Health inspection·June 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure that call lights are answered in a timely manner per policy. This deficiency affects four (R1, R12, R13 and R14) of four residents reviewed for accommodation of needs. Findings include: 1.) R1 was admitted on [DATE] with diagnoses of Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Difficulty in Walking, Not Elsewhere Classified; Unsteadiness on Feet; Need for Assistance with Personal Care and End Stage Renal Disease. R1's MDS (Minimum Data Set) dated 05/25/23 under Section C indicated that her BIMS (Brief Interview for Mental Status) score is 15 which means intact cognition. R1 was discharged to home on [DATE]. According to concern form dated 05/28/23, she (R1) complained of poor call light response during night shift. V1 (Administrator) stated during interview on 06/13/23 at 2:59 PM that R1 was talking about call light responses that she waited for longer periods of time because she wanted staff to respond quicker. V1 continued, It happened more on the night shift. She mentioned that night shift did not respond quicker. I did education on call light. 2.) R12 was initially admitted in the facility on 05/23/23 with diagnoses of End Stage Renal Disease; Shortness of Breath; Difficulty in Walking, Not Elsewhere Classified and Unsteadiness on Feet. On 06/14/23 at 12:26 PM, R12 was observed in her room, alert and oriented. Her call light was observed within her reach. R12's BIMS score is 15 which means intact cognition, per MDS dated [DATE]. R12 was asked regarding issues on call lights. R12 stated, This early morning, I pushed the call light around 3, 3:30 AM and no one came to my room until around 5:00 AM. I waited for an hour and a half to two. No staff cared to respond to my call light. Concern form dated 05/29/23 documented R12 complained that she was not satisfied with the call light responses from staff. 3.) R13 was admitted with diagnoses of Nondisplaced Zone 1 Fracture of Sacrum, Subsequent Encounter for Fracture with Routine Healing and Dependence on Supplemental Oxygen. On 06/14/23 at 12:35 PM, R13 was observed in her room, lying in bed, on continuous oxygen at 3 lpm (liters per minute) via nasal cannula. Her call light was within her reach, by bedside rail. Per MDS dated [DATE], her BIMS score is 9 which means moderately impaired cognition. R13 was asked if she has any concern with staff responding to her call light. R13 stated, It was during night shift, staff don't come when I pushed the call light. I need to go to the bathroom, but no one came so I just got up and walked to the bathroom. And I have this oxygen in me. It was 2:30 AM that I used my call light, but no one checked on me and came to my room until next shift came. According to concern form dated 06/12/23, she (R13) complained that it took too long for staff to respond to her call light. (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: 145701 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 145701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107 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)