Inspection·April 4, 2024

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 follow their policy and procedure related to infection control by not wearing appropriate personal protective equipment (PPE) in resident rooms who required contact isolation and by not practicing hand hygiene while performing incontinence care for a resident. This failure applied to three of three (R82, R275, R277) residents reviewed during review of facility infection control practices. Residents Affected - Few Findings include: Per contact isolation log dated 04/2024, shows R275 on contact isolation for MRSA in the urine and R277 on contact isolation for VRE in the urine. 1.) On 4/1/24 at 1:20PM, V9 (Dialysis Social Worker) was observed entering R275's room not wearing any PPE. V9 sat on the edge of R275's bed next to R275 to have a discussion. 2.) On 4/2/24 at 12:40PM, V11 (Director of Rehab) was observed to be in R277's room not wearing a gown. V20 (family member) was also observed entering R277's room without putting on any PPE and without performing any hand hygiene. V20 was then observed leaving the room and going to the nursing station to speak with staff without performing any hand hygiene. On 4/2/24 at 1:40PM, V21 (Infection Preventionist) was interviewed regarding contact isolation expectations. V21 said my expectation is that prior to entering the room of any resident who is on contact isolation, no matter who it is: staff and visitors should perform hand hygiene with hand sanitizer and put on a gown and gloves. Prior to exiting the room, they are to take PPE off and perform hand hygiene. Family is informed of this when a resident is put on isolation and there is also a sign and PPE placed outside of the door for them to utilize. Policy titled Infection Prevention and Control with last revision date of 10/23/23 states in part but not limited to the following: 2. Contact Precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Use of gown and gloves is necessary prior to room entry. Residents are restricted to leave the room except for medically necessary procedures and appointments. 3.) R82 is a cognitively impaired [AGE] year-old resident with diagnosis listed in part, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, vascular dementia, and type II diabetes mellitus. On 04/03/2024 at 9:57am, V22 (Wound Care Coordinator) said R82 has poor appetite, does not eat (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 3 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 04/04/2024 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)