Inspection·July 15, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for accidents in the sample of 9. This failure resulted in R1 receiving stitches to a left leg laceration. This past noncompliance occurred from 6/3/25 to 6/9/25.The findings include: The facility's initial incident report sent to IDPH (Illinois Department of Public Health) showed R1 sustained a laceration to her left lower extremity on 6/3/25 at approximately 11:15 AM. The report showed R1 was provided first aid and orders were obtained to send R1 to the local hospital emergency department. The report showed R1 left the facility with paramedics at around 1:06 PM the same day. R1's face sheet printed on 7/10/25 showed a [AGE] year-old female admitted on [DATE]. The face sheet showed diagnoses including but not limited to heart failure, cataracts, left foot drop, hypertension, venous insufficiency, and polyneuropathy. R1's facility assessment dated [DATE] showed moderate cognitive impairment and total staff assistance for chair to bed transfers. R1's care plan showed a focus area related to ADLs (activities of daily living). Interventions included: TRANSFER: (R1) requires weight bearing physical assist (full body lift) of 2 staff participation in moving between surfaces to and from bed, chair, wheelchair, standing position. Date initiated 12/05/2023. On 7/10/25 at 9:50 AM, R1 was lying in bed and covered with a light sheet. R1 was pleasantly confused and had no recall of a leg injury or emergency room visit. V3 (Registered Nurse) entered the room and removed the sheet. R1's left lower leg was wrapped in white gauze from the mid-calf to the foot and elevated on a pillow. V3 stated she had a leg injury while being transferred from her chair to the bed. Her left leg hit the side rail of the bed. She has been a mechanical lift transfer since she was admitted . The aide called me in right away after it happened. R1 was already on the bed and her leg was bleeding. The aide was in the room alone and no one else was helping him. He was very shaken up and so sorry. I applied pressure and cleansed the open wound. The wound care nurse was notified and came right in to assess it. R1 was sent to the emergency room the same day. She had to get stitches and came back the same day. V3 said all residents requiring a mechanical lift should be done with two people. The aide (V4) is a big, tall guy and he did it by himself. V4 likely thought since R1 is so small that it wouldn't be a problem. On 7/10/25 at 10:18 AM, V4 (CNA-Certified Nurse Aide) stated he was assigned to give R1 a shower on 6/3/25. V4 said resident transfer status is posted inside the closet doors and in the care plans. V4 said R1 has always been a two person assist using a mechanical lift. V4 said he wheeled R1 into her room after the shower and got her dressed in day clothes. V4 was attempting to get the lift sling under R1 while seated in her wheelchair. V4 said he pulled on the sling to get her closer to the bed and her left leg hit the side rail. V4 said he saw it bleeding and continued to transfer her by himself onto the bed. V4 said he should have done the transfer preparation and actual transfer itself with another staff member. V4 said he was in a hurry and thought he could do it alone. V4 said it is safer with two people and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145638 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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)