Inspection·March 14, 2024

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 grooming to a resident that is dependent on staff for care. Residents Affected - Few This applies to 1 of 3 residents (R40) reviewed for ADL (activities of daily living) care in the sample of 22. The findings include: R40's face sheet included diagnoses of hemiplegia, unspecified affecting right nondominant side, cerebrovascular disease, spinal stenosis, cervical region. R40's Quarterly MDS (minimum data set) dated December 13, 2023, showed that R40 was cognitively intact and was depended on staff for personal hygiene. On March 11, 2024, at 11:35 AM, R40 was lying in bed and noted to have fingernails that were very long (about an inch) with some of them jagged and with extensive blackish substance underneath nail beds. R40 also had extensive thick black color facial hair on entire lower chin that was also about an inch long. R40 stated that she would like to have her fingernails cut and cleaned and facial hair removed. R40's son (V7) who was present agreed with the same. V5 (Licensed Practical Nurse) and other staff were present right outside the room within hearing distance. On March 12, 2024, at 10:03 AM, R40 was lying in bed and stated that someone came in and cut her nails but wants her facial hair also removed. This was relayed to V5 who stated that R40 has a hormonal problem, and her facial hair grows fast, and she will ensure that the facial hair is removed. On March 13, 2024, at 9:45 AM, R40 was seen again lying in bed with facial hair still present and R40 remarked that she wanted it removed. This was relayed to V12 (Restorative Nurse). R40's care plan revised on December 1, 2023, showed that R40 requires assistance with ADLs including personal hygiene related to cervicalgia, spinal stenosis of cervical region with radiculopathy, CVA (cerebrovascular accident) with right hemiplegia. Goal for the same care plan with target date June 12, 2024, included that R40 will be assisted with ADLs as needed. On March 13, 2024, at 2:29 PM, V2 (Director of Nursing) stated that the CNAs (Certified Nursing Assistants) should cut and clean the nails of residents at least weekly during showers and remove facial hairs as it grows. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 2 of 11 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 03/14/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow manufacturer's instructions for a pressure relieving mattress. Residents Affected - Few This applies to 1 of 6 residents (R4) reviewed for pressure ulcers in the sample of 22. The findings include: R4's EMR (electronic medical records) included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture left hand, contracture right hand, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's Annual MDS (minimum data set) dated January 23, 2024, showed that R4 was severely impaired in cognition. Facility matrix showed that R4 has an acquired pressure ulcer stage 3. Wound evaluation dated March 4, 2024, also showed that R4 acquired an in-house pressure ulcer Stage 3 on left buttocks. R4's weights and vitals section in EMR showed that R4 was 116 pounds on March 4, 2024. On March 11, 2024, at 11:16 AM, R4 was lying in bed that had a pressure relieving mattress. The control knob was switched ON and had the label for Proactive Medical Products with weight dial set between 250-280 for weight in lbs. When asked, R4's nurse V6 (Licensed Practical Nurse) stated that she is not aware of what the settings should be. On March 12, 2024, at 9:55 AM, R4 was lying in bed with pressure relieving mattress control knob still showing the weight setting dial between 250-280 for weight in lbs. V4 (Infection Preventionist), who was in the hallway, was called to the room to enquire about the settings. V4 stated that she is not familiar with the same and will reach out to V3 (Wound Care Nurse). It was also confirmed with V4 that the Pressure relieving mattress setting was switched ON. On March 12, 2024, at 10:07 AM and 2:41 PM, V3 stated that the mattress setting should be by patient's weight and the manufactures recommendations. V3 added You don't want the mattress to be too firm to cause pressure on the bony prominence. V3 added that the initial set up is done by the Housekeepers and the Nurses are also encouraged to set it at the correct setting. Proactive medical products operation manual instructions of the mattress showed as follows: Step 6. Determine the patient's weight and set the control knob to the weight setting on the control unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 3 of 11 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 03/14/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to provide perineal and indwelling catheter care in a manner that would prevent urinary tract infection (UTI) and failed to ensure that an indwelling catheter is secured to the resident. This applies to 4 of 4 residents (R21, R63, R93, and R102) reviewed for catheter and bowel and bladder care in the sample of 22. The findings include: 1. On March 12, 2024, at 4:38 PM, V15 (Wound Care Nurse) provided wound care to R102. R102 had an indwelling urinary catheter. The catheter tube was not secured to R102, it was pulling whenever R102 turned or moved during wound care. 2. On March 13, 2024, at 10:45 AM, V16 (Certified Nursing Assistant/CNA) rendered peri-care to R21 who had an indwelling urinary catheter tube. V16 cleaned R21's pubic area, penis, and groins, however V16 did not clean the scrotum. V16 proceeded to clean the buttocks and rectum. After V16 cleaned the back perineum, she went back to the frontal perineum to clean the catheter tube while wearing the same soiled gloves. 3. On March 13, 2024, at 11:03 AM, V13 (CNA) rendered incontinence care to R63 who had a bowel movement. R63 had an indwelling urinary catheter tube. V13 cleaned R63's pubic area, groins, and wiped the outer labia. However, V13 did not separate the labia to clean the inner corners and she did not clean the urinary catheter tube. 4. On March 13, 2024, at 1:27 PM, V14 (CNA) rendered peri-care to R93. V14 cleaned R93's frontal perineum, outer labia, and groins. However, she did not separate the labia to clean the inner corners of the labia. On March 13, 2024, at 1:48 PM, V2 (Director of Nursing/DON) stated that when staff provides peri-care the staff must clean from front to back, and every part of the frontal and back perineum, including the inner areas of the perineum to prevent infection. In addition, V2 also stated that when a resident has a catheter, the catheter must be secured/anchored to prevent injury or trauma. Facility's Policy and Procedure for Incontinent and Perineal Care dated July 28, 2023, 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 condition. Facility's Policy and Procedure for Urinary Catheter Care dated July 28, 2023, shows: Policy Statement: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Steps in the Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 4 of 11 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 03/14/2024 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 0690 18. Secure catheter utilizing a leg band. Level of Harm - Minimal harm or potential for actual harm Facility's ADL and Incontinence Care Competency shows: a. Wash perineal area, wiping from front to back. Residents Affected - Some (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 5 of 11 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 03/14/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 provide lunch meal and assistance with feeding to a resident with weight loss. Residents Affected - Few This applies to 1 of 5 residents (R40) reviewed for nutrition in the sample of 22. The findings include: R40's EMR (electronic medical records) included diagnoses of hemiplegia, unspecified affecting right nondominant side, unspecified protein-calorie malnutrition, non-pressure chronic ulcer of other part of right lower leg with other specified severity, cervical disc disorder with radiculopathy, unspecified cervical region, and anorexia. R40's Quarterly Minimum Data Set, dated [DATE], showed that R40 was cognitively intact and required partial moderate assistance in eating. R40's diet order on EMR showed Regular diet, Regular texture, thin liquids consistency, 1:1 feeding assistance required. R40's care plan created August 30, 2023, included that R40 with compromised nutritional status due to diagnoses of hemiplegia, anorexia, and requires assistance with meals. Interventions included to provide/serve the resident's nutritional diet as ordered. Prescribed diet is Regular diet, Regular texture, thin liquids. On March 11, 2024, at 11:28 AM, R40 was lying in bed and stated I lost some weight since I have been here. My appetite was not good when I first came here. But it's picking up. I don't like all the food here. My son brings me food when he can get off work. R40's right hand appeared to have deformity of the thumb and index finger. R40 continued I need help to eat. My hands feel real hard. On March 12, 2024, at 9:38 AM, R40 was again seen lying in bed and stated that some of the weight loss is because often times the staff forget to bring her a tray or feed her. R40 stated that her son brings her food and feeds her if he can get off work and often times, he is unable to come. On March 12, 2024, starting around 12:30 PM, R40's hallway was served room trays including R40's roommate, but R40 did not receive a tray. R40 stated that she had given her meal choices to a V9 (CNA, Certified Nursing Assistant) the day before (March 11, 2024) when she (V9) had taken her meal order for March 12, 2024. On March 12, 2024, at 1:24 PM, V8 (CNA) was seen collecting trays from resident rooms in R40's wing after they finished eating and putting it on a mobile cart. V8 stated that all residents in the wing have been served their meal. When notified that R40 did not receive a tray, V8 stated that R40 must have not ordered a tray as her family brings her food. V8 then went into R40's room to confront R40 why she did not order a tray and R40 told her that she placed an order with V9 the day before. When V8 asked her if she wants a tray, R40 stated that she just called her son to bring her food as its past mealtime. When V8 (CNA) left the room, R40 remarked It's not the first time it's happened. Whether or not my son brings me food, I should still get a tray from here. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 6 of 11 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 03/14/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R40's weight history recorded EMR weights and vitals section included as follows: 99.6 lbs/pounds (March 4, 2024), 103.6 lbs (February 7, 2024) 99.6 lbs (January 10, 2024), 101.0 lbs (December 13, 2023), 105.6 lbs (November 15, 2023), 127.0 lbs (October 10, 2023), 130.0 lbs (August 29, 2023). V11's (RD/Registered Dietitian) quarterly progress note dated March 07,2024 Current weight of 99.6 lbs, BMI (Body Mass Index) 17.6, classified as underweight for age. Triggering wt (weight) loss -26.3% since 9/8 (September 10) wt of 135.2 lbs. Diet: Regular diet, regular texture, with thin liquids. No chewing or swallowing problems reported. According to EMR, appetite is poor, 25% consumption. Family member occasionally provide meals to patient. RD encouraged to order off the always-available menu when needed. Patient requires 1:1 feeding assistance during meals On March 13, 2024, at 1:45 PM, V11 stated that R40 has had times she refuses the food, however every single patient should always receive meal trays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 7 of 11 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 03/14/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy to attempt a gradual dose reduction for a resident on psychotropic medications. This applies to 1 of 5 residents (R14) reviewed for unnecessary medications in the sample of 22. The findings include: R14's EMR (Electronic Medical Record) showed R14 was 94 years-old and was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, anxiety disorder, insomnia, and chronic kidney disease. R14's MDS (Minimum Data Set) dated December 28, 2023, showed R14 had severe cognitive impairment. R14's Order Summary Report dated March 13, 2024, showed the following medications for R14: Alprazolam (anti-anxiety/sedative) oral tablet 1 mg (milligram), give one tablet by mouth at bedtime for anxiety, order started on December 7, 2022. Amitriptyline (antidepressant) oral tablet 25 mg, give 25 mg by mouth at bedtime for sleep, order started on December 9, 2022. Mirtazapine (antidepressant) tablet 15 mg, give one tablet by mouth at bedtime for depression, order started on November 22, 2022. R14's antidepressant medication care plan dated December 5, 2022, showed [R14] uses antidepressant medication (mirtazapine, amitriptyline). The care plan continued to show multiple interventions dated December 5, 2022, including Monitor/record occurrence of (sadness, agitation) target behaviors symptoms and document per facility policy. R14's anti-anxiety medication care plan dated December 5, 2022, showed [R14] uses anti-anxiety medications (alprazolam) related to anxiety disorder. The care plan continued to show multiple interventions dated December 5, 2022, including Monitor/record occurrence of [R14's] target behavior symptoms (agitation) and document per facility protocol. Multiple observations were made of R14 on March 11, 2024, March 12, 2024, and March 13, 2024, R14 was not observed having targeted behaviors of sadness, agitation, or anxiety. R14's Behavior Monitoring dated March 13, 2024, for the period of February 13, 2024, to March 13, 2024, showed R14 had no observed behaviors. On March 13, 2024, at 9:29 AM, V10 (Assistant Director of Nursing/Psychotropic Nurse) said she has been working as the psychotropic nurse since February 2023. V10 continued to say the facility has not received any recommendations for GDR (Gradual Dose Reduction) from pharmacy or the psychiatrist. V10 said from February 2023, to present, R14 was only seen by psychiatry on September 6, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 8 of 11 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 03/14/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm V10 provided all psychiatry notes for R14. The psychiatry notes showed R14 was visited by psychiatry providers on November 26, 2022, and September 6, 2023. The facility does not have documentation to show a GDR was attempted for R14's psychotropic medications in two quarters in the first year R14 was started on psychotropic medications. Residents Affected - Few The facility's policy titled Psychotropic Medications dated July 24, 2023, showed, Policy: It is the facility's policy to adhere to federal regulations in use of psychotropic medications. Procedure: . 5. Check that all antipsychotics and antidepressants have gradual dose reduction (GDR) within the first year or after initiation of initial dose in two quarters within the first year. If no reduction was done, there should be a psychiatric note why GDR is contraindicated specifically saying the GDR is contraindicated because it increased the target behavior or that the psychiatrist had documented the rationale that GDR is likely to impair resident's function and increase the distress behavior. Make sure that the GDR the there is an annual GDR after the first year. Check that hypnotics and sedatives are reduced quarterly unless clinically contraindicated. Same as above, the psychiatrist should indicate in the same way as antipsychotic why GDR is contraindicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 9 of 11 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 03/14/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of peri-care and wound care. Residents Affected - Some This applies to 4 of 22 residents (R21, R63, R93, R102) reviewed for infection control in the sample of 22. The findings include: 1. On March 12, 2024, at 4:26 PM, V15 (Wound Care Nurse) provided wound care to R102 who had Moisture Associated Skin Disorder (MASD) to abdomen and stage 3 pressure ulcer to sacrum. During the wound care procedure, V15 kept changing her gloves in between tasks without performing hand hygiene. 2. On March 13, 2024, at 10:45 AM, V16 (Certified Nursing Assistant/CNA) rendered peri-care to R21. V16 cleaned R21 from front to back to front, V16 applied clean incontinence brief and repositioned R21 while wearing the same soiled gloves. Afterwards, V21 changed her gloves without performing hand hygiene, and applied barrier cream. V16 proceeded to straighten R21's gown and bed linen while still wearing the same gloves. 3. On March 13, 2024, at 11:03 AM, V13 (CNA) rendered incontinence care to R63. Prior to rendering care, V13 carried the garbage bin near R63's bedside. V13 continued to set up cleaning items and clean incontinence brief, then V13 proceeded to render incontinence care while wearing the same gloves. V13 wiped R63's back perineum multiple times due to R63's bowel movement, she used peri-care solution in a spray bottle to clean R63. V13 helped to reposition R63 and placed a new incontinence brief underneath R63 while still wearing the same gloves. Then V13 removed her soiled gloves and washed hands after the procedure. V13 donned a new set of gloves, she proceeded to apply barrier cream to R63's front and back perineum, closed the incontinence brief, straightened the gown, placed pillows underneath the legs and arms, adjusted the bed position, and straightened the linen while wearing the same gloves. V13 did not wash or sanitized the spray bottle she used (used/touched with fecal soiled gloves) for peri-care and kept it at R63's bedside. 4. According from V2 (Director of Nursing/DON) and from observation of the PPE (personal protective equipment) set-up, R93 was on isolation for C. Diff (clostridium difficile). On March 13, 2024, at 1:27 PM, V14 (CNA) rendered peri-care to R93. V14 cleaned R93 from front to back and changed gloves without performing hand hygiene. V14 turned R93 on her back and applied barrier cream on the frontal perineum. V14 closed the incontinence brief, changed gloves without performing hand hygiene, and continued to straighten R93's gown and bed linen. Facility's Hand Hygiene Policy and Procedure with revision date of July 28, 2023, 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 Guidelines in regards to hand hygiene. Procedures: Hand Hygiene using alcohol-based hand rub is recommended during the following situations: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 10 of 11 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 03/14/2024 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 0880 g. Before moving from work on soiled body site to a clean body site on the same resident. Level of Harm - Minimal harm or potential for actual harm h. After contact with blood, body fluids or surfaces contaminated with blood and body fluids. i. After removing gloves including during wound care. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145711 If continuation sheet Page 11 of 11