Inspection·March 28, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R46's 10/30/24 SBAR showed that on 10/30/24 R46's was transferred to the hospital and the form showed under Bed hold policy, b. prior to hospital transfer, the facility's Bedhold policy was not given to the resident and/or representative. On 03/26/25 at 03:53 PM V1 (Administrator) said that the facility does not notify the Ombudsman if they send a resident out for medical reasons. V1 said that the facility is not giving written notice of the reason for transfer to the residents and the family representatives. On 03/27/25 at 12:55 PM V2 ADON (Assistant Director of Nursing) said that the facility did not know that they were to notify the ombudsman of hospital transfers. Based on interview and record review, the facility failed to provide to a resident and/or their representative in writing for the reason of transfers to the hospital, and failed to notify the ombudsman of the transfers. This applies to 4 of 4 residents (R4, R46, R70, and R75) reviewed for discharge in a sample of 24. The findings include: 1. R4's Face Sheet showed R4 was admitted to the facility on [DATE]. R4 had multiple diagnoses which included moderate protein-calorie malnutrition, osteomyelitis of vertebra, Alzheimer's Disease, chronic kidney disease, and adult failure to thrive. R4's MDS (Minimum Data Set) dated 03/10/25 showed R4 was cognitively impaired. R4's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form dated 02/22/25 showed R4 had a change in condition with delayed response and an elevated heart rate. The same form showed R4 was transferred to the hospital via emergency medical transport on 02/22/25. The form showed written notice for reason of transfer was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and notification of the ombudsman. 2. R70's Face Sheet showed R70 was admitted to the facility on [DATE]. R70 had multiple diagnoses which included heart failure, dysphagia, asthma, anemia, depression, hypertension, and atrial fibrillation. R70's MDS dated [DATE] showed R70 had moderate cognitive impairment. R70's Change in Condition with SBAR Form dated 08/13/24 showed R70 had a change in condition with dizziness. The same form showed R70 was transferred to the hospital. The form showed written notice for reason of transfer was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 2 of 12 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 03/28/2025 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 0623 the reason for transfer to the hospital and notification of the ombudsman. Level of Harm - Minimal harm or potential for actual harm 3. R75's Face Sheet showed R75 was admitted to the facility on [DATE]. R75 had multiple diagnoses which included acute on chronic diastolic (congestive) heart failure, restlessness and agitation, hypertension, and asthma. R75's MDS dated [DATE] showed R75 had moderate cognitive impairment. Residents Affected - Some R75's progress notes dated 11/02/24 at 2:08 AM, At 1:20 AM, the nurse heard resident asking for help. The nurse entered the room and observed R75 sitting at the edge of the bed. He stated, I'm having a hard time breathing. The nurse started immediately obtaining his vitals. Spo2 (oxygen) was 77. 911 was called. Will call the hospital to obtain an admitting diagnosis. 11/02/24 at 2:25 AM, admitted to (Hospital) per nurse. Admitting dx (diagnosis) of hypertension. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and notification of the ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 3 of 12 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 03/28/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or their representative of the facility bed hold policy in writing. This applies to 1 of 1 resident (R75) reviewed for discharge in a sample of 24. The findings include: R75's Face Sheet showed R75 was admitted to the facility on [DATE]. R75 had multiple diagnoses which included acute chronic diastolic (congestive) heart failure, restlessness and agitation, hypertension, and asthma. R75's MDS (Minimum Data Set) dated 03/16/25 showed R75 had moderate cognitive impairment. R75's progress notes dated 11/02/24 at 2:08 AM, showed At 1:20 AM, the nurse heard resident asking for help. The nurse entered the room and observed R75 sitting at the edge of the bed. He stated, I'm having a hard time breathing. The nurse started immediately obtaining his vitals. Spo2 (oxygen) was 77. 911 was called. Will call the hospital to obtain an admitting diagnosis. 11/02/24 at 2:25 AM, admitted to (Hospital) per nurse. Admitting dx (diagnosis) of hypertension. No documentation for bed hold policy given to resident and/or their representative uploaded into the medical record. The facility was unable to provide documentation of bed hold policy given to the resident and/or the representative. On 03/27/25 at 11:39 AM, V1 (Administrator) stated a bed hold policy should have been given to R75 and or his representative. The facility's Bed Hold and readmission Policy (revised 07/26/24) showed: Procedures 1. The facility must inform the resident or family members being transferred of the duration of bed hold in writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 4 of 12 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 03/28/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct required care plan meetings and invite residents to participate in their care plan meetings. This applies to 4 of 4 residents (R20, R32, R69 and R79) reviewed for care planning in a sample of 24. Findings include: 1. R32's MDS (Minimum Data Set) dated 2/12/23 shows he is cognitively intact. On 03/25/25 at 11:45 AM, R32 stated he did not know what a care plan meeting was and had never been invited to one and feels the doctors make changes to his medications without discussing it with him. No documentation for care plan meetings were noted in R32's EMR. The facility was unable to provide any care plan meeting documentation for R32 for the past year. 2. R69's MDS dated [DATE] shows he is cognitively intact. On 03/25/25 at 10:40 AM, R69 stated he had been in the facility over two years and has never been invited to a care plan meeting. The only care plan documentation in the EMR able to be provided by the facility for R69 is dated 11/13/24. The only attendees documented were social services and R69's POA (Power of Attorney). 3. R79's MDS dated [DATE] shows he is cognitively intact. On 03/25/25 at 10:40 AM, R79 stated he had not been invited to a care plan meeting and most all of his family lived out of state. Documentation in the EMR and provided by the facility for R79 was dated 12/5/24. The attendees documented were social services, therapy, nursing administration, and a sister and brother-in-law. 4. R20's MDS dated [DATE] shows he has moderate cognitive impairment. No documentation for care plan meetings were noted in R20's EMR (Electronic Medical Record). No documentation of care plan meetings for R20 was received from the facility for the last year. On 03/27/25 at 11:59 AM, V20 Social Services Director stated care plan meetings are to be held quarterly. Residents are supposed to be invited to their care plan meetings. V20 stated she did not have any documentation of R20, R32, R69 or R79 being invited to their care plan meetings. V20 stated there is no sign in sheet listing care plan meeting attendees. V20 stated social services is responsible for setting up care plan meetings. V20 stated she is responsible for over seeing the social services department to assure assignments have been completed. V20 stated residents should be invited to their care plan meetings so they are aware of their care and the facility can address any concerns they may have. The facility wants to assure residents needs are being met while they are in the facility. V20 stated, R20, R32, R69, and R79 are able to be active participants in their care planning. The facility policy Care Plan dated 7/26/24 states it is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 5 of 12 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 03/28/2025 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 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 2. On 03/25/25 at 11:12 AM R14's nails were long, jagged, and with a brown substance under the nails. R14 said that her nails bothered her, and she wanted the staff to provide nail care for her. Residents Affected - Few R14's 3/1/25 electronic health record shows that R14 needs substantial/maximal assistance from the staff for personal hygiene. 3. On 03/25/25 at 12:27 PM R46 nails were long, jagged and with a brown substance under the nails, and the right thumb nail was curling on top of the thumb. R46's 2/13/25 electronic health record showed that his cognition is severely impaired, and he is dependent on staff for personal hygiene. On 03/27/25 at 12:52 PM V2 ADON (Assistant Director of Nursing) said that it is her expectation that staff provide ADL care for the residents including hand hygiene and trimming nails for safety and hygiene. The facility's General Care policy with a revised date of 7/30/24 showed that the facility's policy is to provide care for every resident to meet their needs including ADL needs. Based on observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents who require assistance to maintain their cleanliness and comfort. This applies to 3 of 5 residents (R14, R46 and R395) reviewed for ADLs in a sample of 24. Findings include: 1. On 03/25/25 at 11:45 AM, R395 stated he has not been washed up since he entered the facility on 3/21/25. R395 stated he gets sweaty, and his gown sticks to his skin. R395 had a full-face beard. R395 stated he is not a beard guy. R395 stated he is itchy and uncomfortable with the facial hair. R395 stated he has asked staff for assistance, but they have not shared their names and when staff comes in his room, he feels like he is bothering them. On 03/27/25 at 09:13 AM, R395 still had a full beard and smelled of body odor. On 03/27/25 at 10:06 AM, V19 CNA (Certified Nursing Assistant) stated he did not know he was assigned to R395. V19 stated he was working a double shift, but the current shift started at 7am. V19 stated he needed to check the assignment board at the desk. V19 stated he needed to look to see when R395's shower day was scheduled. V19 stated he did not know how R395 transfers and he only gets residents out of the bed and offer care assistance if they ask. V19 CNA stated R395 would be bathed if he had time after assisting the other residents scheduled to shower. On 03/27/25 at 02:00 PM, V2 ADON (Assistant Director of Nursing) stated, the CNAs are responsible for bathing and shaving residents. The CNAs should know which residents are on their assignment list. V2 stated residents should be made aware of who their caregivers are. V2 stated residents are showered or bathed twice per week unless they request it more frequently. V2 stated CNAs should offer care assistance and to get residents up every day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 6 of 12 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 03/28/2025 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 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 Based on observation, interview, and record review, the facility failed to ensure a resident's IV (intravenous) antibiotic therapy bag was labeled. Residents Affected - Some This applies to 1 of 1 resident (R81) reviewed for IV's in sample of 24. The findings include: On 3/25/25 at 10:18 AM, during initial tour, R81 was lying in bed. There was an IV pump toward the right side of R81's bed. There was an empty IV bag of Ceftriaxone without any label that included the date and time by the nurse. R81 stated that she is taking this antibiotic because she has an abscess in her liver. On 3/25/25 at 2:43 PM, R81's morning nurse was V4 (RN-Registered Nurse). She stated that the IV antibiotic was infused over the night shift at 6:00 AM by V5 (RN). V4 stated, The IV bag should have been labeled with the date, time, flow rate, and room number. On 3/27/25 at 10:24 AM, V2 (ADON-Assistant Director of Nursing) stated, The nurses need to make sure all information related to the antibiotic is on the IV bag. This includes the patient's name, what medication it is, when they started the medication, the rate, and start time. They should check the vitals before administration. They then should initial, add the time, and date it. R81's face sheet shows diagnoses of Escherichia Coli (E. Coli) as the cause of diseases, hepatomegaly, and secondary malignant neoplasm of bone. Review of R81's POS (Physician Order Sheet) for March 2025 shows an order dated 3/04/25 for Ceftriaxone 2 GM (Grams) IV with directions to use 1 dose intravenously in the morning for abdominal infection. R81's EMAR (Electronic Medication Administration Record) shows that the medication was last administered around 6 AM by V5. The facility was unable to provide an IV therapy policy that included the labeling of IV bags. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 7 of 12 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 03/28/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 9. On 03/25/25 10:22 AM, during initial tour, surveyor went to R81's room. R81 was lying in bed. There was a mediation cup with 5 chewable tablets of Tums on her bedside table. R81 stated, This is my Tums. The nurse always leaves it here for me to take it whenever I want it. R81's POS (Physician Order Sheet) for March 2025 shows an order for Calcium-Carb-Cholecalciferol Oral Tablet Chewable 500-10 MG-MCG (Milligrams-Micrograms) with instructions to Give 2 tablets by mouth one time a day for supplement. 5. On 03/25/25 at 12:17 PM, observed Nystatin cream and Lubricant Eye Drops on R8's bedside drawer. R8 stated, she used the nystatin cream for the redness under her breast and the eye drops when she felt that her eyes are dry. On 03/27/25 at 11:53 AM, R8 still had the Lubricant Eye Drops on her drawer. On 3/27/25 at 1:02 PM, R8's Physician Orders were reviewed for March 2025. It showed Nystatin External Cream, apply to groin, abdominal fold and breast topically as needed for redness. R8's Physician orders did not include any orders for the Lubricant eye drops. 6. On 3/25/25 at 10:52 AM, observed a few tabs of large colorful pills in a cup on R247's bedside table. R247 stated, they are tums and she takes them for nausea because her IV (intravenous) antibiotic makes her nauseous. R247 stated, she had a whole bottle and she pulled out a bottle of tums from her drawer, almost full. On 03/26/25 at 09:53 AM, R247 still had the bottle of tums in her drawer, and on 03/27/25 at 10:55 AM, R247 had the bottle of tums in her drawer. On 3/27/25 at 1:07 PM, R247's Physician Orders were reviewed for March 2025. R247's Physician orders did not include any orders for Tums. On 03/27/25 at 12:05 PM, V6 (LPN-Licensed Practical Nurse) stated, residents should not have any medications at the bedside. 7. On 03/25/25 at 10:57 AM in R5's bathroom there was one 1oz open tube of hydrocortisone cream 1%, one 2.11oz opened tube of hydrocortisone cream 1%, and one 2.11oz opened tube of Zinc Oxide ointment 20 %. R5 said that she uses the creams under her breast. R5's electronic health records showed a physician's order for 11/07/22 for Zinc oxide 20% apply to under let breast topically every 12 hours as needed. On 03/27/25 at 12:28 PM V2 ADON (Assistant Director of Nursing) said that no medications should be in residents' bathrooms for safety and hygiene reasons. 8. On 03/25/25 at 10:39 AM on R35's overbed side table there was 1 Albuterol Sulfate HFA inhaler and 1 fluticasone propionate (Nasal spray). R35's electronic health record showed a physician's order dated 1/13/25 for Albuterol Sulfate HFA every 4 hours as needed and an order for Fluticasone Propionate nasal spray with a start date of 3/24/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 8 of 12 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 03/28/2025 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 0761 On 03/27/25 at 12:32 PM V2 ADON said that medications need to be locked and secured. Level of Harm - Minimal harm or potential for actual harm The facility's Medication Storage, Labeling and Disposal policy dated 8/16/24 showed that medications will be secured in locked storage area. Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure medications are labeled and stored securely. This applies to 8 of 8 residents (R5, R8, R19, R35, R81, R101, R102 and R247) reviewed for medication storage in a sample of 24. 1. On 03/27/25 at 12:51 PM, a first-floor medication cart was reviewed with V10 LPN (Licensed Practical Nurse). The hydrocodone- acetaminophen 5/325 mg (Milligram) medication card for R101 had one tablet blister that had been taped closed. The medication card had a count of 30 tablets. R101's current physician orders include hydrocodone- acetaminophen 5/325 mg one tablet every four hours as needed for pain. V10 LPN stated once the blister is opened it should be wasted not taped back, but she was not sure why it should not be taped. V10 stated she was one of the nurses that did the narcotic count for that cart, but she did not look at the back of the medication cards when she did the count. 2. On 03/27/25 at 12:51 PM, the pregabalin 25 mg medication card for R102 one tablet blister that had been taped closed. The medication card had a count of 7 capsules. R102's current physician orders include pregabalin 25mg give one capsule by mouth every 24 hours for neuropathy at bedtime. 3.On 03/27/25 at 12:51 PM, the lorazepam 1mg medication card for R247 had one tablet blister that had been taped closed. The mediation card had a count of 22 capsules. R247's current physician orders include lorazepam 1mg give one tablet two times per day for anxiety. 4.On 03/27/25 at 01:08 PM, a second-floor medication cart was reviewed with V22 LPN. An insulin aspart flex pen did not have a label with resident's name, open on or use by dates. V22 stated the insulin pen belonged to R247. V22 stated she was not sure how long the pen is good for after it is opened. R247's MAR (Medication Administration Record) shows she receives 7 units of insulin aspart three times per day at 9am, 12pm and 5 pm. On 03/27/25 at 02:00 PM, V2 ADON (Assistant Director of Nursing) stated narcotics should not be taped to assure accuracy and safety assuring the mediation isn't contaminated or misappropriated. If medications are opened and not administered, they should be wasted, and the waste witnessed by two nurses. Insulins should be labeled with the resident's name, an opened on and use by date. Each pen should be stored in an individual bag. The facility policy Controlled Substances dated 8/16/24 states when a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason is not placed back in the container. It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The facility policy Medication Storage, Labeling and Disposal dated 8/16/24 states mediations from pharmacy will be labelled by the pharmacy to include the name of resident, route of administration, instruction, medication name, strength and expiration date when applicable. The facility did not provide a policy specific to insulins. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 9 of 12 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 03/28/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 6. On 3/26/25 at 8:30 AM, soiled linen and a used resident gown were seen on the floor in R72's room. Residents Affected - Some On 3/26/25 at 8:35 AM, V10 (LPN-Licensed Practical Nurse) stated R72 was discharged the previous day and the room was not cleaned yet. V10 (LPN) stated, for infection control reasons, soiled linen should not be left on the floor. On 3/27/25 at 10:29 AM, V2 (ADON-Assistant Director of Nursing) stated, for infection control reasons, soiled linen should not be left on the floor and that it should be bagged and sent to the laundry. Based on observations, interviews, and record reviews, the facility failed to implement infection control measures while providing resident care and with the handling of soiled linen. This applies to 6 out of 7 residents (R3, R6, R47, R77, R15, R72) reviewed for infection control in a sample of 24. The findings include: 1. On 03/25/25 at 01:08 PM during lunch service, V13 (Nurse) wiped food off R3's mouth with her right hand and then uses the same right hand and puts a spoonful of food into R47's mouth. V13 did not clean her hands after wiping R3's mouth. From 01:08 PM - 01:23 PM V13 was observed using both her right and left hand to assist R3 and R47 with eating their lunch. Both R3 and R47 were sitting at the same table and V13 never cleaned her hands between each resident for the entire meal. V13 used her left hand to give R3 a drink and then V13 used her right hand to touch R47's hand to stop her from putting a bite of food into her mouth, then went back to feeding R3 with her right hand. On 03/27/25 at 01:00 PM V2 ADON (Assistant Director of Nursing) said that V13 should have cleaned her hands while feeding the residents for infection control. 2. On 03/26/25 at 12:11 PM V26 CNA (Certified Nurse's Assistant) was providing incontinence care for R6. V25 (Wound Nurse) was present. V26 wiped R6 buttocks that had stool on it, then V26 did not clean her hands and continued with putting on a new brief on R6, repositioned R6, adjusted R6's bed linen and touched the bedrails with her dirty gloved hands. On 03/26/25 at 12:15 PM V26 said that she should have washed her hands after cleaning R6 buttocks for infection control. At 12:18 PM, V25 said that she saw that V26 did not clean her hands after wiping R6 buttocks and she should have for infection control. On 03/27/25 at 12:41 PM, V2 ADON (Assistant Director of Nursing) said that the staff should have cleaned her hands after touching the resident's buttocks before doing anything else for infection control. 3. On 03/25/25 at 11:50 AM V12 CNA (Certified Nurse's Assistant) was providing incontinence care for R77 without wearing a gown. Outside of R77's door showed a sign EBP (Enhanced Barrier Precaution). V12 with a wet washcloth wiped V12 perineal area several times and then wiped R77's buttocks with the same washcloth and she did not fold the cloth before moving to a different area. Then V12 removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 10 of 12 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 03/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm R77's soiled brief and touched the curtain with her dirty gloved hands as she put the soiled brief in the garbage. V12 then applied new gloves, did not clean her hands first and then applied barrier cream to R77's buttocks and attached a new brief with the same dirty gloves. V12 with the same dirty gloves then moved R77's over the bedside table before removing her gloves and cleaning her hands. At 11:56 AM V12 said that she should have cleaned her hands, and she should have worn a gown. Residents Affected - Some R77's electronic health records showed that R77 has diagnoses including a stage 4 pressure ulcer of the sacral region. On 03/27/25 at 12:45 PM V2 (ADON) said that the staff should use a clean side of the washcloth with new area for infection control. V2 said that the staff should have worn a gown and staff should have changed her gloves and performed hand hygiene before touching any objects to prevent the spread of infections. The facility's infection Prevention Control policy dated 2/10/25 showed that when a resident is on EBP the staff is to use gloves and gowns during high contact resident care activities for residents infected or colonized with MDRO's as well as residents with wounds and or indwelling medical devices. The policy showed that the staff and contracted workers will perform hand hygiene before and after direct patient contact and after each situation that necessitates hand hygiene. The facility's Enhanced Barrier Precaution policy dated 7/26/24 showed the facility uses enhanced barrier precautions to reduce transmission of multi drug resistant organisms in the nursing home. The policy shows that EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wounds and or indwelling medical devices. The facility's Hand Hygiene policy dated 7/30/24 showed that hand hygiene is important in controlling infections. The policy showed that the facility will comply with the CDC guidelines regarding hand hygiene. Hand hygiene will be done during the following situations before and after direct contact with residents, before and after performing aseptic task, before and after assisting a resident with meals, before and after assisting a resident with toileting, before moving from one soiled body site to a clean body site on the same resident, after contact with blood, body fluids. or surfaces contaminated with blood and body fluids and after removing gloves, including during wound dressing change. 4. R15 admitted to the facility o 10/10/18. R15's current care plan includes impairment to skin integrity to bilateral buttocks (Kennedy terminal ulcers). On 03/25/25 10:58 AM, R15 in enhanced barrier precautions received assistance from V15 LPN (Licensed Practical Nurse), V16 LPN and V17 RN (Registered Nurse) to be repositioned in the bed. V15, V16 and V17 did not put on isolation gown before providing care to R15 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 11 of 12 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 03/28/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to offer staff the Covid-19 immunization vaccine and have written documentation of it. Residents Affected - Many This applies to all 97 residents in the facility reviewed for immunizations in the sample of 24. The findings include: The CMS (The Centers for Medicare and Medicaid Services) form 671 titled Long-Term Care Facility Application for Medicare and Medicaid dated 3/25/25 shows the facility has a census of 97 residents. On 3/26/25 at 2:02 PM, V3 (LPN-Licensed Practical Nurse/Infection Preventionist) stated, I don't have the documentation that shows where I offered the vaccine to staff. Now, our corporate changed their policy. The Covid vaccines are not free anymore. The staff must use their own insurance, so we tell them that they can get the Covid-19 vaccines from clinics or pharmacies that accept their insurance. We don't offer it to them, but they can ask us to give it to them if they have insurance. V3's infection control binders did not have any documentation that staff were educated regarding the benefits and potential side effects of the Covid-19 vaccine. Neither did she have any documentation that staff accepted and received the vaccine. She had nothing to show the vaccination status of staff. Facility's policy titled Covid 19 Vaccination Policy (7/16/24) shows: The facility will comply with the applicable CMS, CDC (Centers for Disease Control and Prevention), and/or IDPH (Illinois Department of Public Health guidance on Covid-19 vaccination. As CMS had rescinded the mandatory Covid 19 vaccine requirement for staff and resident, the facility will continue to promote and provide Covid-19 vaccination whenever the vaccine is available, and individuals consent to Covid vaccination. Staff may obtain Covid 19 vaccine from clinics and pharmacies that offer the vaccines, as billing is now through staff insurance. If the facility pharmacy is able to bill staff's insurance, the staff may get Covid 19 vaccination in house, as long as the staff consent to it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 12 of 12