Inspection·June 30, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 6 (R1) residents reviewed for abuse in the sample of 12. The findings include: The facility's Final Abuse Report dated 6/15/23 documents on 6/10/23 (R1) reported to V13 (Nurse Supervisor) that he was involved in a resident-to resident altercation with (R2). (R1) was noted with an abrasion above his upper lip. (R2) is alert and oriented to self, confused with diagnosis of dementia, delusion disorder and anxiety. (R2) has poor judgement and decision-making skills .(R2) was sent out for further evaluation. R1's Minimum Data Set assessment dated [DATE] shows he's cognitively intact. R1's nurse's note dated 6/10/23 documents, notified by (V13) (R1) had an altercation with another resident (R2) that resulted in (R1) bleeding in the upper lip. On 6/30/23 at 9:10 AM, R1 was observed in his room. He said on 6/10/23, R2 was wandering into another resident's room. I told him he was not supposed to be in there. I held on to his wheelchair and started wheeling him out and that's when he hit me in the face by my lip and drew blood. I told him to stop, and I did not engage back. He attacked me. R9 was there and saw what happened. I reported the incident to V13. R2 has been physical before, and he wanders into other resident's room. On 6/30/23 at 9:27 AM, R9 said (R2) was in another resident's room going thru all his things. R1 went in the room to get him out of there. R1 held onto R2's wheelchair handles and started getting him out of the room and that's when R2 hit R1 in the face by his mouth. I saw it happen. R2 doesn't speak English and he wanders into other resident rooms and has been physical with other residents. On 6/30/23 at 12:34 PM, V13 (Nurse Supervisor) said she was alerted of the incident with R1 and R2. She said R1 reported R2 hit him the face. He was trying to get R2 out of another resident's room. R1 had an abrasion to the top of his lip. After the incident R2 was very agitated, he was pointing his finger at R1. R2 was sent out for his behaviors, he was a history of physical abuse towards others. Staff should be monitoring him. She spoke with R9 who saw the incident and he told me the same thing. R2 hit R1 in the face. R2 hit R1 purposely. R2's face sheet shows he is a [AGE] year-old male with polish as his primary language. His diagnosis include hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant (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 3 Event ID: 145835 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 145835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Wheeling 730 West Hintz Road Wheeling, IL 60090 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)