Inspection·August 4, 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 interview and record review, the facility failed to safely transfer a resident with a mechanical lift. This failure resulted in R1 sustaining a closed fracture of the distal end of his right femur and requiring surgery.This applies to 1 of 4 residents (R1) reviewed for transfers.The findings include: R1's EMR (Electronic Medical Record) showed R1 admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis related to cerebral infarction affecting his left side, spinal stenosis, general weakness, decreased mobility, polyneuropathy, and contractures to his lower extremities. R1's care plan with a review date of 6/18/2025 said R1 had a self-care deficit with his activities of daily living and required physical assistance of two-staff members. R1's care plan said he was dependent on bed mobility and transfers and required the use of a mechanical lift.On 8/02/2025 at 10:20 AM, R1 was in bed. R1's legs were severely contracted. R1's left lower leg was hyperextended in a fixed flexed position towards his pelvic area, and the right lower leg was in a straight fixed position. R1's right lower leg had surgical scars. R1 was unable to move his lower body. R1's memory was impaired and was he unable to provide details regarding the right femur fracture that occurred on 5/27/2025. On 8/04/2025 at 8 AM, V20 and V21 (R1's Family Members) said they had concerns regarding R1's assisted mechanical lift transfer on 5/27/2025. They said R1 informed them he had acute pain in his right lower leg after he was transferred by V4 and V5 (Certified Nurse Assistants/CNAs). V21 said she accompanied R1 to his medical urology appointment on 5/27/2025, and R1 did not have any injury or vocalized pain in his right lower leg. V21 said R1 had to be assisted back to his bed from his wheelchair after he returned to the facility. V20 said the facility called her later that evening, informing her R1 was having acute pain and swelling to his right lower leg and was going to have x-rays done at the facility. V20 said she was then informed R1 had a fracture to his right leg and had to be transferred to the hospital. V20 said she informed V1 (Administrator) about R1's transfer concern on 5/27/2025 because they were concerned about his safety. On 8/04/2025 at 2:50 PM, V5 (CNA) said V4 assisted her with R1's mechanical lift transfer when he returned from his appointment at approximately 1 PM. V5 said R1's legs were severely contracted. V5 said she maneuvered the lift machine while V4 placed his hands behind R1's back to direct him into the bed. V5 said no one was supporting or guiding R1's legs to safely position them onto the bed. V5 said R1 was complaining of pain, and she informed the nurse on duty. On 8/04/2025 at 12:30 PM, V4 (CNA) said he assisted V5 with R1's mechanical lift transfer after his appointment on 5/27/2025. V4 said he was behind R1 while V5 started to operate the machine. V4 said R1's legs went on the bed first and then his upper body. V4 said he was unable to visually see R1's legs during the transfer. V4 said R1 was severely contracted, and his legs were not supported during the transfer.On 8/04/2025 at 9 AM, V11 (CNA) said on 5/27/2025 at 3:30 PM during rounds R1 declined care, and at approximately 6 PM she attempted to provide care again. V11 said R1 reported they hurt me and was complaining of severe right leg pain. (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 08/04/2025 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)