Inspection·August 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm the morning shift but I was not here that time. I am assigned to watch this room (dining room) today and you can see there are a lot of residents here so we can't get to all of them if they fall. Surveyor counted the number of residents in the room which showed 41 residents with only V11 monitoring the room. Surveyor asked V11 who the residents were that were at risk for falls currently in the dining room, V11 stated, I don't know, I think they all are. Residents Affected - Few On 8/11/23 at 1:31 PM, V4 (LPN) stated, I am a new nurse here about 1 month. I remember when (R1) fell because that was my first time working that floor and on that day I remembered I was passing medications and (R1) was in the dining room waiting for breakfast and there was a CNA watching the residents. I didn't hear anything and the CNA just came running out and said (R1) fell and she was lying on her right side and she was bleeding on the floor. I called the DON (V2) and we do check up and everything and she helped me with my assessment. We ordered X-rays for a possible fracture and I immediately sent her 911 to hospital for further evaluation. Surveyor asked who the CNA was that was assigned to watch the dining room, V4 stated, She was agency CNA that day and was supposed to be there and she said she just heard a noise, but the resident was already on the floor Surveyor asked what preventative measures were in place to prevent R1 from falling, V4 stated, I am not sure. I am new but I know the CNA should be watching the room. Surveyor asked if she was provided any fall prevention training during her orientation, V4 stated, Not really. Surveyor asked V4 how she knew R1 did not lose consciousness since she did not witness the fall, V4 stated, I don't know. Surveyor asked if she asked R1 if she knew she lost consciousness, V4 stated, No she is too confused. On 8/12/23 at 3:09 PM, V8 (Agency CNA) stated, I'm with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room. I didn't see (R1) fall and I didn't even know her but I was with another patient when she fell. I think everyone else was passing trays or feeding residents when the patient fell. I just heard this loud noise. There was some other resident by her before she fell, but like I said I don't know the residents at all since it was my first time there. All I heard was just the noise of her falling hard . Surveyor asked if she ever worked another shift at the facility, V8 stated, No I haven't been back since that last time and I only was there once. Surveyor asked if she was told anything about fall interventions or fall risk of residents, V8 stated, No, I didn't know anything about her fall risk. Is she one because they didn't tell me anything? All they do like every place is give you the residents and they don't tell you anything. Surveyor asked if she received any kind of dementia or fall prevention training, V8 stated, I'm with agency, they don't do training. On 8/11/23 at 11:15 AM, V15 (Clinical Manager) stated, I am usually on the dementia floor but I am on call for the whole building. Surveyor asked what her role was in preventing falls in the building as the clinical manager, V15 stated, The only thing I did was check the wheelchair for malfunctioning. I helped the nurse with the assessments but V4 was the nurse on duty so she did most of the paperwork. Surveyor asked if she was part of the IDT (interdisciplinary team) and if they discussed fall prevention, V15 stated, I am part of the IDT and we discussed R1's incident that happened and she needed the x-rays and went to the hospital, but that is all I do. The restorative nurse manager (V7) does the root cause analysis regarding R1's fall but she's been on maternity leave. I don't do that. We do not do anything else. We don't discuss fall prevention in the meetings and the restorative nurse and her team are responsible for the fall prevention. I also do psychotropic review, I do medication review, but I do not have any input in the falls whatsoever. Surveyor asked if she saw R1's injuries or assessed R1 after she fell, V15 stated, No I did not, I was not present during the incident. Surveyor clarified what her role was for the building, V15 stated, I am an RN BSN and the clinical manager for the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 2 of 8 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 08/13/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Policy dated August 5, 2020 titled Fall Occurrence states in part, It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. A fall risk assessment form will be completed by the nurse upon admission, readmission, quarterly, significant change and annually. Those identified as high risk for falls will be provided interventions to prevent falls. An interim Falls Care Plan may be started but a Fall Care Plan is necessary and required after the State required MDS was done. Event ID: Facility ID: 145835 If continuation sheet Page 3 of 8 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 08/13/2023 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to prevent falls with significant injuries, and failed to train facility nursing staff on fall preventions and provide implementation of assistive and/or preventative devices to prevent falls. This failure affected 1 of 3 residents (R1) reviewed for falls in the sample. Residents Affected - Few Findings include: R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom in between meals. Keep call light within reach when in bedroom or bathroom. Side rails to aid in bed mobility and transfers. Use of assistive device during ambulation to prevent falls. There were no interventions for assistive/preventative devices such as chair alarms and/or wedge cushions or other devices while in wheelchair to prevent further accidental falls. A fall risk assessment dated [DATE] showed R1 at high risk for falls. A facility incident report dated 8/2/23 written by V4 (LPN) reads in part, Went directly to resident (R1) and noticed her lying on her right side. Notified by CNA that resident was lying on the right side. Resident was immediately assessed. Resident was awake, no loss of consciousness. Neurological checks initiated and ongoing PERRLA (pupils equal, round, reactive to light and accommodation) . On 8/11/23 at 1:31 PM, V4 (LPN) stated, I am a new nurse here about 1 month. I remember when (R1) fell because that was my first time working that floor and on that day I remembered I was passing medications and (R1) was in the dining room waiting for breakfast and there was a CNA watching the residents. I didn't hear anything and the CNA just came running out and said (R1) fell and she was lying on her right side and she was bleeding on the floor. I called the DON (V2) and we do check up and everything and she helped me with my assessment. We ordered X-rays for a possible fracture and I immediately sent her to hospital for further evaluation. Surveyor asked who the CNA was that was assigned to watch the dining room, V4 stated, She was agency CNA that day and was supposed to be there and she said she just heard a noise, but the resident was already on the floor Surveyor asked what preventative measures were in place to prevent R1 from falling, V4 stated, I am not sure. I am new but I know the CNA should be watching the room. Surveyor asked if she was provided any fall prevention training during her orientation, V4 stated, Not really. Surveyor asked V4 how she knew R1 did not lose consciousness since she did not witness the fall, V4 stated, I don't know. Surveyor asked if she asked R1 if she knew she lost consciousness, V4 stated, No she is too confused. On 8/12/23 at 3:09 PM, V8 (Agency CNA) stated, I'm with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room. I didn't see (R1) fall and I didn't even know her but I was with another patient when she fell. I think everyone else was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 4 of 8 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 08/13/2023 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few passing trays or feeding residents when the patient fell. I just heard this loud noise. There was some other resident by her before she fell, but like I said I don't know the residents at all since it was my first time there. All I heard was just the noise of her falling hard . Surveyor asked if she ever worked another shift at the facility, V8 stated, No I haven't been back since that last time and I only was there once. Surveyor asked if she was told anything about fall interventions or fall risk of residents, V8 stated,No I didn't know anything about her fall risk. Is she one because they didn't tell me anything? All they do like every place is give you the residents and they don't tell you anything. Surveyor asked if she received any kind of dementia or fall prevention training, V8 stated, I'm with agency, they don't do training. On 8/11/23 at 11:15 AM, V15 (Clinical Manager) stated, I am usually on the dementia floor but I am on call for the whole building. Surveyor asked what her role was in preventing falls in the building as the clinical manager, V15 stated, The only thing I did was check the wheelchair for malfunctioning. I helped the nurse with the assessments but V4 was the nurse on duty so she did most of the paperwork. Surveyor asked if she was part of the IDT (interdisciplinary team) and if they discussed fall prevention, V15 stated, I am part of the IDT and we discussed R1's incident that happened and she needed the x-rays and went to the hospital, but that is all I do. The restorative nurse manager (V7) does the root cause analysis regarding R1's fall but she's been on maternity leave. I don't do that. We do not do anything else. We don't discuss fall prevention in the meetings and the restorative nurse and her team are responsible for the fall prevention. I also do psychotropic review, I do medication review, but I do not have any input in the falls whatsoever. Surveyor asked if she saw R1's injuries or assessed R1 after she fell, V15 stated, No I did not, I was not present during the incident. Surveyor clarified what her role was for the building, V15 stated, I am an RN BSN and the clinical manager for the facility. Facility radiology results report interpreted by V13 (MD) shows in part, There is evidence of suspected acute subcapital fracture of the right proximal femur. The hip space is narrowed and the femoral head has abnormal contour. Impression: Subcapital fracture right proximal femur suspected. Hospital records dated 8/2/2023 and signed by V14 (Hospital Physician) shows in part, [AGE] year old female with past medical history of dementia, atrial fibrillation and anticoagulation presents status post fall. Already with outpatient X-ray showing hip fracture, will repeat X-ray of hip and chest here, CT scans of head, neck, face ordered. Will dermabond wound here (face). Will reassess but anticipate admission. Facial lacerations; X-rays of the right hip were performed; multiple CT scans for the brain without contrast, CT scan for cervical spine, CT scan for the maxillorfacial area; and finally, a CT scan of the right hip. Policy dated August 5, 2020 titled Fall Occurrence states in part, It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. A fall risk assessment form will be completed by the nurse upon admission, readmission, quarterly, significant change and annually. Those identified as high risk for falls will be provided interventions to prevent falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 5 of 8 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 08/13/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 3 (R1) residents with severe cognitive impairment and fall risk reviewed for accident/hazards in the sample; failed to provide an environment that was free of accidental hazards; and failed to follow R1's plan of care to prevent accidental falls. Findings include: On 8/11/23 at 10:22 AM, R1 was observed in the dining area slumped over and asleep in a wheelchair. R1 displayed facial injuries of a swollen lip with dried blood on the right side of her mouth and a right eye that appeared to be swollen shut. R1 was slumped over to the same side she had recently fallen on and there were no preventative devices observed such as a chair alarm nor wedge cushion to prevent R1 from further falls. V5 (Memory Care Manager) stated, This is her usual place in the dining room and it was where she was seated when she fell over last week. Surveyor asked what the facility did to prevent the fall from happening to begin with, V5 stated, There is usually somebody here to watch the residents but I was told that she just ended up on the floor. Surveyor asked again if there was anything else the facility did to prevent R1 from falling, V5 stated, You would have to ask the nurses about that. Surveyor asked what her role was on the unit, V5 stated, I am the memory care manager for this dementia unit. V11 (CNA/Certified Nursing Aide) who was standing nearby was asked about R1 stated, R1 fell during the morning shift but I was not here that time. I am assigned to watch this room (dining room) today and you can see there are a lot of residents here so we can't get to all of them if they fall. Surveyor counted the number of residents in the room which showed 41 residents with only V11 monitoring the room. Surveyor asked V11 who the residents were that were at risk for falls currently in the dining room, V11 stated, I don't know, I think they all are. R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom in between meals. Keep call light within reach when in bedroom or bathroom. Side rails to aid in bed mobility and transfers. Use of assistive device during ambulation to prevent falls. A fall risk assessment dated [DATE] showed R1 at high risk for falls. A facility incident report dated 8/2/23 written by V4 (LPN) reads in part, Went directly to resident (R1) and noticed her lying on her right side. Notified by CNA that resident was lying on the right side. Resident was immediately assessed. Resident was awake, no loss of consciousness. Neurological checks initiated and ongoing PERRLA (pupils equal, round, reactive to light and accommodation) . On 8/11/23 at 1:31 PM, V4 (LPN) stated, I am a new nurse here about 1 month. I remember when (R1) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 6 of 8 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 08/13/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fell because that was my first time working that floor and on that day I remembered I was passing medications and (R1) was in the dining room waiting for breakfast and there was a CNA watching the residents. I didn't hear anything and the CNA just came running out and said (R1) fell and she was lying on her right side and she was bleeding on the floor. I called the DON (V2) and we do check up and everything and she helped me with my assessment. We ordered X-rays for a possible fracture and I immediately sent her to hospital for further evaluation. Surveyor asked who the CNA was that was assigned to watch the dining room, V4 stated, She was agency CNA that day and was supposed to be there and she said she just heard a noise, but the resident was already on the floor Surveyor asked what preventative measures were in place to prevent R1 from falling, V4 stated, I am not sure. I am new but I know the CNA should be watching the room. Surveyor asked if she was provided any fall prevention training during her orientation, V4 stated, Not really. Surveyor asked V4 how she knew R1 did not lose consciousness since she did not witness the fall, V4 stated, I don't know. Surveyor asked if she asked R1 if she knew she lost consciousness, V4 stated, No she is too confused. On 8/12/23 at 3:09 PM, V8 (Agency CNA) stated, I'm with agency and I had just got there that day and they (facility) assigned me to be in charge of watching the dining room. I didn't see (R1) fall and I didn't even know her but I was with another patient when she fell. I think everyone else was passing trays or feeding residents when the patient fell. I just heard this loud noise. There was some other resident by her before she fell, but like I said I don't know the residents at all since it was my first time there. All I heard was just the noise of her falling hard . Surveyor asked if she ever worked another shift at the facility, V8 stated, No I haven't been back since that last time and I only was there once. Surveyor asked if she was told anything about fall interventions or fall risk of residents, V8 stated,No I didn't know anything about her fall risk. Is she one because they didn't tell me anything? All they do like every place is give you the residents and they don't tell you anything. Surveyor asked if she received any kind of dementia or fall prevention training, V8 stated, I'm with agency, they don't do training. On 8/11/23 at 11:15 AM, V15 (Clinical Manager) stated, I am usually on the dementia floor but I am on call for the whole building. Surveyor asked what her role was in preventing falls in the building as the clinical manager, V15 stated, The only thing I did was check the wheelchair for malfunctioning. I helped the nurse with the assessments but V4 was the nurse on duty so she did most of the paperwork. Surveyor asked if she was part of the IDT (interdisciplinary team) and if they discussed fall prevention, V15 stated, I am part of the IDT and we discussed R1's incident that happened and she needed the x-rays and went to the hospital, but that is all I do. The restorative nurse manager (V7) does the root cause analysis regarding R1's fall but she's been on maternity leave. I don't do that. We do not do anything else. We don't discuss fall prevention in the meetings and the restorative nurse and her team are responsible for the fall prevention. I also do psychotropic review, I do medication review, but I do not have any input in the falls whatsoever. Surveyor asked if she saw R1's injuries or assessed R1 after she fell, V15 stated, No I did not, I was not present during the incident. Surveyor clarified what her role was for the building, V15 stated, I am an RN BSN and the clinical manager for the facility. Facility radiology results report interpreted by V13 (MD) shows in part, There is evidence of suspected acute subcapital fracture of the right proximal femur. The hip space is narrowed and the femoral head has abnormal contour. Impression: Subcapital fracture right proximal femur suspected. Hospital records dated 8/2/2023 and signed by V14 (Hospital Physician) shows in part, [AGE] year old female with past medical history of dementia, atrial fibrillation and anticoagulation presents status post fall. Already with outpatient X-ray showing hip fracture, will repeat X-ray of hip and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 7 of 8 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 08/13/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete chest here, CT scans of head, neck, face ordered. Will dermabond wound here (face). Will reassess but anticipate admission. Facial lacerations; X-rays of the right hip were performed; multiple CT scans for the brain without contrast, CT scan for cervical spine, CT scan for the maxillorfacial area; and finally, a CT scan of the right hip. Policy dated August 5, 2020 titled Fall Occurrence states in part, It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. A fall risk assessment form will be completed by the nurse upon admission, readmission, quarterly, significant change and annually. Those identified as high risk for falls will be provided interventions to prevent falls. Event ID: Facility ID: 145835 If continuation sheet Page 8 of 8