Inspection·September 23, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few socially inappropriate behavior such as yelling and grabbing onto others .BEHAVIOR/IMPULSIVENESS: (R5) exhibits significant confusion r/t her Alzheimer's Disease and does not appear to be oriented to her surroundings. She often attempts to get up without regard to her own safety, she also slides herself down when in her w/c and his been observed attempting to lift her legs to her chest while in her w/c. She tends to lean onto others when she does walk with assistance. She also grabs others as they walk by her and holds on tightly without letting go and will attempt to pull them closer to her. More recently, she has been dangling her legs while lying in bed between the bedrails and over the bedrails. These behaviors put her at high risk for falling, obtaining an injury, and/or abuse Date Initiated: 04/06/2022 . Interventions include: Identify if there are behaviors or factors from the past that should be considered in treatment planning and conduct appropriate assessments to promote knowledge and understanding of the resident's past. Facility submitted final incident report dated 8/25/23, submitted by V2 (Director of Nursing): On 8/20/2023 at approximately 2:15 pm, CNA (V4) reported that while in the dining room, he observed (R4) bite resident (R5) in the left hand. Both residents were immediately separated and assessed by NOD. Body check was completed on both residents and resident (R5) was noted with bite marks to her left hand, no broken skin was noted. Resident (R4) is AAOx1, confused, with diagnosis of Alzheimer's disease, anxiety disorder, blindness to right eye, and macular degeneration. She has poor Judgement and decision-making skills. POA for (R4), and MD were notified. (R4) was placed on 1:1 supervision pending transfer to ED for evaluation. POA for (R5) and NP were notified. The investigation identified that both residents have cognitive impairments and lack willful intent to harm. Resident (R5) is a [AGE] year old female who is AAO x 0 with confusion and with severely impaired cognition. She has a diagnosis of Alzheimer's Disease with early onset and Psychotic Disorder with Anxiety. She has care planed behaviors that address her attempts of reaching out to others and attempting to pull them close to her and grabbing items and not letting go. She exhibits difficulty with concentration due to her Alzheimer's disease, which makes it difficult for her to process the environment around her and her behaviors do not appear intentional but more so are related to her confusion. Post incident resident did not exhibit any psychosocial distress. Resident (R4) is a [AGE] year old female who is AAO x 1 with periods of confusion and agitation. She has a diagnosis of Alzheimer's disease, Anxiety, Depression and has right eye blindness. She scored a 1/15 on the BIMs indicating severe cognitive impairment. She has care planned behaviors that address her becoming easily annoyed with others, her agitation and poor impulse control. Based upon the investigation conducted, it has been determined that both residents lacked willful intent to harm based on their severely impaired cognition and confusion causing them to have poor Judgement and decision-making skills. Physical Abuse cannot be substantiated. 9/22/23 at 1:48 PM V4 (CNA) stated (regarding incident between R4 and R5), that they were in the dining room, and he saw R4 go towards R5 and R5 said that R4 was pulling her. Then R4 bit R5. After that, R4 was put on one-to-one supervision. V4 said that he had not witnessed these behaviors prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 2 of 4 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 09/23/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this incident. V4 said he did report the incident but couldn't remember to who he reported it to and that now R4 is seated by herself at the table and is provided activities to keep her distracted. V4 did not recall other staff in the dining room who may have witnessed incident. 9/22/23 at 1:37 PM V5 (CNA) confirmed that she has worked at the facility for about a year and usually works on this floor so is familiar with the residents. V5 was not on duty during the incident between R4 and R5 but stated that she is familiar with R4's behavior of grabbing on people and spitting at people. V5 confirmed that R4 needs to be kept busy with activities but only participates when she feels like it. 9/23/23 at 3:58 PM V2 (Director of Nursing) was asked about the incident between R4 and R5 and said, we tell the staff to separate her (R4) if they see that she's reaching out to people. She is blind and so she reaches out and puts things in her mouth. Her son is here frequently to help keep her busy and give her one-on-one time. That helps. Facility provided Abuse and Neglect Policy (Effective Date: 7/14/23), which reads: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Definitions of Abuse, Neglect, Exploitation, & Abuse Coordinator Abuse Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Types of abuse. 1. Physical 2. Verbal 3. Mental 4. Sexual 5. Neglect (including medical neglect) 6. Theft/ Misappropriation of Property/Financial abuse 7. Involuntary Seclusion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 3 of 4 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 09/23/2023 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 0600 8. Exploitation Level of Harm - Minimal harm or potential for actual harm 9. Injury of Unknown Origin . Types of Abuse and Examples Residents Affected - Few 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employers, family members, volunteers, students in an affiliated Nurse-training Program, students in affiliated academic institutions including therapy, social, and activity programs, guardian, and other visitors . Prevention (483.13 (b) and 483.13 (c)): Have procedures to: o Provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution: and provide feedback regarding the concerns that have been expressed. .o Identify, correct, and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident properly is more likely to occur. o Establish a safe environment that supports consensual sexual relationship o Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property o Deployment of sufficient and trained staff to deal with behaviors in the units o Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 4 of 4