Health inspection·January 16, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's change of condition progress notes dated January 1, 2025 at 8:53 PM, created by V7 (Registered Nurse) showed in-part that the resident had, Positive blood culture gram positive cocci in both left and right arm cultures and elevated WBC 17.92. The progress notes documented that R1's vital signs included blood pressure of 88/42, pulse of 141, respiration of 16, temperature of 100.2 and oxygen saturation of 95%. The same progress notes showed under observations and evaluations, At [4:00 PM] writer assessed patient's vitals, BP 88/42, heart rate 141, [temperature] 100.4, [oxygen saturation] 98%. Patient was alert, stated she was not in any pain, did not display any signs or symptoms of pain. Writer received a call from [laboratory] reporting gram positive cocci in both left and right arm cultures and elevated WBC 17.92. Writer attempted to contact on call physician to relay laboratory results, left voicemail. Writer contacted infectious disease NP (V6). Per infectious disease NP send patient to [hospital] via [ambulance]. 911 not necessary resident stable, no signs of distress noted. On January 15, 2025 at 11:37 AM, V7 (Registered Nurse) stated that she was the assigned nurse to R1 on January 1, 2025 during the morning (7:00 AM-3:30 PM) and afternoon (3:00 PM -11:30 PM) shifts. V7 stated that on January 1, 2025 during the entire morning shift, R1 was doing well, took her medications and received therapy services. However, at around 4:00 PM, R1's condition changed, manifesting low blood pressure (88/42), increased heart rate (141) and high temperature (100.2), and then she received a call from the laboratory reporting gram positive cocci in both of R1's left and right arm blood cultures, as well as elevated WBC. According to V7, she attempted to call the physician to relay the laboratory results but was not successful, so she (V7) contacted V6 (Infectious Disease Nurse Practitioner). V7 stated that she informed V6 of R1's gram positive cocci blood culture, elevated WBC, and the abnormal vital signs, including low blood pressure, increased heart rate and high temperature. V7 stated that she received the order from V6 to send R1 to the emergency department for further evaluation and treatment. V7 stated that R1 waited between 45 minutes to an hour at the facility for the regular ambulance to transport her to the emergency department. V7 was asked, why 911 was not called to transport R1 to the hospital since the resident's blood pressure was low, her heart rate was high and with fever. V7 responded that she had consulted V17 (Registered Nurse/Afternoon Nursing Supervisor) whether to send R1 via 911 or regular ambulance and it was decided to use the regular ambulance since the resident was eating dinner with her daughter at the bedside. On January 15, 2025 at 11:59 AM, V6 (Infectious Disease Nurse Practitioner) stated that on January 1, 2025 she was informed by the Nurse (V7) that she was attempting to contact R1's physician but had not received any response, so she (V6) was contacted. V6 stated that she was informed of R1's trending high WBC of 17.92, hypotension (low blood pressure), increased confusion and gram positive cocci blood cultures. According to V6, that was the first time she was called/consulted regarding R1 and with the information provided to her by the nurse, she ordered to send R1 right away to the emergency department for further evaluation and treatment of the abnormal vital signs, severe leukocytosis, and possible sepsis due to bacteremia. V6 further stated that because of the presenting change in R1's condition, the appropriate and best method to transfer the resident to the hospital was via 911, especially with the abnormal vitals to immediately evaluate and treat the resident. On January 15, 2025, 2025 at 3:47 PM, V3 (Primary Care Physician) stated that when he evaluated R1 on December 28 and December 30, 2024, the resident was doing fine with stable vital signs. According to V3, he and the Nurse Practitioner were aware of R1's condition and the trending elevation of the resident's WBC, which was why blood cultures, urine culture and chest x-rays were also performed to help determine the resident's condition. V3 stated that he believed that R1's condition gradually changed on December 31, 2024, as reflected on the blood culture that was obtained that same day which showed positive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 2 of 3 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 01/16/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm staphylococcus aureus, however R1's change in condition did not manifest until January 1, 2025 when her vital signs became abnormal. According to V3, the facility should have sent R1 to the hospital via 911 on January 1, 2025 due to hypotension and increased heart rate. V3 further stated that sending R1 via 911 was the appropriate method to transport the resident to the hospital to ensure that the resident could be immediately evaluated and treated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 3 of 3