Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on interview and record review, the facility failed to follow their policy to immediately notify a
resident's representative when a resident had a change in condition requiring transfer to the local hospital.
Residents Affected - Few
This applies to 1 of 3 residents (R1) reviewed for change in condition notification in the sample of 8.
The findings include:
The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2020 with multiple
diagnoses including, aphasia following cerebral infarction, chronic kidney disease, myocardial infarction,
pulmonary embolism, hypertension, heart failure, atrial fibrillation, dementia, and chronic respiratory failure.
The EMR continues to show R1 was sent to the local hospital on December 16, 2023, due to low blood
pressure and returned to the facility on December 19, 2023.
R1's MDS (Minimum Data Set) dated November 4, 2023, shows R1 has severe cognitive impairment, is
able to eat with setup or clean-up assistance, requires supervision for oral hygiene, and partial/moderate
assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder.
On December 17, 2023, at 8:00 AM, V6 (Agency RN/Registered Nurse) documented: Patient was sent to
hospital for hypotension, blood pressure was 66/44 (mmHg-Millimeters of Mercury), and pulse was 87.
On December 20, 2023, at 1:56 PM, V6 said, I worked the overnight shift on December 16. I started at 7:00
PM and worked until 7:30 AM the following day. I remember speaking to [R1's] contact person, but it was
later, possibly after midnight. It is possible that the contact person was called after [R1] left the facility which
was between 8:30 PM and 10:30 PM. There was a nurse who called off and we had a lot of patients. The
patient load was heavy. We had 30 people each to care for, and some other things happened at the
beginning of the shift. The night was all over the place. For the most part I try to call right away, but there
was a lot going on. I try to be timely about it. That would be the best practice.
On December 27, 2023, at 1:34 PM, V10 (R1's POA-Power of Attorney) said, I have an app on my
telephone with [R1's] medical information from the local hospital. It was around 10:15 PM at night on
December 16, and I received a notification to register [R1] at the hospital on my app. I live in another state,
and I was worried about what was going on because the hospital was saying he was in the ER (Emergency
Room), but I never heard a thing from the nursing home.
(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 8
Event ID:
145711
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
At 1:00 AM on December 17, I got a call from the facility and the gentleman said to me he was the nurse
who had been taking care of [R1] and wanted to tell me that [R1] had gone to the hospital because he had
low blood pressure. I had been told by the facility staff they were busy passing medications and did not
have a chance to call me.
The facility's policy entitled Notification for Change of Condition adopted December 3, 2016, and revised
12/27/23 shows: Policy Statement: The facility will provide care to residents and provide notification of
resident change in status. Procedures: 1. The facility must immediately inform the resident; consult with the
resident's physician; and if known, notify the resident's legal representative or an interested family member
when there is: .b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a
deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical
complications); c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of
treatment due to adverse consequences, or to commence a new form of treatment); or d. A decision to
transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii) as in the continued
presence of the resident poses a threat to the safety and health of the resident and other individuals in the
facility.
Event ID:
Facility ID:
145711
If continuation sheet
Page 2 of 8
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to hold care plan conferences with residents and their
representatives and failed to invite residents and their representatives to participate in the care planning
process.
This applies to 5 of 5 residents (R1, R3, R5, R7, and R8) reviewed for policy and procedures in the sample
of 8.
The findings include:
1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2020 with multiple
diagnoses including, aphasia following cerebral infarction, chronic kidney disease, myocardial infarction,
pulmonary embolism, hypertension, heart failure, atrial fibrillation, dementia, and chronic respiratory failure.
The EMR continues to show R1 was sent to the local hospital on December 16, 2023, due to low blood
pressure and returned to the facility on December 19, 2023.
R1's MDS (Minimum Data Set) dated November 4, 2023, shows R1 has severe cognitive impairment, is
able to eat with setup or clean-up assistance, requires supervision for oral hygiene, and partial/moderate
assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder.
R1 is not able to be interviewed due to his cognitive status.
On December 21, 2023, at 3:29 PM, V1 (Administrator) identified the facility providing the resident with a
baseline care plan on December 20, 2023, as a comprehensive care conference. V1 was unable to provide
documentation to show R1 and his representative were invited to attend a care plan conference. The facility
does not have documentation to show R1 or his representative were involved in the development of a
comprehensive care plan.
On December 20, 2023, at 3:23 PM, V9 (Clinical Care Coordinator) documented, Baseline care plan
presented at bedside. Call made to niece (POA) and went over medication list and baseline plan of care for
[R1] .
On December 27, 2023, at 1:34 PM, V10 (R1's POA-Power of Attorney) said, I was asked to attend a care
plan meeting three years ago when [R1] was admitted to the facility, and that was the last time we had that
type of meeting. Other than speaking to the wound care nurse about his care, I have not been to any care
plan conferences, or asked for input into [R1's] care planning.
2. The EMR shows R3 was admitted to the facility on [DATE]. The EMR continues to show R3's family
initiated a transfer for R3 to a different long-term care facility, and R3 was discharged to that facility on
December 8, 2023. R3 had multiple diagnoses including, metabolic encephalopathy, dementia, anemia,
history of breast cancer, unsteadiness on feet, lack of coordination, weakness, UTI (Urinary Tract Infection),
dehydration, major depressive disorder, idiopathic epilepsy, and bipolar disorder.
R3's MDS dated [DATE], shows R3 had moderate cognitive impairment, required supervision with eating
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145711
If continuation sheet
Page 3 of 8
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
and oral hygiene, and partial/moderate assistance with all other ADLs. R3 was always continent. R3's MDS
continues to show R3's preferred language was Albanian and wanted an interpreter to communicate with a
doctor or health care staff.
On November 7, 2023, at 8:41 AM, V8 (Clinical Care Coordinator) documented, Baseline care plan
provided to patient.
On December 20, 2023, at 2:53 PM, V1 (Administrator) said the facility did not have a care plan conference
with R3 and V12 (R3's POA). V1 continued to say V12 was frequently given updates by the therapy
department, but no formal care conference was held to discuss R3's goals of treatment or ongoing care. V1
said, Our social worker is on maternity leave currently. She left the end of November before Thanksgiving.
We did not have a care plan meeting for [R3].
On December 27, 2023, at 9:28 AM, V8 (Clinical Care Coordinator) said, I provided a baseline care plan to
[R3] the day after her admission to the facility. It was written in English. She spoke Albanian, but our care
plans do not print in any language other than English. I did not get an interpreter to explain the care plan to
her.
3. The EMR shows R5 was admitted to the facility on [DATE]. R5 has multiple diagnoses including
end-stage renal disease, major depressive disorder, anxiety disorder, anemia, heart failure, dependence on
renal dialysis, diabetes, hypertension.
R5's MDS dated [DATE], shows R5 has moderate cognitive impairment, is able to eat and perform oral
hygiene with set up help, requires supervision with bed mobility, partial/moderate assistance with toilet
hygiene and lower body dressing, and substantial/maximum assistance with all other ADLs. R5 is
occasionally incontinent of urine and always continent of stool.
On October 30, 2023, at 10:32 AM, V8 (Clinical Care Coordinator) documented: Baseline care plan
provided to patient.
On December 21, 2023, at 3:29 PM, when asked when R5's most recent care plan conference was held,
V1 (Administrator) said R5 was presented with a baseline care plan by the clinical care coordinator on
October 30, 2023. V1 was unable to provide documentation to show R5 and his representative were invited
to attend a care plan conference. The facility does not have documentation to show R5 or his representative
were involved in the development of a comprehensive care plan.
4. The EMR shows R7 was admitted to the facility on [DATE]. R7 has multiple diagnoses including,
spondylosis and myelopathy of the cervical region, insomnia, multiple pressure ulcers, diabetes, and
chronic kidney disease.
R7's MDS dated [DATE], shows R7 is cognitively intact.
On November 24, 2023, at 2:14 PM, V9 (Clinical Care Coordinator) documented, Baseline care plan
presented at bedside.
On December 21, 2023, at 3:29 PM, V1 (Administrator) identified the facility providing the resident with a
baseline care plan on December 20, 2023, as a comprehensive care conference. V1 was unable to provide
documentation to show R7 and his representative were invited to attend a care plan conference. The facility
does not have documentation to show R7 or his representative were involved in the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145711
If continuation sheet
Page 4 of 8
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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 0657
development of a comprehensive care plan.
Level of Harm - Minimal harm
or potential for actual harm
5. The EMR shows R8 was admitted to the facility in March 2019. R8 has multiple diagnoses including, cord
compression, cerebral infarction, pulmonary hypertension, major depressive disorder, heart failure,
dependence on oxygen, morbid obesity, functional quadriplegia, seizures, and hypertension.
Residents Affected - Some
R8's MDS dated [DATE], shows R8 is cognitively intact.
On December 21, 2023, at 3:29 PM, V1 (Administrator) said R8's most recent comprehensive care
conference was on June 14, 2023, when R8 was presented with a NOMNC (Notice of Medicare
Non-Coverage).
On June 15, 2023, at 9:51 AM, V13 (Social Worker) documented, Writer notified patient of NOMNC LCD
(Last Covered Day) 6/16 with appeal rights. He stated he does not wish to appeal at this time. NOMNC and
SNF (Skilled Nursing Facility) ABN (Advanced Beneficiary Notice) were completed and uploaded to
[electronic charting system]. Writer will continue to assist with case management.
The facility does not have documentation to show R8 and R8's representative were involved in
comprehensive care planning or attended care plan conferences.
On December 27, 2023, at 9:28 AM, V8 (Clinical Care Coordinator) said, For all new admission residents,
we give them their medication list and a baseline care plan printed out, the day after they are admitted to
the facility. These are not comprehensive care plans. We do not have a social services person right now.
There has been a lot of overturning of the Social Service Director and the last one we had only lasted for a
few weeks. We have not had a Social Service Director for at least a year, so we are not doing care plan
conferences with residents and their representatives.
On December 27, 2023, at 11:54 AM, V9 (Clinical Care Coordinator) said presenting the resident with a
copy of the baseline care plan the day after admission to the facility, or the day after readmission to the
facility from the hospital is not meant to replace a comprehensive care plan conference.
On December 27, 2023, at approximately 1:00 PM, V1 (Administrator) said the facility has not been having
care plan conferences with residents and their representatives.
The facility's Standardized admission Packet, revised January 2022 shows: Family and Resident
Participation in Care Plan Conferences: This facility conducts care planning conferences at regular intervals
in order to develop the interdisciplinary approach to the care that is delivered. Members of each
professional discipline attend care planning meetings and every aspect of care is addressed at these
meetings. Care plan meetings are utilized to discuss any changes in condition or developments related to
the Resident's well-being. This facility encourages the participation of both Residents and families in the
care planning process. In fact, participation by the Resident and family is considered to be vital to the staff
understanding the needs of the Resident and family. At a designated time prior to the care planning
conference, both the Resident and family/authorized representative will be informed of the time and place
of this scheduled meeting.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145711
If continuation sheet
Page 5 of 8
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow physician orders to weigh residents daily, and to
check systolic blood pressure readings prior to administering cardiac/blood pressure medications.
Residents Affected - Few
This applies to 3 of 3 residents (R1, R4, and R7) reviewed for improper nursing care in the sample of 8.
The findings include:
1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2020 with multiple
diagnoses including, aphasia following cerebral infarction, chronic kidney disease, myocardial infarction,
pulmonary embolism, hypertension, heart failure, atrial fibrillation, dementia, and chronic respiratory failure.
The EMR continues to show R1 was sent to the local hospital on December 16, 2023, due to low blood
pressure and returned to the facility on December 19, 2023.
R1's MDS (Minimum Data Set) dated November 4, 2023, shows R1 has severe cognitive impairment, is
able to eat with setup or clean-up assistance, requires supervision for oral hygiene, and partial/moderate
assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder.
R1's care plan initiated on August 23, 2021, shows R1 is at risk for cardiac complications related to
diagnosis of hypertension and hyperlipidemia. Interventions initiated on August 23, 2021, show: Give
antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and
increased heart rate and effectiveness. Weight will be maintained as ordered by MD.
R1's care plan, initiated January 10, 2023, shows: R1 is at risk for fluctuating weights. [R1] has the flowing
conditions and risk factors that puts him at risk for fluctuating weights: CHF (Congestive Heart Failure),
CKDIII (Chronic Kidney Disease Stage 3, and diuretic use. Interventions initiated January 10, 2023,
include: Monitor weights daily and Notify physician of weight changes.
The EMR shows the following order dated September 20, 2023, and discontinued on December 19, 2023:
Daily weight, Cardio patient, every day shift.
The facility does not have documentation to show R1's daily weight was obtained as ordered on December
1, 2, 3, 7, 8, 9, 10, 12, 13, 15, and 16, 2023.
The EMR shows the following order dated December 21, 2023: Daily weight, Cardio patient, everyday shift.
The facility does not have documentation to show R1's daily weight was obtained as ordered on December
23, 24, and 25, 2023.
The EMR shows the following order started September 21, 2023, at 9:00 PM and discontinued on
December 19, 2023: Entresto (cardiac medication) Oral Tablet 24-26 mg. (Milligrams). Give 0.5 tablet by
mouth two times a day for CHF. Hold for SBP (Systolic Blood Pressure) less than 90.
The facility does not have documentation to show the facility obtained R1's systolic blood pressure
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145711
If continuation sheet
Page 6 of 8
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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
readings prior to administering the medication as ordered on December 2, 3, 4, 5, 6, 7, 8, 13, and 14, 2023.
Level of Harm - Minimal harm
or potential for actual harm
On December 20, 2023, at 11:54 AM, V4 (ADON-Assistant Director of Nursing) reviewed the lack of
documentation for R1's blood pressures and weights. V4 confirmed the facility does not have
documentation to show R1's weights and blood pressure readings are being obtained as ordered and said
facility staff should follow physician orders to do daily weights and obtain R1's blood pressure reading prior
to administering his medications.
Residents Affected - Few
2. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including,
Covid-19, acute cough, fever, weakness, osteoporosis, persistent mood disorder, unsteadiness on feet, lack
of coordination, acute kidney failure, hypertension, Alzheimer's disease, insomnia, mood disorder, and
vascular dementia.
R4's MDS dated [DATE], shows R4 is cognitively intact, requires setup or clean-up assistance with eating
and oral hygiene, supervision with toilet and personal hygiene, and partial/moderate assistance with all
other ADLs. R4 has an indwelling urinary catheter and is occasionally incontinent of stool.
R4's care plan, initiated October 10, 2023, shows R4 is at risk for altered cardiovascular functioning related
to hypertension, hyperlipidemia, and coronary artery disease. Interventions initiated October 10, 2023,
include: Obtain labs and weights as ordered. Monitor vital signs as ordered. Report to MD for any changes.
The EMR shows the following order started October 12, 2023: Daily weight. Notify if greater than 2-pound
increase in 1 day or 5 pounds in 1 week, in the morning for on diuretic.
The facility does not have documentation to show the facility obtained daily weights for R4 on December 1,
2, 7, 9, 11, 12, 14, 15, 16, and 19, 2023.
The EMR shows the following order started November 23, 2023: Metoprolol Succinate (cardiac/blood
pressure medication) ER (Extended-Release) tablet 25 mg. Give 1 tablet by mouth one time a day. Hold if
SBP less than 100.
The facility does not have documentation to show the facility obtained R4's systolic blood pressure readings
prior to administering the medication, as ordered on December 1, 4, 5, 7, 8, 9, 15, 18, and 20, 2023.
3. The EMR shows R7 was admitted to the facility on [DATE]. R7 has multiple diagnoses including,
spondylosis and myelopathy of the cervical region, insomnia, multiple pressure ulcers, diabetes, and
chronic kidney disease.
R7's MDS dated [DATE], shows R7 is cognitively intact.
The EMR shows the following order for R7 started on October 31, 2023: Amlodipine Besylate Tablet 10 mg.
Give 1 tablet by mouth one time a day for hypertension. Hold for SBP < (less than) 100.
R7's care plan, initiated December 3, 2022, shows, [R7] is at risk for altered cardiovascular functioning
related to CAD (coronary artery disease), HTN (Hypertension). Interventions initiated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145711
If continuation sheet
Page 7 of 8
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
145711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Elmhurst
420 West Butterfield Road
Elmhurst, IL 60126
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
December 3, 2023 include: Administer medications as ordered. Monitor vital signs as ordered. Report to
MD for any changes.
The EMR shows the following order for R7 started on October 31, 2023: Lisinopril Oral Tablet 5 mg. Give 2
tablet by mouth one time a day for hypertension. Hold for SBP < 100.
Residents Affected - Few
The facility does not have documentation to show the facility obtained R7's systolic blood pressure readings
prior to administering the medication on December 1, 2023.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145711
If continuation sheet
Page 8 of 8
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
FAQ · About this visit
Common questions about this visit
What happened during the December 28, 2023 survey of BELLA TERRA ELMHURST?
This was a inspection survey of BELLA TERRA ELMHURST on December 28, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BELLA TERRA ELMHURST on December 28, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.