 3. On May 21, 2025 at 11:20 AM, R3 was walking in her room with a walker. R3 was not able to recall concerns regarding medications being given late due to her cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, asthma, vascular dementia, obstructive uropathy, chronic diastolic heart failure, low potassium, major depressive disorder, chronic kidney disease, atrial fibrillation, and psychosis. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, substantial/maximal assistance with lower body dressing, and partial/moderate assistance with all other ADLs. R3 is occasionally incontinent of bowel and bladder. R3's care plan entitled chronic back pain, joint/knee pain, initiated October 4, 2023 shows R3 receives lidocaine to lower back, and gabapentin as ordered. The EMR shows the following order for R3 dated November 19, 2024: Gabapentin Capsule 100 mg. Give 1 capsule by mouth three times a day for nerve pain. R3's May 2025 MAR shows R3's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 2 of 11 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 05/22/2025 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 - Some documentation to show R3's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time. 4. The EMR shows R13 was admitted to the facility on [DATE] with multiple diagnoses including, COPD with exacerbation, polyneuropathy, spinal stenosis, Type 2 diabetes, and heart disease. R13's MDS dated [DATE] shows R13 is cognitively intact and requires setup assistance with all ADLs. The EMR shows the following order for R13 dated July 19, 2024: Gabapentin capsule 100 mg. Give 2 capsules by mouth three times a day for nerve pain. R13's May 2025 MAR shows his Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R13's Gabapentin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered at 20:54 (8:54 PM), almost four hours after the scheduled administration time. 5. The EMR shows R15 was admitted to the facility on [DATE] with multiple diagnoses including, acute and chronic respiratory failure with hypercapnia, COPD, atrial fibrillation, pulmonary fibrosis, hypertension, Type 2 diabetes, asthma, heart failure, and abnormal gait and mobility. The EMR continues to show R15 has an order for continuous oxygen dated March 6, 2025. R15's MDS dated [DATE] shows R15 is cognitively intact, requires partial/moderate assistance with showering, and setup and/or supervision with all other ADLs. The EMR shows the following order for R15 dated February 20, 2025: Budesonide-Formoterol Fumarate Inhalation Aerosol. Two puffs, inhale orally two times a day for COPD. R15's May 2025 MAR shows R15's Budesonide-Formoterol Fumarate inhaler is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R15's Budesonide-Formoterol Fumarate inhaler, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:02 (9:02 PM), four hours after the scheduled administration time. On May 21, 2025 at 3:45 PM, V8 (Pharmacist) said, Velphoro has to be given with meals. If you take the medication three hours after the meal, it will decrease the effectiveness of the medication. The manufacturer recommends it should be given with the meal. If Coreg is given an hour before or after the scheduled time, I wouldn't expect a huge change. When you go three, four, or five hours, you might experience some symptomatic results, like fluctuations in blood pressure. Gabapentin is administered for nerve pain. As compared to an opioid, it works differently. All the medications should be administered as ordered. The facility's policy entitled Physician Orders, revised on 8/16/24 shows: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). The facility's policy entitled Medication Pass, revised on 8/16/24 shows: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.7. PO (Oral) Meds: .e. After medication is administered to each resident, sign MAR that it was given. The facility's policy entitled Oral Medication Administration, revised on 08-2020 shows: 9. Chart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 3 of 11 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 05/22/2025 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 medication administration on the MAR (or eMAR-Electronic MAR) immediately following each resident's medication administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 4 of 11 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 05/22/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer insulin as ordered by the physician. Residents Affected - Some This applies to 4 of 16 residents (R1, R2, R3, R4) reviewed for quality of care in the sample of 16. The findings include: 1. On May 21, 2025 at 11:26 AM, R1 was sitting in his room. R1 said on May 17, 2025 the day shift nurse left at approximately 3:00 PM, and the evening shift nurse did not arrive at the facility until 5:45 PM. R1 said he was upset because he did not receive his medications on time and no facility staff were asked to fill the void left by V6's (RN-Registered Nurse) [NAME] arrival. R1 said dinner was served at 5:00 PM on May 17, 2025. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dependence on renal dialysis, chronic kidney disease, type 2 diabetes, bilateral vitreous hemorrhage, heart failure, hypertension, and heart disease. R1's MDS (Minimum Data Set) dated April 1, 2025 shows R1 is cognitively intact, requires setup assistance with eating, oral and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The EMR shows the following order for R1 dated February 5, 2025: Lyumjev KwikPen Solution pen-injector. Inject 24 units subcutaneously with meals for DM (Diabetes Mellitus). R1's May 2025 MAR (Medication Administration Record) shows R1's Lyumjev insulin is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:14 (9:14 PM), more than four hours after dinner was served, and the scheduled administration time. 2. On May 21, 2025 at 11:12 AM, R2 was lying in bed in her room. R2 said V6 (RN) arrived at the facility at approximately 5:45 PM on May 17, 2025. R2 said, She got here and just sat at the desk and didn't even bother to check on us. R2 said dinner was served at 5:00 PM on May 17, 2025. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, sciatica, atrial fibrillation, chronic kidney disease, left eye cataract, pressure ulcer of the left heel, presence of cardiac pacemaker, depression, heart failure, pulmonary hypertension, anemia, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, oral hygiene, dressing, and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering. R2 is occasionally incontinent of bowel and bladder. R2's care plan for being at risk for fluctuating blood sugars due to diabetes, initiated July 22, 2024 shows multiple interventions, including administer medications as ordered, and administer sliding scale per physician's order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 5 of 11 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 05/22/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The EMR shows the following order for R2 dated July 25, 2024: Lyumjev KwikPen subcutaneous solution pen-injector. Inject 25 units subcutaneously three times a day for antidiabetics. R2's May 2025 MAR shows R2's Lyumjev insulin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. The EMR shows the following order for R2 dated July 22, 2024: Humalog KwikPen subcutaneous solution pen-injector. Inject as per sliding scale before meals and at bedtime for diabetes. R2's May 2025 MAR shows R2's Humalog insulin is scheduled to be given at 8:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Humalog insulin, scheduled to be administered at 4:00 PM on May 17, 2025, was administered by V6 (RN) at 18:50 (6:50 PM), almost three hours after the scheduled administration time, and two hours after dinner was served. 3. On May 21, 2025 at 11:20 AM, R3 was walking in her room with a walker. R3 was not able to recall concerns regarding medications being given late due to her cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, asthma, vascular dementia, obstructive uropathy, chronic diastolic heart failure, low potassium, major depressive disorder, chronic kidney disease, atrial fibrillation, and psychosis. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, substantial/maximal assistance with lower body dressing, and partial/moderate assistance with all other ADLs. R3 is occasionally incontinent of bowel and bladder. The EMR shows the following order for R3 dated November 19, 2024: Lyumjev KwikPen solution pen-injector. Inject 6 units subcutaneously with meals for DM II (Type 2 Diabetes). R3's May 2025 MAR shows R3's Lyumjev is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Lyumjev insulin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time and the dinner meal was served. 4. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, cerebral infarction, unsteadiness on feet, lack of coordination, cognitive communication deficit, constipation, hemiplegia affecting left non-dominant side, Type 2 diabetes, mood disorder, atrial fibrillation, emphysema, heart failure, bilateral hearing loss, depression, and heart disease. R4's MDS was not completed at the time of this investigation. The EMR shows the following order for R4 dated May 16, 2024: Novolog FlexPen subcutaneous with meals as per sliding scale. R4's MAR shows R4's Novolog insulin is scheduled at 8:00 AM, 12:00 PM, and 5:00 PM, and R4's blood sugar reading was 150 on May 17, 2025 at 5:00 PM. V1 (Administrator) provided EMR documentation to show R4's Novolog insulin, 2 units, scheduled for 5:00 PM on May 17, 2025 was administered at 20:42 (8:42 PM), over three and a half hours after the scheduled administration time. On May 21, 2025 at 3:45 PM, V8 (Pharmacist) said, the Lyumjev insulin is a short acting insulin. V8 said, It is to be given with meals. There is a possibility of blood sugar fluctuations and symptoms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 6 of 11 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 05/22/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when it is not given correctly. It is not meant to be given four hours late or after a meal. The sliding scale Humalog should be done before the meals is eaten, because the sliding scale is tailored to pre-meal blood sugar levels. The idea with all the insulin regimens is to keep the blood sugar stable at the level you want. Any sort of variation in timing, that is going to potentially cause more fluctuations in the blood sugar. The facility's policy entitled Physician Orders, revised on 8/16/24 shows: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). The facility's policy entitled Medication Pass, revised on 8/16/24 shows: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. The facility's policy entitled Diabetes Management, revised on 7/26/24 shows: Policy Statement: It is the policy of this facility to provide optimal nursing care for diabetic patients to: Assist in establishing a balance between diet, exercise, oral medications, and insulin therapy. Prevent episodes of hyperglycemia/hypoglycemia and prevent recurrence. Recognize, assist, and document the treatment of complications commonly associated with diabetes. Individualize teaching according to carefully assessed resident and family needs. Procedure: .5. Blood Glucose Check: Verify physician's order for this procedure.7. Complete the MAR or the Blood Sugar Monitoring Log as per policy. 8. If resident is on a sliding scale, administer insulin as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 7 of 11 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 05/22/2025 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the administration failed to provide oversight and leadership to ensure resident nursing care assignments were revised due to a change in staffing to ensure residents received nursing care and medications as ordered by the physician. Residents Affected - Some This applies to 16 of 16 residents (R1- R16) reviewed for quality of care and administration in the sample of 16. The findings include: On May 21, 2025 at 9:52 AM, V4 (Staffing Coordinator) reviewed the facility's Daily Schedule dated Saturday, May 17, 2025 and the resident room assignments for that day. V4 said day shift nurses and CNAs (Certified Nursing Assistants) work the day shift from 7:00 AM to 3:00 PM, evening shift from 3:00 PM to 11:00 PM, and night shift from 11:00 PM to 7:00 AM. V4 continued to say five nurses (V7, V9, V10, V13, and V14) worked on the day shift on May 17, 2025. V4 said V7 (LPN-Licensed Practical Nurse) worked a double shift that day and continued to work the entirety of the evening shift until 11:20 PM. V4 said any other day shift nurses who worked after 3:00 PM were not providing resident care after 3:00 PM, but were performing administrative tasks, such as charting. V4 said five nurses (V6, V7, V11, V12, V15) were scheduled to work on the evening shift on May 17, 2025. V4 said V6 (Agency RN-Registered Nurse) came to the facility late and no staff were assigned to fill the void of her absence until she was able to get to the facility. V4 reviewed the resident assignments for May 17, 2025 and said V6 (Agency RN) was assigned to care for the rooms occupied by R1 through R16. V4 provided the staffing agency invoice for V6 (Agency RN) dated May 17, 2025. The invoice shows V6 (Agency RN) worked at the facility on May 17, 2025 from 17:45 (5:45 PM) to 00:30 (12:30 AM) on May 18, 2025. The Resident Listing Report dated May 21, 2025 shows R1-R16 resided on the unit assigned to V6 (Agency RN) on May 17, 2025 from 3:00 PM to 11:00 PM. On May 21, 2025 at 8:38 AM, V7 (LPN) said he was working at the facility on May 17, 2025 from 7:00 AM to 11:20 PM. V7 said, I worked a double shift that day. One of the nurses (V6) came in late on the afternoon shift so there were two of us working the unit. No one asked us to cover her assignment (V6's residents) or administer medications to them because she was late. On May 21, 2025 at 12:24 PM, V1 (Administrator) said, We knew [V6] (Agency RN) was going to be late on May 17. We thought she would be here around 3:45 PM. At 4:15 PM she still had not shown up, and we found out she had more car trouble and was arriving later. We did not have a manager on duty at the facility on that weekend that was clinical (a nurse). We were going to call our ADON (Assistant Director of Nursing) in, but she would have gotten here about the same time as [V6] thought she would get here. [V6] didn't end up getting here until about 5:45 PM. V1 (Administrator) was unable to say why the nursing assignments were not revised or why the nursing staff present in the facility were not instructed to absorb V6's assignment until her arrival to ensure residents received any necessary nursing care or their medications as ordered by the physician. 1. On May 21, 2025 at 11:26 AM, R1 was sitting in his room. R1 said on May 17, 2025 the day shift nurse left at approximately 3:00 PM, and the evening shift nurse did not arrive at the facility until 5:45 PM. R1 said he was upset because he did not receive his Velphoro (Phosphorous binder) or his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 8 of 11 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 05/22/2025 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 0835 Level of Harm - Minimal harm or potential for actual harm carvedilol (cardiac medication) at 5:00 PM. R1 said, I receive dialysis, and I need to take the Velphoro when I eat to absorb any extra phosphorous. If I don't receive it with my meal, then it doesn't do any good. We were served dinner at 5:00 PM that night. It is just upsetting because management knew [V6] (RN-Registered Nurse) was going to be late, and they didn't bother to get anyone else to cover for her to get us our medications on time. R1 said dinner was served at 5:00 PM on May 17, 2025. Residents Affected - Some The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dependence on renal dialysis, chronic kidney disease, type 2 diabetes, bilateral vitreous hemorrhage, heart failure, hypertension, and heart disease. R1's MDS (Minimum Data Set) dated April 1, 2025 shows R1 is cognitively intact, requires setup assistance with eating, oral and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The EMR shows the following order for R1 dated February 4, 2025: Coreg 25 mg. (milligrams) orally, twice a day for hypertension. R1's May 2025 MAR (Medication Administration Record) shows R1's Coreg is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Coreg medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 2114 (9:14 PM), more than four hours after the scheduled administration time. The EMR shows the following order for R1 dated February 4, 2025: Velphoro oral tablet chewable 500 mg. Give 2 tablets by mouth three times a day to control phosphorous level. R1's May 2025 MAR shows R1's Velphoro is scheduled to be given at 9:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Velphoro medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:14 (9:14 PM), more than four hours after the scheduled administration time. The EMR shows the following order for R1 dated February 5, 2025: Lyumjev KwikPen Solution pen-injector. Inject 24 units subcutaneously with meals for DM (Diabetes Mellitus). R1's May 2025 MAR (Medication Administration Record) shows R1's Lyumjev insulin is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R1's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:14 (9:14 PM), more than four hours after dinner was served, and the scheduled administration time. 2. On May 21, 2025 at 11:12 AM, R2 was lying in bed in her room. R2 said V6 (Agency RN) arrived at the facility at approximately 5:45 PM on May 17, 2025. R2 said, She got here and just sat and the desk and didn't even bother to check on us. I told her I needed my blood sugar checked. I had to go to the desk to get my Gabapentin (pain medication) because she hadn't passed medications, and no one had filled in for her when she was late getting here. I was not having a lot of pain, but it's just the idea that we like to get our medications on time, and that was not happening. She got here and just sat at the desk and didn't even bother to check on us. R2 said dinner was served at 5:00 PM on May 17, 2025. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, sciatica, atrial fibrillation, chronic kidney disease, left eye cataract, pressure ulcer of the left heel, presence of cardiac pacemaker, depression, heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 9 of 11 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 05/22/2025 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 0835 failure, pulmonary hypertension, anemia, morbid obesity, and PVD (Peripheral Vascular Disease). Level of Harm - Minimal harm or potential for actual harm R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, oral hygiene, dressing, and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering. R2 is occasionally incontinent of bowel and bladder. Residents Affected - Some The EMR shows the following order for R2 dated September 14, 2024: Gabapentin 100 mg. Give 2 capsules by mouth three times a day for pain. R2's May 2025 MAR shows R2's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. The EMR shows the following order for R2 dated July 25, 2024: Lyumjev KwikPen subcutaneous solution pen-injector. Inject 25 units subcutaneously three times a day for antidiabetics. R2's May 2025 MAR shows R2's Lyumjev insulin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R2's Lyumjev insulin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 18:50 (6:50 PM), almost two hours after the scheduled administration time. 3. On May 21, 2025 at 11:20 AM, R3 was walking in her room with a walker. R3 was not able to recall concerns regarding medications being given late due to her cognitive status. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, Type 2 diabetes, abnormal gait and mobility, asthma, vascular dementia, obstructive uropathy, chronic diastolic heart failure, low potassium, major depressive disorder, chronic kidney disease, atrial fibrillation, and psychosis. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, substantial/maximal assistance with lower body dressing, and partial/moderate assistance with all other ADLs. R3 is occasionally incontinent of bowel and bladder. The EMR shows the following order for R3 dated November 19, 2024: Gabapentin Capsule 100 mg. Give 1 capsule by mouth three times a day for nerve pain. R3's May 2025 MAR shows R3's Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Gabapentin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time. The EMR shows the following order for R3 dated November 19, 2024: Lyumjev KwikPen solution pen-injector. Inject 6 units subcutaneously with meals for DM II (Type 2 Diabetes). R3's May 2025 MAR shows R3's Lyumjev is scheduled to be given at 8:00 AM, 12:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R3's Lyumjev insulin medication, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:09 (9:09 PM), over four hours after the scheduled administration time and the dinner meal was served. 4. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, cerebral infarction, unsteadiness on feet, lack of coordination, cognitive communication deficit, constipation, hemiplegia affecting left non-dominant side, Type 2 diabetes, mood disorder, atrial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 10 of 11 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 05/22/2025 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 0835 fibrillation, emphysema, heart failure, bilateral hearing loss, depression, and heart disease. Level of Harm - Minimal harm or potential for actual harm R4's MDS was not completed at the time of this investigation. Residents Affected - Some The EMR shows the following order for R4 dated May 16, 2024: Novolog FlexPen subcutaneous with meals as per sliding scale. R4's MAR shows R4's Novolog insulin is scheduled at 8:00 AM, 12:00 PM, and 5:00 PM, and R4's blood sugar reading was 150 on May 17, 2025 at 5:00 PM. V1 (Administrator) provided EMR documentation to show R4's Novolog insulin, 2 units, scheduled for 5:00 PM on May 17, 2025 was administered at 20:42 (8:42 PM), over three and a half hours after the scheduled administration time. 5. The EMR shows R13 was admitted to the facility on [DATE] with multiple diagnoses including, COPD with exacerbation, polyneuropathy, spinal stenosis, Type 2 diabetes, and heart disease. R13's MDS dated [DATE] shows R13 is cognitively intact and requires setup assistance with all ADLs. The EMR shows the following order for R13 dated July 19, 2024: Gabapentin capsule 100 mg. Give 2 capsules by mouth three times a day for nerve pain. R13's May 2025 MAR shows his Gabapentin is scheduled to be given at 9:00 AM, 1:00 PM, and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R13's Gabapentin, scheduled to be administered at 5:00 PM on May 17, 2025, was administered at 20:54 (8:54 PM), almost four hours after the scheduled administration time. 6. The EMR shows R15 was admitted to the facility on [DATE] with multiple diagnoses including, acute and chronic respiratory failure with hypercapnia, COPD, atrial fibrillation, pulmonary fibrosis, hypertension, Type 2 diabetes, asthma, heart failure, and abnormal gait and mobility. The EMR continues to show R15 has an order for continuous oxygen dated March 6, 2025. R15's MDS dated [DATE] shows R15 is cognitively intact, requires partial/moderate assistance with showering, and setup and/or supervision with all other ADLs. The EMR shows the following order for R15 dated February 20, 2025: Budesonide-Formoterol Fumarate Inhalation Aerosol. Two puffs, inhale orally two times a day for COPD. R15's May 2025 MAR shows R15's Budesonide-Formoterol Fumarate inhaler is scheduled to be given at 9:00 AM and 5:00 PM daily. V1 (Administrator) provided EMR documentation to show R15's Budesonide-Formoterol Fumarate inhaler, scheduled to be administered at 5:00 PM on May 17, 2025, was administered by V6 (Agency RN) at 21:02 (9:02 PM), four hours after the scheduled administration time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145638 If continuation sheet Page 11 of 11