Inspection·March 3, 2023

F 0658 Manufacturer instructions say to throw away all opened Novolog vials after 28 days, even if they still have insulin left in them. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 2 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to apply splint/rolled towel and heel protectors to prevent further decrease in range of motion. Residents Affected - Few This applies to 2 of 2 residents (R11 and R19) reviewed for range of motion in a sample of 22. The findings include: 1. On 02/28/23 at 11:03 AM, R11 was observed not wearing a hand splint, and did not have a rolled towel on left hand. R11's left hand was in a bent position and R11 was not able to open left hand. On 03/01/23 at 09:42 AM, R11 was observed with no hand splint and no rolled towel on left hand. On 03/02/23 10:59 AM, skin check done with V11 (Restorative Nurse). R11 was not wearing any splint or rolled towel on left hand. On 03/02/23 at 09:46 AM, interview with V11 (Restorative Nurse) stated R11 should have hand splint/ rolled towel on left hand. V11 stated R11 is on Restorative Program for splints. V11 stated R11's splints/rolled towel should be applied in the morning and taken off at bedtime. R11's Care Plan, dated 2/14/2023, shows he is on splint program with goal to be able to tolerate use of splints. May use rolled towel on days that R11 refuses to wear splint. 2. On 02/28/23 at 10:48 AM, R19 observed with right foot rotated towards the center of his body. R19 was not able to bring right foot to a neutral position. R19 was not wearing boots. On 03/01/23 at 09:45 AM, R19 had no heel boots on, and his right foot was rotated towards the center of his body. R19's Restorative Assessment, dated 11/9/2022, shows R19 with limited range of motion to left and right ankle and wears inflatable boots. On 03/02/23 at 09:46 AM, V11 (wound nurse) stated R11 should have hand splint or rolled towel on left hand. V11 stated restorative aides put the hand splints on but CNAs (Certified Nursing Assistant) are also educated on how to apply them. V11 stated all floor staff is responsible in verifying that splints, braces, rolled towel and boots are in place and kept in place. V11 stated R19 should always have boots on while he is in bed. V11 stated R19 is always in bed. On 03/02/23 at 12:01 PM, V2 (ADON-Assistant Director of Nursing) stated splints are applied by restorative CNAs and they are expected to communicate with floor staff that splints have been applied. Nurses, CNAs, and restorative aides are responsible to check and verify for splints, braces, rolled towel and heel protectors. V2 (ADON) stated splints, braces, rolled towels are used to improve functional capabilities and if not applied, can lead to contracture, worsening of contracture or deterioration of function. The facility's Restorative Nursing policy (revised 7/28/2022) showed .2. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. 3. Nursing and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 3 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0688 Restorative services may include .c. Contracture Prevention and Management . ii. Splint/Orthotic Management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 4 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R289 was admitted to the facility on [DATE] and is cognitively intact. Diagnoses includes, but is not limited to, cellulitis of the right lower limb, pseudomonas, lymphedema, and chronic lymphatic leukemia. Residents Affected - Few On 2/28/23 at 12:11 PM, R289 was noted with a PICC (Peripherally Inserted Central Catheter), dated 2/23/23, to his left upper arm. The dressing covering the PICC was soiled and lifted at the lower corners. On 3/1/23 at 2:15 PM, R289 was noted with the same soiled PICC dressing dated 2/23/23. The bottom edge of the PICC dressing had lifted off. R289 stated they don't do anything with his PICC. On 3/2/23 at 10:12 AM, V13, RN (Registered Nurse), stated she had not checked his PICC. The PICC dressing is changed by the night shift nurse on Wednesdays and as needed. On 3/3/23 at 9:43 AM, V15, NP (Nurse Practitioner), stated, PICC line dressings are changed weekly and as needed. If the dressing becomes dirty or the (occlusive dressing) is lifted the dressing should be changed. If it is dirty or no longer intact it sets up a risk for infection. The line can become compromised and impact the stability of the line causing it to be inadvertently pulled out if not secured. A line dressing left in place past the change date also poses an increased risk for infection. Physician order, dated 2/17/23, documents, change IV catheter dressing and cap with transparent dressing as needed and every night shift every Wednesday. Check site for signs and symptoms of infiltration, infection, drainage, irritation, and redness during infusion every shift. Facility policy Intravenous Therapy, revised date 7/28/22, states, It is the facility's policy to ensure that intravenous policy and procedure are compliant to federal standards of care. All central line dressing will be changed every 7 days and prn (as needed). Based on observation, interview, and record review, the facility failed to monitor and maintain PICC (Peripherally Inserted Central Catheter) line dressings that were dirty and not occlusive. This applies to 2 of 2 (R79, R289) residents reviewed for PICC lines in a total sample of 22. Findings include: 1. R79's face sheet documents diagnoses including compression fracture of the lumbar vertebra, sepsis, and osteomyelitis of vertebra. R79's MDS (Minimum Data Set), dated 2/2/2023, showed R79 was cognitively intact. R79 requires extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene. On 2/28/2023 at 9:57 AM, R79's PICC line dressing was not occlusive on R79's skin. R79's dressing was lifting 1 inch on the bottom right corner, and the tubing was observed to be exposed to air. R79's PICC line did not have a disinfection cap at the end of the needless connector. R79 said the PICC line dressing was last changed two weeks ago. On 3/2/2023 at 1:04 PM, R79 said, They've [staff] all seen it. Even (V12, LPN/Licensed Practical Nurse) asked me why they hadn't changed it when they saw (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 5 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0694 it coming off. Level of Harm - Minimal harm or potential for actual harm Multiple observations were made from 2/28/2023 through 3/2/2023 of R79's PICC line, and no disinfection cap was placed on the needless connector. Residents Affected - Few On 3/1/2023 at 11:04 AM, V2 (Assistant Director of Nursing/Interim Director of Nursing) observed R79's PICC line, and told R79 his PICC should have a disinfection cap on the end of the needless connector. On 3/1/2023 at 2:03 PM, V2 also said the PICC line dressing should be changed weekly and as needed. V2 said the dressing should be changed and stabilized if the dressing is lifting, saturated, skin irritation, and there are changes around the skin, as there is risk for movement and breaking of the catheter. V2 also said there should be a disinfection cap at the end of the PICC line to prevent infection. Record review of R79's TAR (Treatment Administration Record) documents the dressing was last changed on 2/15/2023. The TAR shows the dressing was due to be changed on 2/22/2023, but no treatment administration was documented. R79's progress notes were reviewed from 2/10/2023 to present, and no documentation of dressing change of the PICC line was found. R79's MAR (Medication Administration Record) shows R79 receives medication through the PICC line every eight hours. The facility's Intravenous Therapy policy, reviewed on 7/28/2022, documents It is the facility's policy to ensure that intravenous policy and procedure are compliant to federal standard of care and All central line dressing will be changed every 7 days and prn (As Needed). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 6 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 for pain management and assessment. This applies to 1 of 3 residents (386) reviewed for pain management in a sample of 22. Residents Affected - Few Finding includes: On 11/22/2022 at 11:08 AM, R386 indicated he wanted to take his Tylenol #3 medication for pain for three days since the admission to the facility on [DATE], and he has been asking staff, with no help. R386 said he has been taking Tylenol #3 for 30 years for his chronic pain. R386 said he was recently admitted to the hospital with severe abdominal pain before coming to the facility and received Tylenol #3 at the hospital also. R1 said he feels he has a 10 out of 10 pain rating (10 indicates highest pain) most of the time in his shoulder, back, and sometimes in his legs due to spinal stenosis of the back, kidney injury, and gallbladder stone-related conditions. On 03/01/2023 at 11:19 AM, R386 said he asked for Tylenol #3 at night and in the morning around 7:30 AM, and still didn't get it. R386 further said he also reported to V8 (Occupational Therapy Aide) and V9(Physical Therapy Aide) on 02/28/2023. On 03/02/2023, V7 (Certified Nursing Assistant) at 2:00 PM, and V9 (Physical Therapy Aide) at 11:45 AM, said R386 reported shoulder pain to them on 02/27/2023, and they reported it to the nurse for R386. V9 said R386 reported back pain on 02/28/2023, and they reported it to the nurse on duty. R386's admission Physician Order Sheet (POS), dated 02/25/2023, indicated R1 could have a Tylenol #3 tablet of 300-30 milligrams every 12 hours as needed for pain. A review of the narcotic binder sign out sheets on 02/28/2023 at 12:00 PM, indicated R386 did not have a sign out sheet for Tylenol #3. R1's Physician's Order sheet, dated 02/25/2023, shows diagnoses included acute cholecystitis, acute kidney injury, spinal stenosis of the lumbar region, and type 2 diabetes. R386's admission Minimum Data Set (MDS) in progress indicated R1 was cognitively moderately intact, and the admission care plan indicated evaluating pain and providing pain medication as ordered. On 02/28/2023 at 11:45 AM, V5 (Nurse from Agency) said she was unaware of the physician's order, and would call the pharmacy immediately. On 03/02/2023 at 12:00 PM, V6 (Licensed Practical Nurse) said she called the pharmacy on 02/25/2023. On 03/02/2023 at 12:50 PM, V10 (Pharmacy Director of Quality) said they don't have any call records of the facility calling for Tylenol #3 on 02/25/2023. They did receive a call on 02/28/2023 for a Tylenol #3 order for R386, and delivered the medication to the facility. On 03/02/2023 at 12:00 PM, V6(Licensed Practical Nurse) and V2 (Assistant Director of Nursing) said nurses should follow the physician's order, residents should be assessed for pain, and pain medication should be administered as ordered. A review of physician order revised policies, dated 07/28/2022, indicated in part, the facility shall ensure to follow physician order as it's written in the POS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 7 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that medications were secured. This applies to R49 and R289 reviewed for medication storage in a sample size of 22. 1. R289 was admitted to the facility on [DATE] per current Physician's Order Sheet, with diagnoses to include, but is not limited to, cellulitis of the right lower limb, pseudomonas, lymphedema, and chronic lymphatic leukemia. On 2/28/23 at 12:11 PM, a half- filled bottle of Cefuroxime 500mg, dated 12/09/22, was on top of R289's bedside table. On 3/2/23 at 9:50 AM, R289 was still in possession of the bottle of Cefuroxime. On 3/2/23 at 10:12 AM, V13, RN (Registered Nurse), stated R289 did not have an assessment to keep medications at his bedside. Residents are not typically allowed to keep their medications at the bedside. On 3/2/23 at 10:23 AM, V14, Nurse Consultant, stated there should not be any medications left at bedside. If a resident was going to have medications at the bedside, they would need an assessment and physicians order. On 3/2/23 at 1:05 PM, V14 stated R289 did not have an assessment to keep medication at the bedside. On 3/3/23 at 9:43 AM, V15, Nurse Practitioner, stated she had no knowledge of any resident at the facility being assessed to keep medications at the bedside. There is a potential for the resident to take something they shouldn't have or take much or not enough. Medications need to be listed by the pharmacy to determine if there is a negative drug interaction. Medications should be secured because a confused resident could wander into the room and take those medications by mistake. Review of R289 current physician orders (March 2023) does not list Cefuroxime. The facility policy Medication Storage, Labeling and Disposal policy, revised date 10/24/22, states federal it is facility's policy to comply with federal regulations in storage, labeling and disposal of medications. Medications will be stored safely under appropriate environmental controls. Medications will be secured in locked storage area. 2. R49's face sheet documents diagnoses including cerebral infarction, attention-deficit hyperactivity disorder, paranoid personality disorder, anxiety, obsessive compulsive disorder, depression, lupus, and seizures. On 2/28/2023 at 10:33 AM, R49's bedside table was observed to have (brand name) multivitamins. On 3/2/2023 at 9:51 AM, R49's bedside table was observed to have (brand name) multivitamins and irritable bowel syndrome therapy. R49's bedside table also had a medicine cup, and R49 said the nurse gave her the medications and she would be taking them after having food. According to R49, the medications were Aspirin, Potassium, Vitamin D, Calcium, and Cranberry. R49 said she had already taken her own (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 8 of 9 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 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supply of Vitamin D 5000 units, and will be throwing away the Vitamin D and another pill given to her by the nurse. R49 opened her bedside drawer and removed additional medications including coenzyme Q10 200 mg (Milligrams), Vitamin D3 5000 units, Acetyl L carnitine 1500 mg, Bio 360 probiotics, Dr. formulated probiotics 40 billion CFU (Colony Forming Unit), and gas relief simethicone 125 mg. On 3/2/2023 at 1:50 PM, V3 (LPN/Licensed Practical Nurse) said R49 takes her vitamins after her meals. V3 said she gives R49 the medications and then comes back after her meal to check if she takes them. V3 was not aware R49 had not taken all the medications given by V3. V3 said she was aware R49 had home medications at the bedside, but was unsure of what they were and what R49 was taking. V3 said she knew it was not appropriate for her to leave the medications in the room if the resident was not taking it, and it was not appropriate for her to take her home supply of medications without the doctor knowing. On 3/1/2023 at 2:03 PM, V2 (Assistant Director of Nursing/Interim Director of Nursing) said residents taking home medications should be assessed, educated, and care planned to have medications at the bedside. V2 said the doctor should be notified and are the ones to put an order in to have medications at the bedside and to self-administer. Record review of R49's POS (Physician Order Sheet) does not show an order for (brand name) multivitamins, irritable bowel syndrome therapy, coenzyme Q10 200 mg, Acetyl L carnitine 1500 mg, Bio 360 probiotics, and Dr. formulated probiotics 40 billion CFU (Colony Forming Unit). R49's POS shows an order for simethicone 80 mg tablet and vitamin D3 1000 units. R49 was taking simethicone 125 mg and vitamin D3 5000 units from her home supply of medications. R49's POS does not have an order in place for medications at the bedside and self-administration of medications. The facility was unable to provide documentation regarding R49's self-administration of medication assessment or care plan. The facility policy Medication Storage, Labeling and Disposal policy, revised date 10/24/22, states federal it is facility's policy to comply with federal regulations in storage, labeling and disposal of medications. Medications will be stored safely under appropriate environmental controls. Medications will be secured in locked storage area. The facility's Self-Administration of Medication policy, reviewed on 7/28/2022, documents, The IDT [Interdisciplinary Team] will assign a staff to evaluate resident's ability to safely administer medication. A Self-Administration Evaluation will be filled out to determine capability and the resident may store the medication at bedside if there is a physician order to keep it at bedside and The nurse on duty will document administration of medication in the MAR [Medication Administration Record]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 9 of 9