Health inspection·April 25, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow its policy to immediately consult with a resident's physician and notify a resident's representative when a resident had a change in condition requiring resident to be transferred to the hospital. This applies to 2 of 6 residents (R1 and R2) reviewed for change in condition. The finding includes: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including an encounter following surgery for a cardiac pacemaker, chronic atrial fibrillation, heart failure, pulmonary embolism, cerebrovascular disease, obstructive sleep apnea, and disorders of lungs. The EMR showed R2 was transferred to the hospital on 4/17/2024. R2's MDS (Minimum Data Set) dated 4/1/2024 shows R2 was cognitively intact and required staff assistance with her activities of daily living. On 4/24/2024 at 8:50 AM, V16 (Agency Registered Nurse/RN) stated she took care of R2 overnight on 4/16/2024. V16 stated R2 kept calling because she felt short of breath. V16 stated R2 was requesting oxygen, and she told R2 there was no order. V16 stated she checked R2's vital signs and told R2 she was not sure what was going on. V16 stated she tried to calm R2 and told her to try to sleep. V16 stated R2's daughter called at 7 AM on 4/17/2024 concerned. V16 stated she asked the incoming nurse V10 (Licensed Practical Nurse/LPN) to assess R2. On 4/23/2024 at 3:34 PM, V10 (LPN) stated on 4/17/2024 R2 told her she felt sick all night and she administered oxygen to R2 because she was short of breath. V10 stated R2 was then assessed by the NP (Nurse Practitioner) and was transferred to the hospital for shortness of breath. On 4/23/2024 at 2:07 PM, V12 (Nurse Practitioner/NP) stated she evaluated R2 on 4/17/2024 and gave orders for her to be transferred to the hospital because she was complaining of being short of breath and weak despite her diuretics recently being increased. V12 stated she would have expected the overnight nursing staff to have called the on-call physician or used the facility's telemedicine physician services to assess R2. The facility does not have documentation to show R2 was assessed overnight on 4/16/2024 by V16 (Agency RN) for shortness of breath nor a record of R2's oxygen saturation levels. R2's hospital records dated 4/17/2024 showed R2 was hospitalized for shortness of breath and (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 5 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 04/25/2024 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)