Health inspection·April 24, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few potential for skin integrity impairment, and has extensive care needs. R2's Minimum Data Set (MDS) dated [DATE] shows R2 requires extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The facility's Incontinent and Perineal Care Policy (Revised 7/28/22) shows the following: 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. The facility's General Care Policy (Revised 7/28/22) shows, It is the facility's policy to provide care for every resident to meet their needs. Physical needs would include, but are not limited to ADL unless it shows that the resident's needs cannot be met in the facility. The resident may be sent out to the hospital to address that need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 2 of 6 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 04/24/2023 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 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** Based on interview and record review the facility failed to ensure safety precautions were in place during a resident transfer for 1 of 3 residents (R1) reviewed for safety in the sample of 5. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, abnormality of gait and mobility, lack of coordination, reduced mobility and aphasia following cerebral infarction. R1's 3/23/23 facility assessment shows her cognition and memory are intact, she requires extensive 2 person staff assistance with transfers from bed to chair, and limited 1 person staff assistance with toileting. On 4/24/23 at 10:05 AM, V2 (Director of Nursing) said she was notified by V8 (Unit Manager) on 4/13/23 that R1 had reported to the therapy department, while R1 was being transferred and toileted a CNA (Certified Nursing Assistant) pulled on her right arm and R1 felt a pop in her arm. V2 said R1 had right sided weakness from a stroke and could not use her right arm. V2 said the CNA that had toileted R1 was identified as V13 and she was in-serviced about proper transfers. On 4/24/23 at 10:56 AM, V8 (Unit Manager) said she was contacted by R1 and V7 (R1's daughter) who said earlier that morning when R1 was being transferred and toileted by V13 who transferred her alone, V13 pulled on R1's right arm and R1 felt a pop. On 4/24/23 at 11:21 AM, V4 (Occupational Therapist) said she worked with R1 during therapy on 4/13/23. R1 told her she was having pain to her right shoulder because a CNA had pulled her arm during a transfer earlier that morning and R1 felt it pop. V4 said she assessed R1's shoulder and found a significant change from the previous day. V4 said R1's shoulder had a 2 finger separation between the acromion process and humerus in her shoulder. V4 said this is consistent with her shoulder being out of alignment. V4 said she was able to move R1's shoulder in a position to re-align it, R1 said she experienced immediate relief. V4 then taped R1's shoulder to add an extra measure of stability. V4 said R1's right arm is flaccid (she cannot use that arm, it dangles down) and she requires a sling during all transfers for protection to that arm. V4 said she had explained this to nursing and also had written instructions on the white board in R1's room. R1's Occupational Therapy note completed by V4 on 4/13/23 at 4:55 PM, states, reported of Inc. R GHJ pain, upon inspection, there is a significant subluxation x2 finger breadths, per pt. the night CNA grabbed her shoulder during the transfers. K tape applied for additional support and to approximate. R1's physician progress note completed by V17 (Medical Doctor/MD) on 4/13/23 at 11:34 PM, states, Patient reports the midnight shift aide pulled her right arm when she was waking up this morning to have her sit upright. She felt a pop. She went to therapy today and they did treatment to the right shoulder. She feels the right shoulder went back into place. Discussed popping sound on right shoulder likely ac jt movement. Sign viewed for staff to take precautions with bil. arm use. Informed nursing of right shoulder injury and need for aide training and precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 3 of 6 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 04/24/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/24/23 at 11:47 AM, V3 (Physical Therapist) said R1 was upgraded from a sit to stand lift to a 1-2 person pivot transfer with a gait belt and she could safely transfer if the staff used a gait belt, went slow with her, and made sure her right arm sling was on during all transfers. On 4/24/23 at 12:43 AM, V6 (CNA) said R1 was able to transfer with 1 CNA but they had to move very slowly and she had to have her arm sling on during all transfers. V6 said gait belts should be used for all resident transfers and residents should be lifted with that and not by their arms. On 4/24/23 at 1:02 PM, V13 (CNA) said on the morning of 4/13/23 she went into R1's room to take R1 to the bathroom. V13 was alone in the room and assisted R1 out of bed and into the bathroom. V13 then put both of R1's arms on the rail in the bathroom and grabbed the back of R1's pants to help guide her up. V13 was unable to recall when asked if R1 had her sling on during the transfer. V13 confirmed that R1's arm was flaccid but said She could curl it up. V13 said after R1 was finished toileting she went back into the room and assisted her to transfer off the toilet, again using the rail and both arms and put her in her chair to watch TV. On 4/24/23 at 1:09 PM, V12 (Medical Director) said she spoke with R1 after the incident with her arm being pulled. V12 said R1 had told her she heard a pop while a CNA was using her arm to transfer her. V12 said therapy had treated R1's arm so the dislocation probably would not have shown up on the X-ray but she ordered one for R1 anyway. V12 said safety measure were in place that staff were supposed to be using such as a sling during transfers. V12 said she cannot speak for sure if a CNA using R1's arm during the transfer caused a dislocation. On 4/24/23 at 2:10 PM, V14 (Restorative Nurse) said R1 had been upgraded on 4/4/23 from a sit to stand lift to a partial-extensive assist and gait belt and a sling during transfers. V14 staff were in-serviced on this change in R1's transfer status for safety measures to use. The facility provided Gait Belt policy revised on 7/8/22 states, The facility will use gait or transfer belts to assist residents needing limited total assistance during transfers and walking. 1. Staff will use a gait/transfer belt on residents who need limited to total assistance with transfer or walking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 4 of 6 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 04/24/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on interview and record review, the facility failed to ensure adequate pain management was provided for 1 of 5 residents (R2) reviewed for pain control in the sample of 5. This failure resulted in R2 experiencing unrelieved pain after a fracture. Residents Affected - Few The findings include: On 4/24/23 at 9:52 AM, V2, Director of Nursing (DON), said R2 has a lot of pain due to advanced cancer. R2 had increasing pain on Saturday (4/15/23). On 4/24/23 at 12:21 PM, V9, Licensed Practical Nurse (LPN), said she was R2's nurse on the day shift (7 AM to 3:30 PM) on 4/15/23. V9 said R2 requested pain medication around 8:00 AM and she administered it. V9 said R2 has bone cancer and they have to be very careful with R2's care due to his cancer and chronic pain. V9 said around lunch, R2 still had pain. V9 said R2 had a BM and they were unable to clean his backside due to his pain. V9 said she told the evening shift nurse they were unable to change R2 due to his pain not being relieved by the narcotics she gave around 8:00 AM and again around lunch. V9 said she called R2's doctor for an X-ray. V9 said the following day (4/16/23), the night shift nurse told her R2 had been in too much pain during the night to wait for the in house x-ray results, so they sent him to the hospital. On 4/24/23 at 2:55 PM, V16, LPN, said she was R2's nurse on the evening shift (3 PM to 11:30 PM) on 4/15/23. V16 said R2 complained of pain in the left knee. V16 said she spoke with R2's daughter and was told not to change R2 because he was in too much pain. V16 said she did not contact R2's doctor during her shift. V16 then said R2 told her he was not in pain. On 4/15/23 at 6:54 PM, V16 documented an eMAR note which rated R2's pain a 0. However, V16 said she gave R2 pain medication around 9 something. V16 said when she gives pain medication, she documents it on the Medication Administration Record (MAR). R2's MAR provided by the facility for 4/1/23-4/30/23 (printed 4/24/23) does not show any documentation of R2 receiving PRN (as needed) Oxycodone (narcotic pain medication) after 3:30 PM on 4/15/23. There is no correlating documentation in R2's Progress Notes to explain why or when R2 may have received pain medication while V16 was his nurse on 4/15/23 nor was there documentation regarding R2's doctor being contacted during that time. On 4/24/23 at 2:41 PM, V15, Registered Nurse (RN), said she was R2's nurse during the night shift on 4/15/23 going into 4/16/23. V15 said she went to check on R2 and R2 told her he was in pain and did not want to be touched. V15 said R2 complained of pain when they tried to change him or give him care. V15 said she believes R2 had been rating his pain a 7 or 8 on a 0-10 scale. V15 said R2 was not comfortable. V15 said she did not administer any pain medications to R2. V15 said when pain medication is given, it is documented on the MAR. V15 said she contacted R2's doctor and was told to send him to the hospital because they could not control his pain. R2's Progress Notes written by V15 on 4/15/23 at 11:15 PM show V15 attempted to call R2's doctor and was waiting for a return call and R2 was refusing care due to pain of his left knee and left hip. V15 noted swelling to R2's left knee. V15's documentation on 4/16/23 at 2:15 AM in R2's General Progress Note shows V15 spoke to R2's doctor and received an order to send R2 to the hospital for further evaluation. R2 was sent to the hospital at 3:20 AM and at 2:16 AM R2 continued to complain of pain to his left leg. No other pain interventions were documented as being attempted. On 4/24/23 at 1:30 PM, V18, Emergency Medical Personnel (EMS), said he went to the facility on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 5 of 6 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 04/24/2023 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 0697 911 call and the nurse said R2 could not be moved due to being in so much pain. V18 said R2 was in a lot of pain and no one called EMS until 3 AM. V18 said they gave R2 pain medication in the ambulance. Level of Harm - Actual harm Residents Affected - Few R2's admission Record dated 4/24/23 shows R2's diagnoses include, but are not limited to, pathological fracture of the left femur, weakness, fatigue, reduced mobility, malignant neoplasm of the lung, pain in left hip, and malignant neoplasm of unspecified bones. R2's MAR shows he received Oxydocone on 4/15/23 at 8:20 AM and a last documented dose at 3:30 PM. On 4/15/23 at 3:52 PM, V9 documented that R2's pain medication was ineffective and rated R2's pain a 5. R2's Physician's Order Sheets (POS) dated 4/24/23 does not show any new medication ordered in April of 2023. The facility's Pain Policy (Revised 7/28/22) shows, After the administration of PRN pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer to the lack of relief. It is important that pain medication will be administered to residents prior to repositioning. If despite the administration of pain medication. The resident still complains or shows signs of pain. The staff will stop the procedure and allow more time. If the resident continues to exhibit signs of pain afterwards, the nurse will call the physician and obtain additional pain relieving interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 6 of 6