Inspection·April 8, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect residents' right to be free from resident to resident physical abuse. This applies to 2 of 3 residents (R2 and R3) reviewed for abuse in the sample of 3. The findings include: R1's face sheet showed R1 was a [AGE] year old female with the diagnosis of dementia with other behavioral disturbance and major depression disorder. R1's diagnoses did not include a diagnosis of a neurological disease with involuntary movements. On 4/8/24 at 9:46 AM, V7 (Registered Nurse- RN) said she was taking care of R1 on 3/16/24. R1 said V8 (Certified Nursing Assistant- CNA) reported to her that R1 had, .hit . two residents with her hands. V7 said the two residents that were hit by R1 were R2 and R3. On 4/8/24 at 9:48 AM, V8 said she did not witnessed the event of R1 hitting R2 and R3. V8 said V10 (CNA) witnessed the event. V8 said V10 reported that R1 slapped R2 and hit R3 with a fist. On 4/8/24 at 2:31 PM, V10 said on 3/16/24, R1 was in the dining room. V10 said R1 .Smacked . R2 in the head. V10 described R1 hitting R2 as a slap with an open hand. V10 said R1 used the front and back of her hand and slapped R2 4 times. V10 said as staff went to intervene R1 made a fist with her hand and hit R3 in the back of the head 2 times. V10 said the contact between R1, R2, and R3 was not accidental contact. R1's progress notes dated 3/16/24 showed R1 was in the dining room and started hitting a resident in the head. R1's Change in Condition Note dated 3/16/24 showed R1 was in the dining room, got up from her chair, and started hitting a resident on her head several times. The same note showed R1 hit a second resident in the head with her fist as R1 was shouting and cursing profanities in Spanish. Under the Behavioral Evaluation portion of the note showed R1 was a danger to self or others and was verbally/physical aggressive. The same note indicated R1 was sent to a local Hospital. R1's Hospital admission History and Physical showed R1 was sent to the hospital for increased aggression. On 4/8/24 at 9:37AM, V6 (RN) said a resident hitting another resident would be considered abuse. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145678 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 04/08/2024 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)