Inspection·April 26, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure food containers are stored off the floor and ensure staff are employing hygienic practices during food handling in the dining room. This deficiency has the potential to affect all 165 residents receiving food from the kitchen. Findings include: On 4/23/2024 at 11:05 AM, observed 6 cans of fruit cocktail on the floor in the dry storage room during the initial tour. On 4/23/2024 at 11:05 AM, V12 (Cook) stated those cans should not be on the floor. On 4/23/2024 at 01:00 PM, V1 (Administrator) stated cans of food should be stored on the shelves when delivered. It should be off the floor. On 4/23/2024 at 12:23 PM, observed V13 (Dietary Aide) during lunch in the dining room touched and adjusted her eyeglasses with gloved hands then proceeded to continue preparing food without performing hand hygiene and changing gloves. On 4/23/2024 at 12:24 PM, V13 said I should have changed gloves before continuing to prepare food. On 4/24/2025 at 10:31 AM, V3 (Assistant Director of Nursing/Infection Control) stated V13 should have removed her gloves and performed hand hygiene after touching her eyeglasses and before continuing her task. Policy: Food Storage - Dry Goods, Revision History Date: October 2019 Policy Statement: It is the center policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code. Action Steps: Dry Storage 1. (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 4 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 04/26/2024 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)