Health inspection·November 20, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. 1. R31's Progress Notes dated 10/20/24 at 5:15 PM show R31 is awaiting transport to the ER (Emergency Room). R31's Progress Notes dated 10/20/24 at 7:00 PM show an ambulance has arrived to transport R31 to the ER. R31's Progress Notes dated 10/20/24 at 9:38 PM show R31's POA (Power of Attorney) was called and informed that R31 was being admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. 2. R13's Progress Notes dated 10/30/24 at 3:26 PM show R13 was admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. On 11/18/2024 at 12:28PM, V19 (Registered Nurse/RN) said we give documents to the paramedics but not the family. On 11/19/2024 at 10:22AM, V23 (Licensed Practical Nurse/LPN) said she contacts the family when a resident transfers but does not send a written copy to the family. V23 said documents are sent with the EMTs (Emergency Medical Technicians). On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said we don't send a hard copy of transfer to family. V2 said we talk to the family over the phone. The facility failed to provide a policy that addresses written notification of transfer to the resident or their representative. Based on interview and record review the facility failed to notify the resident or their representative in writing of transfer. This applies to 2 of 30 (R31, R13) reviewed for notice of transfer or discharge in the sample of 30. The findings include: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 2 of 21 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 11/20/2024 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)

F 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review the facility failed to notify the resident or their representative of the bed hold policy. This applies to 3 of 30 (R23, R31, R13) reviewed for notice of bed hold in the sample of 30. Residents Affected - Few The findings include: 1. On 11/18/2024 at 3:39PM, V22 (Registered Nurse/RN) said he was caring for R23 when she went to the hospital in February of this year. V22 said he gave the paperwork to the EMTs (Emergency Medical Technicians) because the resident was confused that day. V22 said he does not recall if he notified the family of the bed hold policy. V22 said the bed is held for 10 days after a resident transfers to the hospital. V22 said he couldn't find anything in his documentation that shows he notified the family of the bed hold policy. 2. R31's Progress Notes dated 10/20/24 at 5:15 PM show R31 is awaiting transport to the ER (Emergency Room). R31's Progress Notes dated 10/20/24 at 7:00 PM show an ambulance has arrived to transport R31 to the ER. R31's Progress Notes dated 10/20/24 at 9:38 PM show R31's POA (Power of Attorney) was called and informed that R31 was being admitted to the hospital. The facility was unable to provide documentation of providing a written bed hold policy to R31 or his POA. 3. R13's Progress Notes dated 10/30/24 at 3:26 PM show R13 was admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. The facility was unable to provide documentation of providing a written bed hold policy to R13's POA. On 11/18/2024 at 12:28PM, V19 (RN) said the bed hold policy is given to the paramedics upon transfer. On 11/18/2024 at 1:44PM, V20 (RN) said we give the paperwork to the EMTs and sent it with them. V20 said we call the resident's family to notify them about the transfer, but we don't necessarily call about the bed hold. On 11/18/2024 at 1:46PM, V21 (RN) said we give the bed hold policy to the paramedics when the resident transfers out. V21 said we tell the family the bed is held for 24 hours. On 11/19/2024 at 10:22AM, V23 (Licensed Practical Nurse/LPN) said we give a copy of the bed hold information to the EMTs when we send the resident out. On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said we don't send a hard copy of transfer to family. V2 said we give paperwork to the paramedics upon transfer to the hospital. The facility provided Bed Hold and readmission policy revised 7/26/2024 states, the facility must inform the resident or family members being transferred of the duration of bed hold in writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 3 of 21 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 11/20/2024 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was assessed prior to being diagnosed with a serious mental illness according to professional standards of practice. This applies to 1 of 1 residents (R99) reviewed for professional standards of practice in the sample of 30. Residents Affected - Few The findings include: R99's face sheet shows, she was admitted to the facility on [DATE]. The same face sheet lists Schizophrenia as a diagnosis as of May 2, 2023 (2 years after admission). On November 20, 2024 at 10:38 AM, V25 Psychotropic nurse stated, she didn't know how R99 got that diagnosis. She has only been doing the psychotropics since May of this year. R99's progress notes dated May 2, 2023 documented by V30 R99's primary care physician (PCP) shows, .schizophrenia, continue seroquel to 25 mg (milligram) daily . The progress note does not show, any information to add diagnosis of schizophrenia. On November 20, 2024 at 2:19 PM, V30 R99's PCP stated, her understanding was that R99 came to the facility with that diagnosis. She had not done any testing to confirm the diagnosis. On November 20, 2024 at 3:17 PM, V29 Psych Nurse Practitioner stated, R99 has had that diagnosis since she has been seeing her. She has been seeing her since February 2024. R99 does have a diagnosis of dementia which she agreed R99's behaviors could be a result of her dementia diagnosis which comes with mania and psychosis. You can manage dementia with the same psychotropic medications. Schizophrenia is a big diagnosis and the gold standard is a full psych evaluation and long hours of testing. Which she has not done with R99 since she has been seeing her. R99's face sheet does also include dementia, bipolar disorder, psychotic disorder with delusions, generalized anxiety disorder, delusional disorders and major depressive disorder as diagnoses. R99's admission hospital records do not list schizophrenia as a diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 4 of 21 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 11/20/2024 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)

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 Based on observation, interview and record review the facility failed to provide ADL's (activities of daily living) for residents who require extensive assistance. This applies to 3 of 30 residents (R59, R118 & R49) reviewed for ADL's in the sample of 30. Residents Affected - Few The findings include: 1. On November 17, 2024 at 1:15 PM, V6 R59's family complained, her dad doesn't get the care he needs. They don't change his clothes or his adult diaper in a timely manner. On November 18, 2024 at 10:40 AM, V8 Hospice CNA (Certified Nursing Assistant) was giving R59 a bed bath. She stated, R59 had the same clothes on from the last time she was here. She was last there on Thursday (November 14, 2024 - 4 days prior). R59's adult diaper was saturated with urine. V8 stated, he is always like this when she comes in to care for him. R59's care plan initiated on January 11, 2022 shows, Focus: R59 has an ADL self care performance deficit and impaired mobility AEB (as evidence by): impairments in over-all strength, generalized weakness, decrease activity tolerance, poor endurance secondary to Chronic complex medical diagnosis such as Gout, AFIB (atrial fibrillation), basal cell carcinoma, limited range of motion, abnormality of gait and mobility, gait unsteadiness r/t hemiplegia and hemiparesis following CVA (cerebral vascular accident), osteoarthritis, cognitive impairment such at ST (short term) memory loss, forgetfulness, confusion r/t dementia, behavioral issues, mood disturbance r/t major depression and anxiety disorder, impaired hearing. Interventions: Dressing: I require substantial/maximal assistance of 1 staff participation to put on, fastens and takes of all items of clothing, including donning/removing a prosthesis or TED hose. Toilet use: I require substantial/maximal assistance of 2 staff participation to use the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination. 2. On November 17, 2024 at 10:47 AM, 11:02 AM & 1:54 PM, R118 was sitting up in his reclining wheelchair in the same spot in the dining room. On November 18, 2024 at 9:26 AM, R118 was up in his reclining wheelchair in the dining room. At 10:19 AM - 12:44 PM, by continuous observation, R118 remained in the same spot in the dining room. At 1:56 PM, R118 was still in the dining room. At the same time, V10 Restorative CNA took R118 to his room to toilet him. V10 stated, R118 was already up in his reclining wheelchair that morning when he got there. The night shift got him up. This was the first time he was toileting R118. R118's care plan initiated November 6, 2023 shows, Focus: R118 has an ADL self care performance deficit and impaired mobility AEB: generalized weakness, easy fatigability, decrease activity tolerance, impaired mobility, limited range of motion, secondary to chronic diagnosis such as: cognitive impairment, poor safety awareness, unspecified dementia. Interventions: Toilet use: I require dependent assistance of 1-staff participation to use the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination. 3. On November 18, 2024 at 9:26 AM, R49 was asleep in her reclining wheelchair in dining room. At 10:19 AM - 12:44 PM, by continuous observation, R49 remained in the same spot in the dining room. At 2:00 PM, R49 was still in the same spot in the dining room. V11 agency CNA stated, R49 was already up this morning when she got there. She had not toileted her that day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 5 of 21 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 11/20/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R49's care plan initiated on August 6, 2024 shows, Focus: R49 has an ADL self care performance deficit and impaired mobility AEB generalized weakness, easy fatigability, decrease activity tolerance, impaired mobility, limited range of motion. Secondary to chronic diagnosis such as metabolic encephalopathy, unspecified fall, asthma, insomnia, autoimmune hepatitis, spinal stenosis, lumbar region without neurogenic claudication, HLD (hyperlipidemia), present of right artificial knee joint, acquired absence of right breast and nipple, UTI-E.Coli (urinary tract infection- escheria coli), AMS (altered mental status), dementia, HTN (hypertension), specified D/O (disorder of) of bone density and structure, an adult failure to thrive. Interventions: Toilet use: I require dependent assistance of 1 staff participation to use the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination. The facility's incontinent and perineal care policy dated July 31, 2024 shows, Policy Statement: 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. Procedures: 1. Do rounds at least every 2 hours to check for incontinence during shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 6 of 21 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 11/20/2024 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)

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 a residents skin preventive treatment was in place per physician orders. This applies to 1 of 5 residents (R59) reviewed for non-pressure skin conditions in the sample of 30. Residents Affected - Few The findings include: On November 18, 2024 at 10:40 AM, V8 Hospice CNA (Certified Nursing Assistant) was giving R59 a bed bath. R59's adult diaper was saturated with urine. His coccyx was red with a small superficial open area. V8 stated, there usually is a dressing on his coccyx but it wasn't there today. On November 19, 2024 at 2:25 PM, V12 and V13 both wound care nurses stated, R59 did not have any open pressure injuries on his coccyx. It was more like MASD (moisture associated skin damage) now. R59 does have a treatment order in place as a preventive measure every shift. R59 has really declined and is on hospice now. He doesn't even get out of bed. The preventive treatment orders are to prevent any skin breakdown or pressure injuries from developing. R59's November 2024 treatment administration record shows orders for: calamine-zinc oxide external lotion, apply to coccyx/buttocks topically every shift for skin breakdown prevention . apply duraseptine to xeroform, apply to noted areas every shift . xeroform oil emulsion gauze external pad, apply to coccyx/buttocks topically every shift for skin breakdown prevention . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 7 of 21 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 11/20/2024 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)

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 report skin alterations, identify an unstageable pressure injury prior to developing and failed to protect a resident's heel from developing a stage 2 pressure injury. This applies to 2 of 5 residents (R137 and R118) reviewed for pressure injuries in the sample of 30. Residents Affected - Few The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of the brain, dementia, cognitive communication deficit and need for assistance with personal care. On November 18, 2024 at 9:46 AM, V13 Wound Care Nurse (WCN) was changing R137's dressing on her coccyx. R137 had an approximately a dime size elongated open area to her coccyx. V13 stated, it was approximately 1 centimeter deep. R137's initial wound assessment dated [DATE] shows, a pressure ulceration, facility acquired, unstageable measuring 3 cm (centimeters) X 5 cm X unknown to her coccyx. Current plan & Comments: noted by nursing staff, presents as an unstageable PI (pressure injury) . R137's shower sheet dated August 9, 2024 shows, a skin alteration to her coccyx. (10 days prior to initial wound assessment). On November 19, 2024 at 2:36 PM, V12 (WCN) and V13 (WCN) stated, R137's pressure injury was acquired in the facility and not found until it was already an unstageable. She was not eating or drinking at the time. She was incontinent of urine so she should have been changed at least every shift and someone should have noticed prior to it becoming an unstageable. Ideally any skin issue would be identified with redness and interventions can be put into place right away so it doesn't turn into an unstageable pressure injury. R137's care plan initiated on August 5, 2024 shows, R137 is potential for alteration in skin integrity related to needs assist with personal care, incontinent of bowel and bladder, and extensive assistance with bed mobility 2. On November 17 & 18, 2024, R118 was sitting up in his reclining wheelchair. He had heel protector boots on both feet. R118's initial wound assessment dated [DATE] shows, a pressure ulceration, facility acquired, stage 2 to his left medial heel measuring 2 cm X 1.80 cm X 0.20 cm. Current plan & Comments: left medial heel presents as a stage 2 blister that partially opened . On November 19, 2024 at 2: 36 PM, V13 (WCN) stated, R118 sits in his reclining wheelchair and his heel was resting on the foot rest which caused a blister to his heel. R118's care plan initiated on August 26, 2023 shows, Focus: R118 is potential for alteration in skin integrity related to needs assist with personal care, incontinent of bowel and bladder, and extensive assist with bed mobility. Diagnosis of depression, pneumonitis, dementia, and chronic COPD (chronic obstructive pulmonary disease). Intervention: Apply green prevalon boots as ordered to offload (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 8 of 21 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 11/20/2024 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)

F 0686 heel areas (date initiated August 26, 2023). Level of Harm - Minimal harm or potential for actual harm The facility's wound care guidelines dated January 24, 2024 shows, Overview of the program: .The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility. The purpose of the prevention recommendations is to guide evidence-based guidance on the most effective strategies to promote pressure injury/ulcer healing. Procedures: 3. Prevention of skin breakdown includes but not limited to: c. Inspection of the skin every shift with care for signs of breakdown. Activity, Mobility, and Positioning: j. Off load elbows and heels as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 9 of 21 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 11/20/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to monitor a resident on the toilet with a history of falls. This applies to 1 of 30 (R10) reviewed for safety supervision in the sample of 30. Residents Affected - Few The findings include: 1. On 11/17/2024 at 2:20PM, shouts of Help me and Help were heard from the hallway. R10 was observed sitting on her bathroom toilet holding the grab bar to the right of toilet. No staff observed in R10's room, bathroom, or outside in the hallway. On 11/17/2024 at 2:28PM, V17 (Agency Certified Nursing Assistant/CNA) said she put R10 on the toilet. V17 said R10 is not alert and oriented. On 11/17/2024 at 2:23PM, V16 (CNA) said staff assist R10 to the toilet. V16 said, We should not leave [R10] on the toilet by herself because she is a fall risk and it's a safety issue. On 11/17/2024 at 2:31PM, V18 (Licensed Practical Nurse/LPN) said, We do not leave [R10] on the toilet alone because she's a fall risk. R10's Fall Risk Evaluation dated 4/1/2024 shows a fall risk score of 15. A score of 8 and above is considered high fall risk according to the Fall Risk Evaluation reference range. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 10 of 21 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 11/20/2024 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)

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. Based on interview, and record review the facility failed to provide catheter care interventions to a resident (R119) with a history of urinary tract infection (UTI). This applies to 1 of 5 (R119) residents reviewed for catheters in the sample of 30. The findings include: 1. On 11/17/2024 at 12:05PM, R119 was observed lying in bed with a urinary catheter in place hanging on the side of his bed. On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said catheter care, catheter flush, and betadine should be applied every shift for R119 as ordered and documented. V2 said this is done to help prevent infection. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order for Betadine External Solution 10% - apply to external meatus topically every shift. No documentation provided for November 15 and 16, 2024 at 9:00AM. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order to flush foley catheter every shift with 60cc (cubic centimeters) of saline. No documentation provided for November 15, 2024 at 9:00AM. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order to provide catheter care every shift. No documentation provided for November 15, 2024 at 9:00AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 11 of 21 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 11/20/2024 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to weigh, assess and monitor a resident with significant weight loss. This failure resulted in R137 losing 21 lbs. (pounds) in 14 days without being re-weighed or assessed. The facility also failed to provide physician ordered supplements for a resident (R118) with a history of significant weight loss. These failures apply to 2 of 7 residents (R137 & R118) reviewed for weight loss in the sample of 30. Residents Affected - Few The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of brain, dementia, unspecified psychosis, major depressive disorder, cognitive communication deficit and hallucinations. R137's face sheet also shows she was admitted to the facility on [DATE]. She weighed 145.6 lbs. R137's initial admission dietary evaluation dated July 31, 2024 shows, [AGE] year old female admitted from the hospital with a dx (diagnosis) of psychosis. Past medical hx (history) includes dementia, depression, hyperlipidemia. Diet: regular with thin liquids. Appetite appears fair with intake of ~50-75% of meals since admission. Current BMI (body mass index) is 22.5 which reflects weight within normal range for height, but low for age. Reviewed meds. No current labs to review. No skin breakdown noted. Visited with patient in the room during breakfast. Observed feeding herself with a good appetite. Patient was confused stating Hi Ma, will you be here all day? Patient was unable to answer any interview questions. Spoke with the POA (Power of Attorney) who reports patient's height to be 5'7 1/2 and states patient used to be ~190.6# (lbs) x ~4-5 months ago- unable to specifically quantify. POA states patient was eating well at home and did receive [NAME] (meals on wheels) for lunch, however continued to lose weight despite eating well. Obtained preferences and left meal tickets and alternative menu to fill out. Per POA, patient prefers cold cereal at breakfast, likes cheeseburgers, chicken and fish and loves anything chocolate. MNA (mini nutritional assessment) score is 12 which is normal nutritional status. Goals: PO (by mouth) intake >/=75%, weight maintenance. Patient appears well nourished at this time but will monitor weight trend and intake d/t (due to) reported wt (weight) loss. R137's progress notes dated August 4, 2024 shows, The patient refused to eat. She's always saying that I don't want to eat, I don't like the food. Spoke with POA she said that a family member will come by today to bring her burger which likes to eat. R137's electronic medical record (EMR) shows no re-weight from admission. R137's order details dated August 5, 2024 shows, mirtazapine tablet was ordered for increase appetite. R137's EMR continues to shows no re-weight from admission. R137's nutrition- amount eaten sheet shows the following percentages of food eaten: 8/3/24- 0-25% for all 3 meals, 8/4/24- 51-75% for all 3 meals, 8/5/24 & 8/6/24- 26-50% for breakfast and lunch, 51-75% for dinner, 8/7/24- 0-25% for breakfast and lunch and refused dinner, 8/8/24- 26-50% for breakfast, 51-75% for lunch and dinner, 8/9/24- 0-25% for all 3 meals and 8/10/24- breakfast refused and 26-50% for lunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 12 of 21 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 11/20/2024 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)

F 0692 R137's weights show, she was not weighed again until August 13, 2024 (14 days later). She weighed 124.5 lbs (21 lb loss). Level of Harm - Actual harm Residents Affected - Few R137's EMR and progress notes show, she was not seen by the dietitian after her initial assessment until August 20, 2024 (7 days later). Reported that resident continues to have varies to mainly poor p.o. (by mouth) intake with meals despite of assist and encourage. Diet was downgraded to Mechanical Soft on 8/19 and to Puree on 8/20 (started for Lunch) d/t (due to) continues poor intake. Per nursing provided Puree for lunch today and ate 100% of the meal with ice cream. Nursing notified MD and families regarding p.o. intake, current wt with wt loss and diet changes. Current wt is 126.6# as of 8/20 which showed 5# or 3.7% loss from last week's wt of 131.6# 8/15. Initial wt of 145.6# on 7/30 and 124.6# on 8/13 were both questionable, resident was re-weighed on 8/15-131.6#. With current wt BMI is 19.5 which remains normal status but at the low-end side. Per wound nurse today, resident has unstageable to coccyx area as of 8/19. Per nursing resident tolerates supplements well. Will recommend increasing to 120ml (milliliters) QID (four times a day) and to provide (fortified shake) which will provide 960kcal (kilocalories) and 40g (grams) of protein if all consumed. Added ice cream with lunch and dinner, super cereal at breakfast. Interventions should help with the healing process and maintain or have wt (weight) gain. Will make Rd (Registered Dietitian) aware. Will continue to monitor wt, labs and intake. On November 19, 2024 at 1:24 PM, V14 (Dietitian) stated, she asked for a re-weigh when R137 was admitted because she didn't believe she weighed 145 lbs. She did not get re-weighed until August 13, 2024. She only saw her on July 31, 2024 and August 20, 2024. New admits should have weekly weights for 4 weeks to make sure the initial weight are correct and monitor for any fluctuations. R137's care plan initiated on July 31, 2024 shows, Nutrition-Dementia focused. R137 is at risk for compromised nutritional status, related to diagnosis of Alzheimer's disease or related dementia . 2. On November 17 & 18th, 2024 both at the noon meals, R118 was not provided a magic cup. R118's dietary evaluation dated October 24, 2024 shows, Resident is seen for significant weight loss of 10.5% x 6 months. Current weight is 129.8# which is down from 145# x 6 months ago. Resident continues under hospice care w/a dx (with a diagnosis) of senile degeneration of the brain. Continues on Pureed with thin liquids, pudding at breakfast, magic cup at lunch and dinner. R118's physician orders shows, Regular diet, Puree texture, Thin liquids consistency. Magic cup with lunch and dinner, pudding at breakfast and whole milk with meals. No Straws. On November 19, 2024 at 1:24 PM, V14 (Dietitian) stated, R118 has had some weight loss. One of the interventions added was a magic cup at lunch and dinner. If he doesn't receive his magic cup, he could lose more weight. R118's care plan initiated on September 10, 2024 shows, Focus: Unintended weight loss/gain: R118 has the following conditions and risk factors that put him at risk for unintended weigh loss/gain: Alzheimer's disease/dementia. Significant weight loss x 6 months. Interventions: Proved pureed diet to meet the nutritional needs of the resident by: 1. providing fortified foods- magic cup BID (twice a day), pudding (date initiated October 25, 2024). The facility did not provide a weight loss/prevention policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 13 of 21 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 11/20/2024 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)

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 there were no discrepancies between physical doses of controlled medications (including methadone) and the correlating number documented on the record of controlled substances for 1 of 30 residents (R62) in the sample of 30 reviewed for pharmacy services. The findings include: On 11/18/24 at 9:05 AM, during medication administration observations, there were 22 physical doses of R62's methadone available. R62's Individual Controlled Substance Record (date received 11/12/24) showed there should have been 23 physical doses of methadone. When V19 ( Registered Nurse) administered R62's prescribed dose of methadone, she wrote in 23, skipped that entry and signed out her dose on the next line. There was no entry made for the 23rd dose. On 11/18/24 at 9:40 AM, V19 said the off-going and the oncoming nurses do a count of the narcotics at every change of shift. V19 said they need to make sure there are no medications missing and they need to make sure the count is accurate. V19 said she will need to report the discrepancy to her supervisor. The facility's Controlled Substance Storage Policy shows at each shift change, or when keys are transferred, a physical inventory of all controlled substances is conducted by two licensed personnel and is documented. Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 14 of 21 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 11/20/2024 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed after being agreed upon by the physician for 1 of 5 residents (R94) reviewed for psychotropic medications in the sample of 30. The findings include: R94's Consultant Pharmacist Recommendation to Prescribed dated 8/2/24 shows the pharmacist requested R94's psychotropic medications, quetiapine and Sertraline, be reevaluated and considered for a gradual dose reduction (GDR). The physician response dated 9/24/24 shows the physician agrees with the recommendations. R94's Order Summary Report dated 11/20/24 shows R94 had an order on 4/4/24 for Sertraline 50 milligrams (mg) once a day and an order on 3/25/24 for Seroquel (quetiapine) 12.5 mg twice a day. There were no orders for the two medications at a reduced dose. On 11/20/24 at 10:30 AM, V25 (Psychotropic Nurse) said the pharmacist reviews the residents' medications and emails the recommendations to her and other leadership personnel in the facility. V25 said she is responsible to address the psychotropic medication recommendations. V25 said since the doctor agreed with the GDR for R94's Sertraline and Seroquel, she or the floor nurse should have clarified what dose of the medications the doctor wanted to prescribe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 15 of 21 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 11/20/2024 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure psychotropic medication doses were reduced for 1 of 5 residents (R94) reviewed for unnecessary psychotropic medications in the sample of 30. The findings include: R94's Consultant Pharmacist Recommendation to Prescribed dated 8/2/24 shows the pharmacist requested R94's psychotropic medications, quetiapine and Sertraline, be reevaluated and considered for a gradual dose reduction (GDR) as Sertraline may cause drowsiness and Seroquel (quetiapine) may lead to falling and may cause hypotension. The physician response dated 9/24/24 shows the physician agrees with the recommendations. R94's Order Summary Report dated 11/20/24 shows R94 has a current order for Sertraline 50 milligrams (mg) once a day and a current order for Seroquel (quetiapine) 12.5 mg twice a day. R94's Medication Administration Record (MAR) for 9/1/24 to 9/30/24 shows R94 was receiving Sertraline 50 mg daily and Seroquel 12.5 mg twice a day. R94's Medication Administration Record (MAR) for 10/1/24 to 10/31/24 shows R94 was receiving Sertraline 50 mg daily and Seroquel 12.5 mg twice a day. R94's Medication Administration Record (MAR) for 11/1/24 to 11/30/24 shows R94 was receiving Sertraline 50 mg daily and Seroquel 12.5 mg twice a day through 9:00 AM on 11/20/24. R94's Order Summary Report for 11/1/24 through 11/30/24 shows orders to monitor for side effects of antidepressants and antipsychotic medications. On 11/20/24 at 9:47 AM, V25 (Psychotropic Nurse) said they monitor residents taking psychotropic medication(s) for side effects such as increased falls and dizziness. On 11/20/24 at 10:30 AM, V25 said since the doctor agreed with the GDR for R94's Sertraline and Seroquel, she or the floor nurse should have clarified what dose of the medications the doctor wanted to prescribe and implemented it in a timely manner. The facility's Psychotropic Medications Policy (revised 8/13/24) shows it is the facility's policy to adhere to federal regulations in use of psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 16 of 21 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 11/20/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's medications were labeled and stored for 1 (R123) of 30 residents reviewed for medication storage in the sample of 30. The findings include: R123's Order Review Report dated November 18, 2024 shows she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, malnutrition, major depressive disorder, other psychotic disorder not due to a substance or known physiological condition, heart failure, rheumatoid arthritis, bilateral primary osteoarthritis of knee, non-infective gastroenteritis and colitis, sepsis, post-traumatic stress disorder, and cognitive communication deficit. R123's Medication Administration Record shows R123 is prescribed atorvastatin for high cholesterol, citalopram for depression, clopidogrel for clot prevention, ferrous sulfate for supplementation, furosemide for diuresis, metoprolol for hypertension, prednisone for rheumatoid arthritis and inflammation, divalproex for convulsions, oyster shell calcium for supplementation, carbidopa-levodopa for Parkinson's disease. All of these medications are scheduled to be administered at 9:00 AM. On November 18, 2024 at 10:00 AM, R123 was laying in her bed. R123 complained of abdominal pain. R123 was holding a medication cup that had 7-10 medication pills in it. There was a small yellow pill on R123's bed mattress. R123 said the medications were her morning medications, and she was going to take them when more food came. On November 19, 2024 at 9:55 AM, V6 RN (Registered Nurse) said R123 usually takes forever when she takes her medications. V6 said R123 likes to take her medications one at a time. She likes to eat crackers or something in between. V6 said that staff should be watching the resident until all the medications are gone. V6 said if the resident is requesting to take the medications later, then she takes them away from the resident and will re-approach later. The facility's undated Medication Administration General Guidelines policy shows, When medications are administered by mobile cart taken to the resident's location, medications are administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose. The resident is always observed after administration to ensure that they dose was completely ingested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 17 of 21 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 11/20/2024 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)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident and/or resident representative understood the arbitration agreement, and failed to educate staff providing the arbitration agreement to residents which applies to 4 of 4 (R20, R73, R144, R251) reviewed for the arbitration agreement in a sample of 30. Residents Affected - Some The findings include: 1. R251's medical record showed R251 was admitted to the facility on [DATE]. R251's Health Care Arbitration Agreement (HCAA) was signed on 11/17/24 by R251. R251's medical record show R251 was assessed as being cognitively intact. On 11/20/24 at 10:00 AM, R251 stated she was in the facility a few days when a young man (V27 Guest Services Director) came into her room to have her sign some documents. R251 stated she knew one of the documents was an admissions packet. The other one had smaller writing. V27 did not explain what the other document was clearly. R251 stated they signed the papers, V27 stated if R251 had any questions to contact them. R251 stated it was not explained to her the details of what the HCAA document meant. R251 was unaware if the HCAA was signed it waived her ability to get legal assistance if something happened to her in the facility. R251 stated that was not mentioned at the time the HCAA was presented to her. 2. R20's medical record showed R20 was admitted to the facility on [DATE]. R20's Health Care Arbitration Agreement (HCAA) was signed on 10/10/24 by V28 (R20's Power of Attorney-POA). R20's medical record showed R20 has severe cognitive impairment. On 11/20/2024 at 9:45 AM, V28 (R20's POA) stated she remembered signing some documents after a careplan meeting for R20. V28 stated she was asked to sign a document (HCAA) at that time, and did not have time to review the documents. When asked if V28 understood the document waives the right to seek legal actions against the facility for malpractice related to care and services R20 may receive in the future, V28 stated that was not explained to her. V28 stated she would have taken the document with and signed it later when she had the appropriate time to look at it. 3. R73's medical record showed R73 was admitted to the facility on [DATE]. R73's HCAA was signed on 10/10/24 by R73. R73's medical record showed R73 was assessed with having moderate cognitive impairment. R73 has no POA listed in this medical record. On 11/20/24 at 10:15 AM, R73 stated someone came in after she was in the building, and had her sign a bunch of papers at the same time. R73 stated she does not remember anyone explaining what the documents (included the HCAA) meant. R73 stated she did not remember any suggestion they could not sue the facility if something bad happened to them in the facility. 4. R144's medical record showed R144 was admitted to the facility on [DATE]. R144's HCAA was signed on 11/18/24. R144's medical record showed R144 was assessed to be cognitively intact. On 11/20/24 at 11:00 AM, R144 stated she had someone come into the room and talk to her about a bunch of documents in the folder on the bedside table. R144 stated she thought an arbitration agreement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 18 of 21 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 11/20/2024 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)

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had a committee work with you and the facility to resolve issues. Not that she could not get a lawyer if any problems happened during her admission. R144 stated she would of had her husband look through the documents if it was explained better to her before she signed it. On 11/20/24 11:56 AM, V26 (Admissions Director) stated the way they were taught to give out the HCAA to the residents was done by the previous admissions director. The previous admission director explained to V26 the HCAA needed to be gone over with the resident when they brought it to the room, and have the resident accept or decline the HCAA. V26 stated that is what was told to V27 (Guest Services Director) when V27 started assisting me with the HCAAs. On 11/20/24 at 11:58, V27 stated V27 agreed with R26 about being verbally told how to approach the residents with the HCAA form. V27 stated they had not received any formal education on the HCAA. On 11/20/24 at 12:30 PM, V31 (Regional Clinical Consultant) stated the facility did not have a policy on the Arbitration Agreement, but provided a power point education packet used for staff education. On 11/20/24 12:50 PM, V26 and V27 stated they had not see the education packet provided by the facility. The undated HCAA education packet showed factors which could have the HCAA be unconscionable (against good conscious) were if there was issue with a resident's age, literacy, or lack of sophistication of a party, the manner and setting in which the contract was formed, and/or whether the party had an opportunity to understand the terms of the contract. It is important to be sure the signer is not signing the agreement while being rushed, and the terms were explained to them in a manner that they can understand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 19 of 21 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 11/20/2024 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)

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** 2. On November 18, 2024 at 9:46 AM, V15 (Certified Nursing Assistant/CNA) was changing R137's adult diaper. R137 had a bowel movement. V15 (CNA) did not remove his gloves or wash his hands after cleaning R137. He continued to place her pillow under her, cover her up and lift the bed down. Residents Affected - Few The facility's hand hygiene policy dated July 30, 2024 shows, Policy Statement: Hand hygiene is important in controlling infections. Hand hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC (Centers for Disease Control) guidelines in regards to hand hygiene. Procedures: 1. Hand hygiene using alcohol-based hand rub is recommended during the following situations: f. Before and after assisting a resident with toileting, h. after contact with blood, body fluids or surfaces contaminated with blood and body fluids . Based on observation, interview, and record review the facility failed to perform hand hygiene and change their gloves during perineal care in a manner to prevent cross contamination for two of five residents (R80, R137) reviewed for infection control in the sample of 30. The findings include: 1. R80's Order Review Report dated November 18, 2024 shows she was admitted to the facility on [DATE] with diagnoses including history of covid, urinary tract infection, obesity, malignant neoplasm of cervix, need for assistance with personal care, pressure injury of right buttock and sacral region. R80's MDS (Minimum Data Set) dated September 23, 2024 shows R80 is dependent on staff for personal and toileting hygiene. R80 is always incontinent of bowel and bladder. On November 18, 2024 at 1:21 PM, V5 and V7 CNAs (Certified Nursing Assistants) performed perineal (peri) care for R80. There was stool noted to R80's front peri area. V7 wiped the stool from R80's front peri area then touched R80's body to help her to turn onto her left side. V7 did not change her gloves or perform hand hygiene prior to touching R80's body. On November 19, 2024 at 9:10 AM, V3 (Infection Control Nurse) said gloves should be changed when they become contaminated. Gloves should be changed to ensure staff is not going from dirty to clean surfaces. Glove change and hand hygiene is to prevent cross contamination. The facility's Hand Hygiene Policy revised July 30, 2024 shows, Hand hygiene is important in controlling infections. Hand hygiene using alcohol based hand rub is recommended during the following situations: Before moving from work on soiled body sit to a clean body sit on the same resident, after contact with blood, body fluids or surfaces contaminated with blood and body fluids. The facility's Incontinent and Perineal Care policy revised July 31, 2024 shows, Perform hand hygiene before the procedure. Put on gloves and appropriate personal protective equipment if indicated. Wash the perineal area and gently dry after the procedure. Remove gloves and dispose to designated plastic bag, wash hands. Put on new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom, and change clothing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 20 of 21 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 11/20/2024 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a resident was not prescribed an unnecessary antibiotic. This applies to 1 of 5 residents (R128) reviewed for unnecessary medications in the sample of 30. Residents Affected - Few The findings include: R128's medication administration record for November 2024 shows, Keflex Oral Capsule 250 MG (milligrams) (cephalexin) Give 250 mg by mouth two times a day for Recurrent UTI (urinary tract infection) prophylaxis. Start Date 03/29/2024. On November 20, 2024 at 1:49 PM, V3 (Assistant Director of Nursing) stated, R128 was on the medication for recurrent UTI's. R128's progress notes do not show any physician notes about starting the medication until November 20, 2024. The progress note shows, .recurrent UT (urinary tract), keflex daily, follow up urology . The facility did not provide any other documentation prior to November 20, 2024. The facility's McGreer criteria infection surveillance checklist dated August 8, 2024 shows, Statement: The facility will utilize the McGreer Criteria Checklist as a valuable infection prevention and control program tool in order help provide standardized guidance for infection surveillance activities in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145678 If continuation sheet Page 21 of 21