Inspection·September 4, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide feeding assistance to dependent residents. This failure applies to 2 of 7 (R8, R12) residents reviewed for activities of daily living. Findings Include: Residents Affected - Few 1. R12 is a is an [AGE] year-old female with diagnoses of history of Dementia, Major Depressive Disorder, Partial Paralysis due to Stroke, Dysphagia, Anemia, Seizures, and COPD who was admitted to the facility 01/19/2020. R12's Current Physician Orders include an active order effective 03/19/2024 for recommendation for one-to-one feeding assistance during all meals to ensure safety during oral intake per the most recent treatment course and active orders effective 10/22/2024 and 10/29/2024 for one-to-one feeding assistance with strict adherence to precautions. R12's current nutritional and dietary care plans initiated August 2021, July 2023, and March 2024 documents she requires a puree texture diet due to dysphagia; she is at risk for compromised nutritional status and unintended weight loss, related to diagnoses including Alzheimer's disease or related Dementia and Swallowing difficulties with interventions including: Monitor resident with difficulty of chewing or swallowing, assess for signs of choking and/or aspiration; and an intervention implemented 09/24/2024 of recommendation for 1:1 feeding assistance during all meals to ensure safety during oral intake per most recent treatment course. R12's current care plan-initiated March 2023 documents she has a self-care performance deficit in activities of daily living with interventions including requiring assistance with feeding. On September 02, 2025, at 12:51 PM, R12 was eating the pureed food with her bare hands. Direct care staff was not providing assistance to R12. On September 03, 2025, at 3:04 PM V2 (Director of Nursing) stated R12 requires one to one feeding assistance due to possible aspiration or choking while eating. The facility's General Care Policy states: “It is the facility's policy to provide care for every resident to meet their needs.” “Upon admission or readmission, the facility will evaluate the resident for physical needs. Physical needs would include but are not limited to ADL (Activities of Daily Living). “ “The facility will assist the resident to meet these needs.” (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: 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 09/04/2025 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)