Inspection·August 25, 2022

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure privacy was provided during incontinence care for 1 of 2 residents (R6) reviewed for privacy in the sample of 29. Residents Affected - Few The findings include: On 8/23/22 at 10:57 AM, R6 was lying in bed in her room. R6's bed was located closest to the window of a first- floor room. V10 CNA (Certified Nursing Assistant) and V11 CNA went into R6's room and provided incontinence care. V10 and V11 did not close the curtains on the window and did not completely close the privacy curtain. After R6's incontinence care was provided, V10 stated she forgot to close the drapes and that it is important to close them for the resident's privacy. On 8/25/22 at 10:28 AM, V2 DON (Director of Nursing) stated, You must make sure the door is closed, window curtains and privacy curtains are closed when providing care for residents for their privacy and dignity. The facility's Privacy and Dignity policy (7/28/22) showed, It is the facility's policy to ensure the resident's privacy and dignity is respected by the staff at all times. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy. The Diagnosis Report dated 8/25/22 for R6 showed diagnoses including hemiplegia and hemiparesis affecting the right side, cerebral infarction, heart failure, cellulitis, diabetes, chronic obstructive pulmonary disease, polyosteoarthritis, abnormal posture, rheumatoid artthritis, and aphasia. R6's MDS (Minimum Data Set) dated 8/8/22 showed she needed extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 restraints were removed during meals for 2 of 3 residents (R14, R40) reviewed for restraints in the sample of 29. Residents Affected - Few The findings include: R14's admission Record, printed by the facility on 8/25/22, showed she had diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, severe protein-calorie malnutrition, hearing loss, restlessness and agitation. R14's Order Summary Report, printed by the facility on 8/25/22, showed due to impaired safety awareness, lap buddy (physical restraint) to be on when in wheel-chair. Remove lap buddy for all ADL (activities of daily living) care. Every two hours remove and offer toilet. Remove for all meals. The facility assessment dated [DATE], showed R14 had severely impaired cognitive skills for daily decision making and required extensive assistance of one staff member for eating. R14's restraint care plan, with a review date of 8/23/22, showed the lap buddy should be removed for all meals. R40's admission Record, printed by the facility on 8/25/22, showed she had diagnoses including Alzheimer's disease, lack of coordination, protein-calorie malnutrition, dementia, legal blindness, dysphagia and need for assistance with personal care. R40's falls care plan, with a reviewed date of 6/10/22, showed Lap buddy as ordered and as indicated. R40's Order Summary Report, printed by the facility on 8/25/22, showed lap buddy to be removed for all meals. The facility assessment dated [DATE] showed R40 had severely impaired cognitive skills for daily decision making and required extensive assistance of one staff member for eating. On 8/25/22 at 8:42 AM, during the breakfast meal R14 and R40 were in the dining room for the breakfast meal. R14 and R40 were sitting in their wheel-chairs. The lap buddy restraints were in place. At 9:05 AM, V14 (Certified Nursing Assistant-CNA) said they (the staff) were told to always leave the lap buddy's on, even during meals. V14 could not recall who informed them to do this. On 8/25/22 at 11:13 AM, V17 (Restorative Nurse) said R14 and R40's lap buddy should be removed for meals. At 10:17 AM, V2 (Director of Nursing) said R14 and R40's lap buddy's should be removed during meals per orders. The facility's policy and procedure titled Restraints, with a revision date of 7/28/22, showed 1. If a resident's condition warrants the use of a restraint, a restraint device assessment will be done to determine if the device is appropriate for the resident. 2. Once the assessment determines that the device or intervention is a restraint, a physician order will be obtained indicating the type of device to be used. The order may be accompanied by the indication/reason for the device, the duration of use, and how often it is supposed to be released. If this information is not reflected in the physician's order sheet, these should be specified in the device assessment, in the progress notes, or in the care plan. 3. A care plan will be put in place to address the use of the restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 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 observation, interview and record review, the facility failed to ensure a resident received the necessary services to maintain good personal hygiene for 1 of 2 residents (R14) reviewed for activities of daily living (ADLs) in the sample of 29. Residents Affected - Few The findings include: R14's admission Record, printed by the facility on 8/25/22, showed she had diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder. The facility assessment dated [DATE] showed R14 had severely impaired cognitive skills for daily decision making and required extensive assistance of one staff member for toileting and personal hygiene. R14's 11/4/21 risk for impairment to skin care plan, with a review date of 8/23/22, showed she is at risk for skin impairment due to fragile skin, malnutrition and being incontinent of bowel and bladder among other things. R14's activities of daily living (ADL) care plan, with a review date of 8/23/22, showed she has an ADL self-care deficit and requires staff participation to use the toilet and to get dressed. On 8/24/22 at 1:39 PM, R14 was sitting in her wheelchair in the dining room/activity room. R14 kept attempting to stand up from her wheelchair. Staff were sitting next to R14 holding her hands and redirecting her to sit back down when she attempted to stand up. At 2:28 PM, V13 (Certified Nursing Assistant-CNA) stood R14 up and started walking through the dining area with R14. R14's pants had a large area (about the size of a dinner plate) that was wet from urine. As they were walking through the dining room, V15 (Registered Nurse) stopped V13 and informed her that R14 needed to be toileted and changed. At 2:35 PM, V13 propelled R14 to her room and assisted her in walking from her wheelchair to the toilet. A large wet area was also observed on the cushion in R14's wheelchair. When V13 removed R14's brief, it looked heavy and soaked with urine. V13 verified that the brief was very soaked with urine. R14 had a bowel movement while on the toilet. After cleaning R14's front and back area of urine and stool, V13 put a clean brief on R14 and pulled up R14's pants. V13 did not change R14's soiled pants. V13 walked R14 back to her wheelchair and sat her down on the wet cushion. At that point, V14 came into the room. V14 propelled R14 back to the dining area, pushed her up to one of the tables in the back of the room and walked away. On 8/25/22 at 8:50 AM, V16 (Registered Nurse-RN) said toileting should be done at least every 2 hours and sooner if needed. V16 said If a resident has wet pants due to incontinence, staff should change the resident's pants. On 8/25/22 at 9:10 AM, V15 (RN) said she stopped V13 in the dining room the previous day and told her that R14 needed to be changed and toileted. V15 said R14's pants were visibly wet. V15 said she would have expected V13 to change R14's soiled pants. On 8/25/22 at 9:13 AM, V13 (CNA) said she did not know that R14's pants were soiled. V13 said she could not tell with her gloves on (she had on two pairs of gloves when providing incontinence care). V13 said when a resident's pants are soiled, they should be changed. On 8/25/22 at 10:04 AM, V2 (Director of Nursing) said residents should be checked at least every 2 hours and sooner as needed. V2 said V13 should have changed R14's soiled pants. V2 said it important (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 to do this for infection control and to prevent skin breakdown. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Incontinent and Perineal Care, with a revision date of 7/28/22, showed It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. 1. Do rounds at least every two hours to check for incontinence during shift .9. Put on new set of clean gloves to put on clean briefs/incontinent pads, to make sure resident comfortable, groom and change clothing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 identify an area of pressure prior to becoming a stage two pressure ulcer and failed to have interventions in place to prevent pressure for a resident at high risk for developing pressure ulcers. This applies to one of eight residents (R13) reviewed for pressure in the sample of 29. Residents Affected - Few The findings include: The facility face sheet for R13 shows diagnosis to include fracture of the right shoulder, vascular dementia, and reduced mobility. The facility assessment dated [DATE] shows R13 to have severe cognitive impairment and requires extensive assistance of two staff for bed mobility. The facility risk assessment for developing a pressure injury dated 11/29/2021 for R13 shows her to be at high risk for developing a pressure injury. On 8/23/2022 at 10:31 AM, V12 Registered Nurse (RN) wound nurse was observed assessing R13's bottom pressure ulcer. V12 said he was just notified of the new area to R13's left buttock. The wound assessment completed by V12 dated 8/23/2022 shows a stage two facility acquired pressure injury to R13's left sacrum. The wound measured 2.70 by 2.90 centimeters. The facility skin alteration evaluation form dated 8/21/2022 shows an area of pressure was found on R13's left buttock measuring one by one centimeter. The Physician Order's shows no new orders for any wound treatment after the discovery of the wound. On 8/25/2022 at 10:30 AM, V12 said he had not been notified of the pressure injury until 8/23/22 and was not aware another nurse had documented on that area until being shown the documentation by this surveyor. V12 said when a new area of pressure is found, they are supposed to let him know right away. On 8/25/22 at 11:10 AM, V2 Director of Nursing (DON) said she would expect a pressure injury to be found before it becomes a stage 2. Once a new skin issue is found, they are to notify the wound nurse. The Physician Order's for August 2022 for R13 shows a special mattress for the bed and wheelchair was ordered on 8/24/2022. An order for the treatment of R13's new stage two pressure injury was started on 8/24/2022. The facility care plan for R13 shows new interventions put into place on 8/23/2022 after the development of the pressure injury. No care plan for risk of skin impairment was identified. The facility policy with a revision date of 7/28/2022 for skin care treatment regimen shows it is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for resident with skin breakdown. 1. nurses must document in the nurses' notes .must obtain a treatment order from the resident's physician. 5. refer any skin breakdown to the skin care coordinator . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 administer medications in a manner to prevent the spread of infection for 1 resident (R305) with a peripherally inserted central catheter (PICC). This applies to 1 of 1 resident reviewed for medication administration outside of the sample. Residents Affected - Few The findings include: R305's electronic face sheet printed on 8/25/22 showed R305 has diagnosis including but not limited to Charcot's Joint, right ankle and foot, Sepsis, Type 2 diabetes, cellulitis of right lower limb, and local infection of the skin and subcutaneous tissue. R305's facility assessment dated [DATE] showed R305 has no cognitive impairment. R305's nursing care plan dated 8/17/22 showed, Resident has potential for infection. R305's physician's orders for August 2022 showed, ceFAZolin Sodium-Dextrose Intravenous Solution 2-4GM/100ML Use 2 gram intravenously every 8 hours for cellulitis for 35 days. On 08/24/22 at 1:27PM, V4 (Registered Nurse) was administering R305's intravenous medication through her PICC line access. V4 prepared the medication, flushed R305's PICC line with a syringe of saline, then threw the syringe in the trash can. V4 then reached her bare hand into the trash can to retrieve the used syringe and disposed of it. V9 went out into the hallway, accessed her nursing cart, retrieved an additional syringe and re-entered R305's room. V9 then cleansed R305's PICC access and hooked up the intravenous medication. During this entire medication administration process, V9 failed to apply gloves or perform any hand hygiene. V9 stated she does not need to wear gloves during intravenous medication administration because it is the not the policy and no one has told her to wear gloves. V9 was unaware that she did not perform hand hygiene during the medication administration process but stated it is important to perform hand hygiene to prevent the spread of infection. On 8/25/22 at 10:32AM, V2 (Director of Nursing) stated, Gloves should be worn and hand hygiene should be performed during PICC line medication administration due to infection control concerns and the risk for exposure to blood and bodily fluids. (V9) needs to understand that it is the policy of the facility to wear gloves during intravenous medication administration. It is never acceptable not to perform hand hygiene during intravenous medication administration. The facility's policy titled, Gloves Usage with a revision date of 3/23/22 showed, Purpose: to provide the use of gloves. Objectives: 1. To prevent the spread of infection .3. To protect hands from potentially infectious material; and 4. To prevent exposure to viruses from blood or body fluids .Miscellaneous .4. Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to dispose of expired food items, failed to store kitchen utensils in a manner to prevent contamination. These failures have the potential to affect all residents in the facility. The findings include: The Resident Census and Condition Report dated 8/23/22 showed 145 residents residing in the facility. On 8/23/22 at 10:23AM, observations of the facility's kitchen freezer showed 1 package of meat with a use by date of 6/7/22, 1 package of meat with a use by date of 4/27/22, 1 package of meat with a use by date of 6/17/22, and 1 package of unlabeled meat. On 8/23/22 at 10:28AM, observations of the facility's coolers showed 1000 island dressing with an expiration date of 6/21/21, Dijon mustard with an expiration date of 4/29/22, pineapple juice with an expiration date of 6/14/22, and a container of beef base with an expiration date of 4/12/22. On 8/23/22 at 10:35AM, V3 (Dietary Manager) stated when food is opened or separated, a received date and use by date is to be placed on all food items. On 8/23/22 at 10:55AM, a shelf with 15 bins containing all of the scoops and ladles for meal service were sitting open with no lids or covers on them or in the vicinity of the bins. V5 (Cook) stated those are all the utensils used for meal service and they never have had lids on them. V5 confirmed these bins travel unopened to meal service on all units of the facility. On 8/23/22 at 11:07AM, observations of the facility's dry food storage area showed 4 bags of grits with an expiration date of 10/10/21, 4 containers of casserole scalloped potatoes with an expiration date of 11/11/21, 5 containers of dry mashed potatoes with an expiration date of 6/15/22, 4 containers of jellied cranberry sauce with an expiration date of 3/13/21, 3 bags of pasta with an expiration date of 3/21/21, 1 opened box of cake mix with an expiration date of 5/26/22, and 2 boxes of muffin mix with an expiration date of 6/2/22. On 8/23/22 at 11:35AM, V3 stated the cooks go through the storage areas one time each week and I also go through them periodically. Expired items should be discarded according to the date on the package. On 8/24/22 at 1:48PM, V3 stated he was not aware of the expired items that were received from the supplier. When foods are delivered, the staff member putting the food away should be checking for the expiration dates. If food is expired, it should be discarded to prevent any illness to the residents. Our scoops and ladles should have a lid on them to prevent anything getting into them and contaminating them. The facility's policy titled, Food Storage-Dry Goods dated 10/2019 showed, It is the center policy to ensure all dry goods will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 0812 The facility's policy titled, Food Handling Policy with a review date of 7/28/22 showed, Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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** Based on observation, interview and record review, the facility failed to ensure equipment soiled with urine was cleaned to prevent bacterial growth and cross-contamination. The facility failed to ensure staff removed soiled gloves, washed their hands, and put on clean gloves after providing incontinent care. The facility also failed to ensure a resident did not drink out of another resident's glass. These failures apply to 3 of 3 residents (R14, R71, R141) reviewed for infection control in the sample of 29. Residents Affected - Few The findings include: 1. R14's admission Record, printed by the facility on 8/25/22, showed she had diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder. The facility assessment dated [DATE] showed R14 had severely impaired cognitive skills for daily decision making and required extensive assistance of one staff member for toileting and personal hygiene. R14's 11/4/21 risk for impairment to skin care plan, with a review date of 8/23/22, showed she is at risk for skin impairment due to fragile skin, malnutrition and being incontinent of bowel and bladder among other things. R14's activities of daily living (ADL) care plan, with a review date of 8/23/22, showed she has an ADL self-care deficit and requires staff participation to use the toilet and to get dressed. On 8/24/22 at 2:28 PM, V13 (Certified Nursing Assistant-CNA) walked R14 through the dining/activity room. R14's pants had a large area (about the size of a dinner plate) that was wet from urine. V13 walked R14 to the hallway, just outside of the dining room, then back into dining room. V13 sat R14 down in a regular chair, at the first table in the dining area. At 2:35 PM, V13 (CNA) placed R14 back in her wheel chair and propelled R14 to her room. V13 stood R14 up and walked her into the bathroom. A large wet area was also observed on the cushion in R14's wheel chair. When V13 removed the brief, she verified that the brief was very soaked. R14 had a bowel movement while on the toilet. V13 put two sets of gloves on and cleaned the urine and stool from R14. V13 removed the top pair of gloves and left the second pair of gloves on. V13 put a clean brief on R14 and pulled up R14's soiled pants. V13 walked R14 back to her wheel chair and sat her down on the soiled cushion in her wheel chair. V14 (CNA) came into the room at that time. V14 propelled R14 back down the hall to the dining/activity area and placed her by a table near the back of the room, then walked away. On 8/25/22 at 8:50 AM, V16 (Registered Nurse-RN) said if a resident has wet pants due to incontinence, staff should change the resident's pants. V16 said staff should not leave soiled pants on for infection control. V16 said the regular chair in the dining room that R14 was sat on should have been sanitized if R14 was sat there with wet pants. V16 said after performing incontinence care, V13 (CNA) should have removed the soiled gloves, performed hand hygiene and put on clean gloves before putting on the clean brief and touching R14's clothes. V16 said the cushion in R14's chair should have been sanitized. On 8/25/22 at 9:10 AM, V15 (RN) said R14's pants were visibly wet. V15 said she would have expected V13 to change the soiled pants for infection control reasons. V15 said the chair should have been sanitized after R14 sat in it and R14's cushion should have also been cleaned. V15 said V13 should have removed her gloves and performed hand hygiene after performing incontinent care. V15 said this should have been done before putting on R14's clean brief and touching R14's clothing-for infection control reasons. On 8/25/22 at 9:13 AM, V13 (CNA) said she did not know that Irene's pants were soiled. V13 said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 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 145678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Schaumburg 675 South Roselle Road Schaumburg, IL 60193 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 - Few could not tell with her gloves on. V13 said soiled pants should be changed for infection control purposes. V13 said she should have removed both sets of gloves after providing incontinence care for R14, then performed hand hygiene and put on clean gloves before putting on her clean brief and touching R14 or her clothes-for infection control. V13 said R14 had a large bowel movement. On 8/25/22 at 10:04 AM, V2 (Director of Nursing) said V13 should have changed R14's soiled pants for infection control and to prevent skin breakdown. V2 said R14's cushion on her wheel chair and the chair in the dining room should have been sanitized for infection control, adding it could breed bacteria if not sanitized. 2. R71's admission Record, provided by the facility on 8/25/22, showed she had diagnoses including Alzheimer's disease, attention and concentration deficit, cognitive communication deficit, and dementia. The facility assessment dated [DATE] showed R71 had severe cognitive impairment. R71's cognition care plan, with a review dated of 7/31/22, showed R71 had impaired cognitive function and impaired thought processes related to dementia. the care plan showed she was challenged by confusion/disorientation and misinterprets her surroundings. The care plan showed she will respond to cueing and redirection. The care plan showed interventions in place were to cue, reorient and supervise her as needed, and to offer guidance and redirection. 3. R141's admission Record, provided by the facility on 8/25/22, showed she had diagnoses including Alzheimer's disease, anxiety disorder, schizoaffective disorder, bipolar type, unspecified psychosis, major depressive disorder and cognitive communication deficit. The facility assessment dated [DATE] showed R141 had severe cognitive impairment. R141's nutrition care plan, with a review date of 8/24/22, showed she is at risk for altered nutritional status related to Alzheimer's disease. One of the interventions in place is to offer extra fluids if not contraindicated. R141's compromised nutritional status care plan, with a reviewed date of 8/24/22, showed she is at risk for dehydration and/or malnutrition, has a terminal illness and is receiving hospice care. On 8/23/22 at 2:10 PM, R71 was standing next to R141, who was sitting in her geriatric chair at a table in the dining/activity room. R71 appeared to be talking to R141. During the interaction, R71 picked up R141's 9 oz glass of water twice and took a drink out of the glass. R71 placed the glass back in front of R141 after each drink. R71 then walked away to a table in the center of the room. As R71 was walking away, another resident was coming around the table to do something with the large blocks that were on the table. As the other resident was coming around the table, R141 pulled the cup of water closer to her. Three staff members were in the activity room at that time. On 8/25/22 at 10:21 AM, V2 (Director of Nursing) said it is not acceptable for R71 to drink out of R141's cup for infection control purposes. V2 said the staff should monitor R71 closer because she walks around and is confused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 11 of 11