Inspection·October 25, 2023

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 provide fingernail care to a resident that required extensive assistance with personal hygiene for 1 of 31 residents (R20) reviewed for activities of daily living in the sample of 31. Residents Affected - Few The findings include: R20's admission Record showed R20 was [AGE] years old and did not indicate R20 was a diabetic. On 10/23/23 at 11:52 AM, R20 was in bed. R20's fingernails extended about 1/8-1/4 of an inch past the tip of her fingers. There was dark brown debris under the nails. The thumb nail of R20's right hand appeared thick and dark in color. R20 said she hated to look at her nails because they were too long and dirty. R20 said she has always had short nails and having her nails long, bothers her. R20 could not recall when her fingernails were last trimmed. R20 used a finger nail of her right hand to clean under the nails on her left hand. R20 was able to remove some brown debris from under her nails. R20's Restorative UDAs document dated 8/4/23 showed R20 required extensive assistance of one staff for personal hygiene. On 10/24/23 at 01:43 PM, V20, CNA (Certified Nursing Assistant), said fingernail care, including trimming nails, is done on shower days and as needed. The Shower Schedule indicated R20 was to receive a shower twice a week. R20's Shower Sheet/Skin Audit Forms dated 10/17/23, 10/13/23, 10/10/23, 10/6/23, 10/3/23, and 9/29/23 indicated R20 received a shower or bed bath. The documents indicated R20's fingernails were not trimmed and R20 did not refuse nail care. A facility assessment done on 8/28/23 indicated R20 did not reject care. The facility's Nail Care policy with a revised date of 7/28/23 shows, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nursing staff shall check the residents for nail care which includes cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 2 of 18 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 10/25/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure wounds were assessed, documented, and treatment orders were placed upon identification of a new wound and failed to ensure a wound dressing was changed daily, as ordered, for 1 of 31 residents (R58) reviewed for quality of care in the sample of 31. Residents Affected - Few The findings include: On 10/23/23 at 10:03 AM, R58 was laying in bed. R58 had a gauze wrap on his right lower extremity dated 10/21/23. R58 had an undated bandage on his right leg below his right knee. R58 had an undated dressing to his buttocks. R58 had an undated bandage to his right 2nd toe. On 10/23/23 at 11:50 AM, V6 (Wound Registered Nurse) and V13 ( Wound Licensed Practical Nurse) performed dressing changes to R58. V6 removed the dressing to R58's buttocks. There was a small open area on his left buttock measuring 1.2 centimeters (cm) x 1.20 cm x 0.10 cm. V6 stated, This is new to me, I did not know about this one. The dressing that was below R58's right knee was removed. There was an open area measuring 1.3 cm x 1 cm x 0.10 cm. V6 stated, I did know about this one, I just have not had time to assess it yet. I would say it is about 5 or so days old. The gauze wrap that was dated 10/21/23 was removed from R58's right lower extremity. There were three open areas on the anterior lower leg (shin) measuring 8 cm x 4 cm x 0.2 cm and an open area on the posterior lower leg. V6 stated, The three areas on the front of the calf are new to me. I did not know about those, the last time I saw it it was just the back of the calf wounds. The dressing to R58's right 2nd toe was removed. There was an open area measuring 0.3 cm x 0.9 cm x 0.1 cm. V6 stated, I do not know anything about the toe. On 10/24/23 at 12:55 PM, V6 said that when a wound is found, the nurse should do an assessment and notify the physician to get treatment orders and notify the wound care team. V6 said that he spoke with the physician on 10/23/23 and received wound treatment orders for R58's buttock, right lower extremity and toe wounds. V6 said that the Certified Nursing Assistants and Nurses are the first eyes on wounds and any changes to the resident's skin. V6 said that the floor nurses should alert them or the doctor with any new or worsening wounds. V6 said that the physician should be called once a new wound is identified to get treatment orders for the wound. R58's October Treatment Administration Record printed on 10/24/23 shows an order started on 10/9/23 for, Adaptic non-adhering dressing external pad. Apply to RLE (right lower extremity) topically every night shift for scab that came off please remove dressing from noted area gently clean with NS (normal saline) cover with adaptic and betadine soaked 4 x 4/kerlix secure w/ (with) adhesive. No orders were found for the wounds on R58's buttock, right lower leg (below knee wound) or left 2nd toe wound. R58's Wound Assessment Details reports dated 10/23/23 shows that R58's buttock, right lower leg (below knee wound), right shin and left 2nd toe wounds were first assessed on 10/23/23. No additional wound notes were in R58's electronic medical record regarding his current buttock, right lower leg (below knee wound), right shin and left 2nd toe wounds. The facility's Skin Care Treatment Regimen Policy revised on 7/28/23 shows, Charge nurses must document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician. Routine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 3 of 18 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 10/25/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician .Refer any skin breakdown to the skin care coordinator for further review and management as indicated. The facilities Wound Care Program Policy revised on 8/12/22 shows, Educate clinical staff and develop appropriate treatment plans .The resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcers and etc .) shall be documented in the resident's clinical records in accordance to the facility's policy and in compliance to current regulatory standards. Treatments documented on the clinical record by treating nurse. Initiate wound care treatment upon identification of the wound with physician's order. Event ID: Facility ID: 145678 If continuation sheet Page 4 of 18 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 10/25/2023 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 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 ensure pressure injury interventions were in place for 3 of 8 residents (R458, R457, R37) reviewed for pressure injuries in the sample of 31. Residents Affected - Few The findings include: 1. R458's admission physician progress note dated 9/28/23 showed R458 was admitted to the facility, from the hospital, where she was treated for an infected wound to her right hip. R458's wound reports dated 10/23/23 showed the following: a) R458's stage 4 right hip pressure injury measured 3.0 cm (centimeters) x 2.7 cm x unknown. b) R458 was admitted with a stage 3 pressure injury to her coccyx area. The coccyx wound currently measured 5.0 cm x 1.0 cm x 0.1 cm. c) R458 was admitted with an unstageable pressure injury to her right medial ankle. The ankle wound currently measured 2.0 cm x 2.0 cm x unknown. R458's physician order dated 10/17/23 showed the dressing to R458's right hip pressure injury was to be changed daily. On 10/23/23 at 10:39 AM, R458 was in bed. Green, cloth, heel protectors were noted on a chair next to R458's bed. R458's heels were resting directly on the bed; no pillow was noted under R458's heels. R458's call light was on. V4 Certified Nursing Assistant (CNA) entered the room. R458 stated, I am wet. I need to be changed. V4 repositioned R458 on her left side to begin providing cares. A dressing to R458's right hip was dated 10/21/23 (2 days prior). The dressing appeared wet and yellow in color. When V4 CNA was asked to read the date on the dressing, V4 CNA stated, It says 10/21/23. R458's incontinence brief was saturated with urine. Urine had leaked onto the cloth pad lying under R458. An undated 4 x 4 gauze dressing laid loosely in R458's wet incontinence brief. The dressing appeared wet and was yellow in color. V4 placed a clean incontinence brief under R458, but placed the wet, 4 x 4 gauze dressing, over R458's coccyx wound, prior to securing the clean brief in place. On 10/23/23 at 10:45 AM, V5 CNA stated, I have (R458) today. I got here late so I haven't done cares on her yet. Prior to (V4 CNA) just changing her, I believe she hadn't been changed since night shift. On 10/23/23 at 1:00 PM, R458 was in bed, lying on her left side. The same yellow dressing, dated 10/21/23, was noted to R458's right hip. The same 4 x 4 gauze dressing laid loosely in R458's incontinence brief. R458's heels rested directly on the bed. [NAME] heel protection boots remained in the chair next to R458's bed. On 10/24/23 at 8:30 AM, R458 was in bed with her heels resting directly on the bed. On 10/24/23 at 8:40 AM, V6 Wound Nurse stated any wound dressing that is soiled should be removed and replaced with a clean dressing. V6 stated if a CNA is concerned a dressing is soiled, they should notify the nurse immediately. Staff are not to place a potentially soiled dressing back onto a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 5 of 18 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 10/25/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound. V6 stated, For (R458), it's important to keep her back, buttocks and right hip area clean and dry. She doesn't necessarily need to wear her heel boots in bed, but she does at least need to off-load her heels with a pillow. R458's care plan dated 10/17/23 showed, Resident has an actual impairment to skin integrity .Apply wound treatment as ordered by the physician .Keep skin clean and dry .Off load heels as ordered . 2. R457's wound reports dated 10/18/23 showed the following: a) R457 was admitted to the facility with a pressure ulceration to her right lateral ankle. The right ankle wound currently measured 1.3 cm x 1.5 cm x 0.0. b) R457 was admitted to the facility with stage 1 pressure injury to her right heel. The right heel wound currently measured 5.0 cm x 3.0 cm x 0.0. c) R457 was admitted to the facility with an unstageable pressure injury to her sacral/coccyx area. R457's sacral/coccyx wound currently measured 4.3 cm x 3.0 cm x unknown. R457's physician orders dated 10/11/23 showed, Please have patient wear green offloading boots when in bed related to wounds to BLE (bilateral lower extremity) . Please offload BLE feet/heels/ankles with multiple pillows when in bed . On 10/23/23 at 10:20 AM, R457 was in bed. R457's heels rested directly on the bed. No pillows were noted under R457's legs or feet. An alternating, low air loss mattress with the attached operating pump, was rolled up, in the corner of R457's room. On 10/23/23 at 11:53 AM, R457 was asleep in bed. A heel protection boot was on R457's left foot. No boot was noted to her right foot. No pillows were noted under R457's bilateral lower extremities. The low air loss mattress and pump remained in the corner of the room. On 10/24/23 at 8:40 AM, V6 Wound Care Nurse stated all facility mattresses are pressure-relieving, but some residents need an upgraded, alternating low air loss mattresses if they have pressure injuries or are on hospice. V6 stated, (R457) needs to be on an alternating pressure relieving mattress due to her wounds and for her comfort. I ordered one for her this weekend. Ideally, a resident should be placed on the mattress when it arrives. I believe (R457's) mattress arrived Sunday .Her heels should be off-loaded with either heel boots or with pillows under her heels. The facility's Skin Care Treatment Regimen policy dated 7/28/23 showed, Residents with Stage III and/or IV pressure ulcers will be placed in specialized air mattresses like Low Air Loss Mattress . The Wound Care Program Care Guidelines policy dated 8/12/23 showed, Prevention of skin breakdown includes but not limited to .Keeping local areas of skin clean, dry and free of body wastes, perspiration, and wound drainage . The policy showed, Elevate and utilize appropriate pressure redistribution surface modalities while in bed and/or up in wheelchair . 3. R37's Care Plan showed R37 was [AGE] years old and had self care deficits related to impaired over-all strength, generalized weakness, and limited range of motion. A facility assessment done on 9/29/23 showed R37 was at risk for developing pressure injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 6 of 18 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 10/25/2023 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 0686 R37's Order Summary Report showed an order for bilateral heel protectors on at all times. Level of Harm - Minimal harm or potential for actual harm On 10/23/23 at 11:24 AM, R37 was in a wheeled reclining chair with a footrest. R37 did not have heel protectors on and her heels were resting directly on the footrest. Residents Affected - Few On 10/23/23 at 02:08 PM, R37 was in bed. R37 did not have heel protectors on and her heels were resting directly on the mattress. R37's heels were not being floated/off loaded. On 10/23/23 at 12:29 PM, V21 (Certified Nursing Assistant- CNA) said she was the CNA taking care of R37. V21 said she was not sure if R37 required heel protectors. On 10/24/23 at 01:43 PM, V20 (CNA) said heel protectors help prevent pressure injuries by offloading the heels. V20 said heels should be offloaded to help prevent pressure injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 7 of 18 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 10/25/2023 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 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 fall interventions were in place for a resident who is a HIGH risk for falls and failed to ensure a resident was safely transferred. This failure resulted in R135 falling on the floor in the dining room sustaining a right femoral neck fracture and requiring surgical intervention. This applies to 1 of 2 residents (R135, R459) reviewed for safety in the sample of 31. The findings include: 1. R135's face sheet shows he is a [AGE] year old male with diagnosis including fracture of the right femur neck, unspecified dementia without behavioral disturbance, unsteadiness on feet, cognitive communication deficit, weakness, monoplegia of upper limb following cerebral infarction affecting right dominant side, hydronephrosis, urine retention and aphasia. R135's Final Incident Report dated 9/19/23 documents on 9/13/23, (R135) stood up from chair in the dining room and lost his balance and fell hitting the right side of his body on the floor. A staff member from a distance observed him fall. He was kept immobilized until the paramedics arrived. (R135) was transferred to the local hospital and admitted for right acute femoral neck fracture and required surgical intervention. R135's Minimum Data Set assessment dated [DATE] shows his cognition is impaired, requires extensive assist with bed mobility, transfers, tolieting. He is not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet, and surface to surface transfers. R135's Fall Risk assessment dated [DATE] shows he is HIGH risk for falls. On 10/22/23 at 9:25 AM, R135 was observed in his room in a low bed near the nurses station. On 10/24/23 at 10:27 AM, V16 (RN) said she was R135's nurse on 9/13/23 when he fell. She was on break and was alerted by staff he was on the floor. Last time she observed R135 was about 6:30 PM, in the dining room he was self propelling in his wheelchair. R135 is alert to self, sometimes he can verbalize his needs and is unable to follow direction. He had a fall a week prior getting up without assistance. V17 (CNA) was the only staff in the dining room. He told me there were so many residents in the dining room at that time who were at high risk for falls and could not watch them all. When she entered the dining room he was laying on the floor on his right side complaining of pain. She called the ambulance and did not move him, he was admitted with femur fracture. V16 said V18 was his assigned CNA (Certified Nursing Assistant) that day and was in another residents room. There's supposed be two staff supervising the dining room for safety. On 10/24/23 at 1:08 PM, V18 (CNA) said R135 is alert to person, does not follow direction. He was R135's CNA on 9/13/23 when he fell. He's supposed to be toileted every two hours, that day he toileted him about 3:30 PM and did not take him to the bathroom after dinner. At the time of the fall he was in another residents room. Residents should be toileted before and after meals, when awake, and before bed to prevent them from getting up on their own. There should be two staff in the dining room to help supervise the residents for safety reasons. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 8 of 18 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 10/25/2023 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 - Actual harm Residents Affected - Few On 10/25/23 at 9:59 AM, V2 (DON) said V17 is no longer an employee at the facility. She said R135 has dementia and poor safety awareness. He got up from the chair and fell and fractured his femur. She confirmed R135 was not assisted to the toilet after the dinner meal and that was an intervention they put in place after his fall on 9/8/23. It doesn't matter if there was only one CNA in the dining room that's considered supervision. We in-serviced the staff to offer tolieting to residents every two hours and frequent monitoring. On 10/25/23 at 2:21 PM, V22 (R135's Nurse Practitioner) said R135 has dementia and is alert to himself, he has poor safety awareness, and is at high risk for fall. Staff should be monitoring him closely. and he needs staff assistance for his activities of daily living. She confirmed he fell and sustained a femur fracture. R135's Post Fall Investigation Report dated 9/9/23 shows on 9/8/23 he had a fall in his room, he was attempting to stand without staff assistance. The interventions included to re-educate staff to offer toileting to the resident upon rising in the morning, before and after each meals and at bedtime. The facility's Falls Policy revised 8/20 states, The Fall Prevention Program is designed to ensue a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed .to assess his/her individual fall risk .implementing an individualized Plan of Care designated to meet the resident's needs. To ensure the consistency in the implementation of preventive measures to assist with the reduction of falls . 2. R459's admission Restorative assessment dated [DATE] showed R459 required maximum assistance from staff for transferring and toileting. On 10/23/23 at 9:15 AM, V5 Certified Nursing Assistant (CNA) transferred R459, from her bed to a wheelchair, by lifting R459 under her armpits and sliding her into the wheelchair. No gait belt was used. V5 CNA wheeled R459 in her wheelchair, into the bathroom. Again, V5 CNA transferred R459, from her wheelchair onto the toilet, by lifting R459 under her armpits. No gait belt was used. Once R459 was finished going the bathroom, V5 CNA lifted R459 off the toilet by her armpits and asked her to hold onto the bar on the wall by the toilet. R459 grasped the bar and began yelling Help me! Help me! as V5 CNA briefly let go of R459 to wipe her. Once V5 CNA had finished wiping R459, V5 placed his hands under R459's buttocks and guided her into the wheelchair. No gait belt was used. On 10/24/23 at 11;45 AM, V2 Director of Nursing stated gait belts are to be used to transfer any resident that requires staff assistance to ensure resident safety. The facility's Gait Belt policy dated 7/28/23 showed, The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 9 of 18 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 10/25/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to maintain a resident's indwelling urinary catheter bag below the level of the resident's bladder and off the floor for a resident with a urinary tract infection (UTI) for 1 of 5 residents (R459) reviewed for urinary catheters in the sample of 31. The findings include: R459's admission Record dated 10/21/23 showed R459 was readmitted to the facility on [DATE] with an indwelling urinary catheter in place and a diagnosis of UTI. On 10/23/23 at 9:10 AM, V5 Certified Nursing Assistant (CNA) stood at R459's bedside as R459 attempted to reposition herself in bed. V5 CNA unhooked R459's indwelling urinary catheter bag from the side of the bed and lifted the bag up to the level of his waist (above the level of R459's bladder), as R459 lay in bed. A backflow of urine was noted from the catheter bag towards R459. As V5 CNA continued to hold the catheter bag at the level of his waist (above R459's bladder), V5 CNA used his other hand to assist R459 into a sitting position on the side of her bed. Once R459 was seated on the side of the bed, V5 hooked the catheter bag back onto the bed, below the level of R459's bladder. At 9:20 AM, V5 CNA placed R459 onto the toilet. R459's urinary catheter bag laid on the floor, in front of the toilet, under the wheel of a wheelchair. On 10/24/23 at 11:45 AM, V2 Director of Nursing stated indwelling urinary catheter bags should be kept below the level of a resident's bladder to prevent the backflow of urine into a resident's bladder. V2 stated catheter bags are to be up off the floor, to prevent any contamination of the catheter that would put the resident at risk for an infection. The facility's Urinary Catheter Care policy dated 7/28/23 showed, The purpose of this procedure is to prevent catheter-associated urinary tract infections .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 10 of 18 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 10/25/2023 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 with a diagnosis of dementia received the necessary care and services for behaviors of wandering. This applies to 1 of 4 residents (R124) reviewed for dementia care in the sample of 31. Residents Affected - Few The findings include: 1. R124's face sheet shows she is a [AGE] year old female with a diagnosis including dementia, unspecified severity with agitation, anxiety disorder, insomnia, neuromuscular dysfunction of bladder. R124's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, no behaviors of psychosis, no rejection of cares and no wandering behaviors. Her activity preferences responded by R124 shows it's very important for her to listen to the music she likes, do her favorite activities and to do things with groups of people. On 10/23/23 at 9:32 AM, R124 was observed leaving room [ROOM NUMBER] (another resident's room) and wandering the halls. At 9:42 AM, R124 opened the door and entered R29's room while staff was providing incontinence care. At 10:04 AM, she was in the dining room with her head down on the table. At 10:23 AM there was a group exercise activity in the dining room with several residents participating. R124 remained at the table and did not participate. At 11:00 AM, R124 was wandering the halls and removing gloves from the nurses cart. At 11:29 AM, she opened the door to room [ROOM NUMBER],entered and left the room. At 12:22 PM, she was observed in room [ROOM NUMBER], going thru another resident's closet, removing clothing items from the closet. A housekeeper entered the room and said this is not your room. This space is not yours and assisted her to the dining room. On 10/24/23 at 8:42 AM, V19 (RN) said R124 has dementia, has behaviors of wandering, and staff re-direct her. On 10/25/23 at 12:01 PM, V3 (Memory Care Clinical Manager) said R124 is a wanderer, she goes in out of other resident rooms, she picks up other resident's belongings, she ask the same questions, and says where am I going repeatedly. She is very forgetful and we have to re-direct her. She does better with 1:1 interactions and does not like loud sounds. When residents have behaviors of wandering we develop a careplan and put interventions in place. She did not know there was no careplan for R124's wandering behaviors. She confirmed there should be more engagement with R124, so she is not wandering. On 10/25/23 at 12:18 PM, V23 (Activity Director) said R124 loves to walk around, and really enjoys reminiscing, likes music but does does not like big groups, she gets overwhelmed. The biggest thing is she likes conversation and connecting with others in small groups or 1:1. R124's Behavior Monitoring Report and Interventions Report form for October shows wandering behaviors on 10/3, 10/5, 10/11, 10/15, and no behaviors recorded on 10/23/23. R124's current care plan does not include behaviors of wandering. R124's care plan shows she demonstrates strong activity involvement her interventions do not include 1:1, reminiscing, music or small groups. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 11 of 18 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 10/25/2023 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R124's 1:1 Activities Response Report for thirty days shows she did not receive 1:1 activities for 20 out of 30 days. The facility's Dementia Care Clinical Guidelines Policy dated 5/23 states, The facility will provide holistic services to patients with diagnosis of Dementia to promote orientation, integration, safety and maximal functioning .Therapeutic diversional activities are provided consistent to the resident's level of functioning, individualized activity preferences are provided either in a small groups or 1:1 setting in accordance to level of functioning and level of activity performance .individualized and interdisciplinary care planning. Event ID: Facility ID: 145678 If continuation sheet Page 12 of 18 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 10/25/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to ensure prescription medications were administered according to standards of practice for 1 of 31 residents (R456) reviewed for medication administration in the sample of 31. The findings include: On 10/23/23 at 2:05 PM, R456 was in bed asleep. V10 (Family of R456) was seated in a chair next to R456's bed. When this surveyor asked V10 if R456 had received any pain medication recently, V10 stated, I don't know but what is this? The nurse dropped this off. She told me to give it to (R456) when he wakes up. V10 handed this surveyor a small plastic medication cup that contained one beige oblong capsule. The medication cup, containing the capsule, was shown to V7 Registered Nurse (RN). V7 RN stated, That's (R456's) Gabapentin (nerve/pain medication). He was sleeping when I went to give it to him, so I left it with (V10 Family of R456) to give to him when he woke up. R456's physician order dated 10/21/23 showed R456 was to receive Gabapentin 300 mg (milligrams), by mouth, daily at 9:00 AM, 1:00 PM, and 9:00 PM. On 10/24/23 at 11:45 AM, V2 Director of Nursing stated, We have no residents in the facility that can self-administer their medications. Nursing is not allowed to leave medications at a resident's bedside for them to take. Nursing must make sure residents take their meds. The facility's Medication Administration policy (undated) showed, Medications are prepared only by licensing nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications .The person who prepares the dose for administration is the person who administers the dose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 13 of 18 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 10/25/2023 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 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 interview and record review, the facility failed to test and record the concentration level of the sanitizer in the third sink of the three compartment sink five of the 12 days reviewed. This failure has the potential to affect all 158 residents residing in the facility. The findings include: During the initial tour of the kitchen on 10/23/23 at 9:30 AM, V15, Dietary Manager, said they check the chemical concentration level in the third sink three times a day after each meal service before washing the dishes. No sanitizer concentration level was recorded for the third sink of the three compartment sink for 10/23/23 and a copy of the Sanitizer Dispenser Log was requested at 9:58 AM. After receiving a copy of the log at 10:02 AM, a concentration level for 8:00 AM on 10/23/23 was present. However, after reviewing the rest of the log for the dates of 10/12/23 through 10/23/23, there was no data recorded on 10/13/23, 10/14/23, 10/18/23, 10/20/23 or 10/22/23. The facility's Kitchen Policy (revised 7/23/23) shows the third sink of the 3 Compartment Sink (Wash, Rinse, Sanitize) is used for sanitizing pots and pans and has to comply with the sanitizer's manufacture's recommendation. The Instructions on the Sanitizer Dispenser Log provided by the facility shows the concentration and temperature are to be recorded three times a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 14 of 18 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 10/25/2023 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 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 have an effective system in place to test staff and residents for COVID-19 during a facility outbreak, failed to ensure a resident exhibiting COVID-like symptoms was tested, separated, and isolated, and failed to ensure staff wore the required PPE (personal protective equipment) when caring for residents with COVID-19. These failures have the potential to affect all 158 residents residing in the facility. Residents Affected - Many The findings include: 1. The facility's Daily Census dated 10/23/23 shows there are 158 resident residing in the facility. At 9:00 AM on 10/23/23, there were 27 residents residing in all three units/floors of the facility positive for COVID-19 on droplet/contact isolation. By 10/24/23, there were 41 COVID positive residents in the facility. On 10/24/23 at 2:22 PM, V3, Infection Prevention Nurse/Memory Care Manager, said their current COVID-19 outbreak started on 10/19/23 with R76 on the third floor. R76 had vomiting and weakness and tested positive for COVID on 10/19/23. V3 said R76 only comes out of his room to walk up and down the hall with restorative and had no roommate, so they started with contact tracing. V3 said they called R76's Power of Attorney (POA) and visitors and none of them had symptoms and did not want to test for COVID. V3 agreed a source was, therefore, not identified. V3 said they tested the employees for COVID who cared for R76 that day and none were positive. On 10/24/23 at 10:57 AM, V3 said R9, who resided on the second floor, developed body aches and a poor appetite on 10/19/23 and tested positive for COVID as did his roommate, R103. V3 said they began broad testing for all of the second and third floor residents and employees since R9 and R103 are social, eat in the dining room, and have contact with a lot of residents. However, the facility's COVID-19 Residents routine testing report run on 10/25/23 for the third floor does not show a COVID test for R79, R71, R99, R134, R135, R111, or R120 (all third floor residents) until 10/20/23, at which time they each tested positive for COVID. V3 said R51, who resides on the first floor, went to the hospital for a procedure, was gone about 24 hours, and had cold symptoms when she returned. The facility tested her for COVID, and she was positive. V3 said the employees who cared for R51 when she returned to the facility were not tested for COVID-19, and would not have been required to wear an N95 mask prior to R51 testing positive. On 10/24/23 at 2:22 PM, V3 said V8, Licensed Practical Nurse (LPN) always works on the second floor, but she came in at 7:00 AM to work the first floor on 10/23/23. V3 said toward the end of her shift, V8 began to feel ill and tested positive for COVID before she left that day. V3 said they did not do any COVID testing on the residents V8 cared for that day. V3 said they have not done broad based testing on staff or residents on the first floor. V3 said they have not tested all employees for COVID since the outbreak began on 10/19/23. V3 said there is no way of knowing if someone has COVID without testing them for it. On 10/25/23 at 9:36 AM, V2 said every resident and every staff member was tested for COVID yesterday. V2 said there are now 41 residents positive for COVID, but no additional staff tested positive. V2 said no residents or staff member have been hospitalized for COVID related illnesses during their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 15 of 18 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 10/25/2023 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 0880 current outbreak. Level of Harm - Minimal harm or potential for actual harm On 10/24/23 at 1:35 PM, V24, Health Department Nurse, said they have no report from the facility regarding a current COVID outbreak. Residents Affected - Many The facility's COVID-19 Residents Tested Cases report run on 10/25/23 for Positive Residents shows R51 tested positive for COVID on 10/22/23. The facility was unable to provide a list showing any residents were tested for COVID on the first floor, other than R51, between 10/19/23 and 10/23/23. On 10/25/23 at 10:01 AM, V2, Director of Nursing (DON) said they just reported the facility's COVID-19 outbreak to the local health department last night. The facility's COVID isolation list (undated) provided on 10/23/23 shows 27 residents and their respective room number on droplet/contact isolation for COVID. There are residents on each of the three floors in the facility. The facility's Isolation List dated 10/24/23 shows 41 residents on droplet/contact isolation for COVID. The facility's COVID-19 Testing Plan and Response Strategy (revised 9/27/23) shows the following: For a facility experiencing a COVID-19 outbreak or that has identified its first case, the facility must promptly report the occurrence to its local health department. The same policy also shows Broad Based (either unit based or facility wide testing) requires testing of all residents and staff in either the unit or the floor or entire facility, when a single case of COVID-19 is identified in the facility. The PPE to be used for residents on Contact and Droplet Isolation and quarantine includes a pair of gloves, gown, eye protection, and N95. A mask is required to be worn by residents/individuals who reside on a unit experiencing an outbreak. When caring for residents positive for COVID, staff should wear full COVID PPE (N95, face shield, gown, and gloves). Residents who exhibit signs/symptoms of COVID will be tested, and placed in quarantine in a private room pending the test results. 3. On 10/24/23 at 2:01 PM, there was a contact/droplet isolation sign on R104's door that read, Put on face protection before room entry .Make sure eyes, nose and mouth are fully covered. V12 (Certified Nursing Assistant) entered R104's room to provide care. V12 had gloves, gown, and a black KN95 mask on. V12 did not have eye protection on. V12 stated, I wear this mask because it is more comfortable. R104's Physician's Order Sheet shows an order dated 10/22/23 for: contact/droplet isolation due to a diagnosis of positive COVID-19. On 10/24/23 at 10:57 AM, V3 (Infection Preventionist) said that all staff should wear gloves, gown, faceshield and a N95 mask when entering a contact/droplet isolation room. At 2:22 PM, V2 (Director of Nursing) said that all staff members are fit tested for N95 masks and cannot wear KN95 masks in place of a N95 mask. The facility's COVID 19 Testing Plan and Response Strategy Policy revised 9/27/23 shows, The PPE (Personal Protective Equiptment) to be used for residents on Contact and Droplet Isolation and quarentine includes a pair of gloves, gown, eye protection, and N95. 4. On 10/23/23 at 9:23 AM, there was a contact/droplet isolation sign on R72's door that read, Put on face protection before room entry .Make sure eyes, nose and mouth are fully covered. V12 (Certified Nursing Assistant) entered R72's room to assist him out of the bathroom. V12 had a surgical mask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 16 of 18 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 10/25/2023 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 0880 on and a N95 mask on over the surgical mask. V12 did not have eye protection on. Level of Harm - Minimal harm or potential for actual harm R72's Physician's Order Sheet shows an order dated 10/19/23 for: contact/droplet isolation due to a diagnosis of positive COVID-19. Residents Affected - Many On 10/24/23 at 10:57 AM, V3 (Infection Preventionist) said that all staff should wear gloves, gown, faceshield and a N95 mask when entering a contact/droplet isolation room. V3 said that the staff should not be wearing a surgical mask under their N95 because the N95 mask needs to be fit directly to the face to provide filtration. The facility's COVID 19 Testing Plan and Response Strategy Policy revised 9/27/23 shows, The PPE (Personal Protective Equiptment) to be used for residents on Contact and Droplet Isolation and quarentine includes a pair of gloves, gown, eye protection, and N95. 2. On 10/23/23 at 9:32 AM, R124 was observed coming out of room [ROOM NUMBER]. A sign posted on 312's room listed Enhanced Barrier Precautions. R124' nose was runny and she had a tissue in her hand. At 10:04 AM, she was in the dining room with her head down on the table sitting with other residents. Her nose remained runny with a tissue in her hand. At 11:29 AM, R124 entered room [ROOM NUMBER]. A sign posted on 317's room listed Droplet/Contact Precautions. At 12:25 PM, she was in the dining room for the noon meal. She was seated at a table with three other residents. On 10/24/23 at 8:42 AM, V19 (RN) said R124 tested positive for COVID-19 yesterday. The nurse on 2nd shift tested her because she was having symptoms. V19 said she was R124's nurse during the day yesterday and did not notice any symptoms. R124 did not report anyting to me. She wanders and we are trying to keep her in her room. When I get done with my morning medication pass, I'm going to sit outside of her room. Residents should be tested right away if they are having symptoms. We have several residents with COVID. The residents in 317 are on isolation for COVID. On 10/24/23 at 9:04 AM, R124 was observed out of her room wandering the halls. Her surgical mask was not covering her mouth, it was under her chin. At 9:06 AM, staff re-directed her back to her room. R124's nurses note dated 10/23/23 documents (R124) reported that she is not feeling good and noted with runny nose. Rapid COVID test done and she is positive for COVID. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 17 of 18 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 10/25/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure all residents were offered and/or received the influenza and/or pneumococcal immunizations for 3 of 5 residents (R118, R122, R16) reviewed for immunizations in the sample of 31. Residents Affected - Few The findings include: On 10/24/23 at 10:57 AM, V3, Infection Prevention Nurse/Memory Care Manager, said they review the residents' vaccination status on admission and with their care plan meetings quarterly. V3 said Pneumococcal vaccinations are offered to residents on admission and quarterly with their care plan meetings. On 10/25/23 at 10:52 AM, V3 said they started offering the Influenza vaccine to the residents after receiving it on 10/13/23. R118, R122, and R16's Immunization records and applicable consent/refusal forms provided by the facility were reviewed. No Pneumococcal vaccination refusal forms for these three residents were provided by the facility. R118's Immunization record printed on 10/24/23 shows he currently resides on the second floor of the facility. There is no record a Pneumococcal vaccination was ever received or offered. No influenza vaccination was offered, given, or refused for 2023. R122's Immunization record printed on 10/24/23 shows he currently resides on the second floor of the facility. There is no record a Pneumococcal vaccination was ever offered, given, or refused. R16's Immunization record printed on 10/24/23 shows she currently resides on the second floor of the facility. There is no record a Pneumococcal vaccination was ever offered, given, or refused. No influenza vaccination was offered, given, or refused for 2023. The facility's Influenza Vaccination Policy (revised 8/5/20) shows the facility is to offer and administer vaccination against influenza when it becomes available each year (typically beginning on October 1) to each consenting resident, unless otherwise contraindicated. All refusals will be documented. Education on the risks and benefits of receiving the vaccination will be provided to the resident/responsible party, and consent/refusal for vaccination will be obtained by signing a new written consent/refusal each year. The facility's Pneumococcal Vaccination Policy (revised 10/15/20) shows the facility is to offer and administer pneumococcal vaccination to each resident who has not received immunization prior to or upon admission, unless otherwise contraindicated, or refused. All refusals will be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 18 of 18