Inspection·August 8, 2024

F 0600 Level of Harm - Actual harm Residents Affected - Few what happened. I'm just glad I don't see V5 (CNA) anymore, she hasn't taken care of me since then. Surveyor asked if V5 (CNA) still works in the facility, R1 said: I think she does, but was moved to another unit. V5 (CNA) is [NAME]. She's the only one like that. Surveyor asked if R1 feels safe in the facility, R1 said: Overall, I feel safe in the facility. I have been here for over a year, and nothing like this happened to me before. I haven't heard of anything like this happen to another resident either. On 08/05/2024 at 2:38 PM, Surveyor interviewed V5 (Certified Nursing Assistant), who stated the following: On 07/15/2024, after dinner, I responded to the call light in R1's room. I went in to check on R1 and R1 said that her roommate (R3) needs to be covered. I asked R3 if she needs assistance, R3 said that she didn't use the call light, it was R1 who used it. Regardless of that, I noticed that R3 needs a flat sheet, so I decided to go get it. At the same time, R1 was accusing me of not doing my job while she was sitting on her bed, when I turned around, R1 was right in my face. R1 started scratching my neck and face, so I held her arm, turned around and ran out of the room. R1 ran out, chasing me, she was trying to hit me. V4 (LPN) was right outside R1's door. R1 then proceeded to show V4 (LPN) her bleeding arm. Surveyor asked if R1's arm was bleeding when V5 (CNA) came into the room, V5 (CNA) responded, Ma'am, I don't need to be rude, but I already told you that I don't know if her arm was bleeding before I came into the room. V5 (CNA) demonstrated what appeared to be hostility against a surveyor and also appeared to be irritable and temperamental during an interview. On 08/05/2024 at 3:05 PM, Surveyor interviewed V4 (Licensed Practical Nurse), who stated the following: I was at the nursing station at the time of the incident involving R1 and V5 (CNA) on 07/15/2024. I heard some commotion coming from R1's room. I went in there and saw V5 (CNA) and R1 standing by the foot of R1's bed. V5 (CNA) and R1 were arguing. I saw scratches on R1's right arm. R1 was repetitively asking V5 (CNA) to leave the room, so I asked V5 (CNA) to step out, and she finally left R1's room. I did not see any scratch marks on V5's (CNA) face or neck, she didn't report to me either. I did not see R1 chasing after V5 (CNA) or try to hit her. When I was providing first aid care to R1's arm, R1 said that she asked V5 (CNA) to close the drapes in the room, but V5 (CNA) responded that she has until 11:00 PM to do it. I haven't talked to V5 (CNA) after the incident, I notified the V10 (Nurse Supervisor) and, I believe, she talked to V5 (CNA). I've worked with V5 (CNA) before, she comes across as loud. I've worked with R1 for over a year now, and she has never been aggressive towards me, nor I witnessed her being aggressive with other staff or residents. On 08/05/2024 at 3:29 PM, Surveyor interviewed V10 (Nurse Supervisor), who said: I was on my break when V4 (LPN) called me to let me know that there was an incident between R1 and V5 (CNA) resulting in R1 acquiring skin tear to her right arm. I returned from my break right away and made sure V5 (CNA) is away from R1 and then I asked R1 what happened. R1 said that she used a call light, V5 (CNA) came in and was asked to close the drapes. V5 (CNA) responded that she's here until 11:00 PM and has time to do that. R1 got upset, got up from the bed, and struggle ensued. V5 (CNA) grabbed R1's right arm and that's probably how R1 acquired the skin tear. I proceeded with full assessment and wound care for R1 and then notified V3 (ADON). V3 (ADON) is who interviewed V5 (CNA). One thing about V5 (CNA) is that she is loud, but I've never heard any complaints about her, other than being loud. On 08/06/2024 at 9:57 AM, Surveyor interviewed V3 (Assistant Director of Nursing), who stated the following: On the evening on 07/15/2024, I was notified by V10 (Nurse Supervisor) that there was an incident between R1 and V5 (CNA). V10 (Nurse Supervisor) asked me to talk to V4 (LPN), she handed the phone off and had me speak to V4 (LPN). V4 (LPN) said that she heard commotion in R1's room, went in, but didn't see physical altercation between R1 and V5 (CNA). R1 was saying She did this to me pointing to her right arm. V4 (LPN) had V5 (CNA) step out of R1's room and went to notify V10 (Nurse (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 08/08/2024 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few Supervisor). Then, I asked to speak to V5 (CNA). V5 (CNA) said that she answered the call light in R1's room. V5 (CNA) was assisting R1's roommate (R3) and that's when R1 started yelling at her. V5 (CNA) said she was trying to leave the room, and that's when R1 jumped out of the bed, pointing at V5 (CNA) swatting, scratching, and spitting at V5 (CNA). V5 (CNA) tried to stop R1 from attacking her and grabbed R1's arm. Right then, V4 (LPN) came into the room and V5 (CNA) was able to leave. I also spoke to R1. R1 said that she asked V5 (CNA) to give a blanket to the roommate (R3), V5 (CNA) responded that she is here until 11:00 PM and has time to do it. R1 then got off the bed, pointed at V5 (CNA) and said that it doesn't matter that V5 (CNA) is here until 11:00 PM, she needs to do it now. R1 said she extended her arms up and that's when V5 (CNA) grabbed her. R1 yelled to show V5 (CNA) what she had done, pointing to her injured right arm, and that's when V4 (LPN) came in and had V5 (CNA) leave R1's room. Once I got R1's, V4's (LPN) and V5's (CNA) statements, I told V5 (CNA) to leave the facility. V12 (Primary Physician) and V1 (Administrator) were notified. Police was not notified. V1 (Administrator) took the investigation over from there. Surveyor asked about R1's general demeanor, V3 (ADON) said: R1 is very pleasant, can get anxious or frustrated; however, she's never been involved in physical altercation with anybody. Normally, R1 comes to staff when she gets upset. Surveyor asked how is V5's (CNA) behavior, V3 (ADON) said: V5 (CNA) hasn't been here that long and works night shift, so I'm not very familiar with her. I did have an interaction with her on the day of the incident, around 4:00 PM, she appeared to be pleasant even though she was loud. On 08/06/2024 at 11:00 AM, Surveyor observed R3 resting in the bed. Surveyor asked about the incident that occurred between R1 and V5 (CNA), R3 responded: I don't remember anything, nothing happened here. On 08/06/2024 at 11:05 AM, Surveyor approached R1 in her room and asked if R1 could answer a couple more questions in regard to the incident that occurred between R1 and V5 (CNA). R1 appeared nervous, apprehensive, and afraid. Surveyor asked R1, in the follow up interview, how does she feel about V5 (CNA) still working in the facility, R1 responded, You know, I was a little nervous when we talked yesterday, but as long as V5 (CNA) is not on this unit, I think I'm ok. I just hope V5 (CNA) doesn't have the same run-in with another resident like she had with me. I've been here for over a year now, and I would have never thought something like this could happen. On 08/06/2024 at 1:16 PM, Surveyor interviewed V1 (Administrator/Abuse Coordinator) who stated: On the evening of 07/15/2024, V3 (ADON) notified me that V4 (LPN) went into R1's room due to ongoing commotion. R1 showed her a skin tear and said that V5 (CNA) caused it. After that, I completed initial report and sent it to IDPH. The police were not called because it didn't constitute to our Abuse policy. I continued the investigation on 07/16/2024. I spoke to R1, V4 (LPN), V5 (CNA), and other staff that was present on the shift. Social services spoke to residents. The conclusion of the investigation was that abuse was not substantiated because R1 reached out towards V5 (CNA) in attempt to scratching her and V5 (CNA) held R1's arms in self-defensed. Surveyor asked if V5 (CNA) should be involved in altercation with a resident, V5 (CNA) should have not been involved in any altercation with R1 but she was attacked by R1, so it justified that V5 (CNA) held R1's arms down. Surveyor clarified whether V5 (CNA) should have stepped out of R1's room to prevent physical altercation, V1 (Administrator) said: I think V5 (CNA) should have stepped away, but as R1 attacked V5 (CNA), it was reasonable for her to hold R1's arms. Surveyor asked why is V1 (Administrator) convinced that R1 attacked V5 (CNA) not the other way around, V1 (Administrator) stated: Because R1 stated to multiple people that she attacked V5 (CNA). Surveyor asked how did R1's injury occur, V1 (Administrator) said: There is no definite conclusion but considering her fragile skin, R1 could have acquired it during interaction with V5 (CNA). Surveyor requested full investigation to collaborate V1's (Administrator) statement, V1 (Administrator) said, You have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 08/08/2024 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few summary of that in the initial and final facility reported incident. Surveyor clarified if those are the only documents available to the surveyor, V1 (Administrator) said, Yes and refused to provide full incident investigation. On 08/06/2024 at 2:33 PM, Surveyor interviewed V12 (Primary Physician). Surveyor asked if it's a good time to talk, V12 (Primary Physician) said, Not really, but I will talk to you. Surveyor asked about the incident that occurred on 07/15/2024 between R1 and V5 (CNA), V12 (Primary Physician) said, I don't clearly recall what happened, but I think R1 was agitated and V5 (CNA) was trying to calm R1 down, but I don't know exactly. Surveyor asked if V12 (Primary Physician) knew why V5 (CNA) grabbed R1?, V12 (Primary Physician) said, R1 was agitated and V5 (CNA) grabbed her. I mean, I think V5 (CNA) grabbed R1, not sure. Surveyor asked if V5 (CNA) behavior was appropriate, V12 (Primary Physician) said, V5 (CNA) should have tried to redirect R1 and call the nurse. Surveyor asked about R1's skin tear: V12 (Primary Physician) said, I don't remember anything about R1's skin tear. On 08/07/2024 at 1:56 PM, In follow up interview, surveyor asked V1 (Administrator) whether V5 (CNA) was suspended and/or moved to another unit as a result of the incident on 07/15/2024, V1 (Administrator) said: Yes, V5 (CNA) was suspended immediately and has been since moved to another floor after the investigation was completed. Surveyor asked how long was V5 (CNA) suspended for, V1 (Administrator) said: V5 (CNA) was suspended for the length of the investigation until the final report was submitted. V5 (CNA) was moved to another floor because R1 did not want to work with her anymore even though the other residents appreciated V5's (CNA) work. The facility final incident reported dated 07/19/2024 reads in part, After review of medical records, staff, and resident interviews, the allegation of physical abuse is unsubstantiated. R1's skin assessment dated [DATE] reads in part, At around 7:20 PM, post incident, (R1) noted with 2 skin tears to right forearm with very small amount of bleeding. Areas of skin cleansed with normal saline and pat dry. Applied Xeroform and covered with dry dressing. V12 (Primary Physician) informed of incident and skin teras. The facility Abuse and Neglect policy dated 07/12/2024 reads in part, 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, negelct, or mistreatment. Abuse is willful infliction of mistreatment, injury, unreasonable confinment, imtimidation or punishment. Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Mental abuse inludes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolaton (involunatry, imposed seclusion) or deprivation to provoke fear or shame. 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 08/08/2024 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)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to keep a severely cognitively impaired resident at high risk for falls and with history of falls from a mechanical fall while providing routine ADLs (activities of daily living care) and failed to follow fall prevention protocols for 1 (R2) of 3 residents reviewed for accidents/hazards in the sample of 5. This failure resulted in R2's transfer to the hospital Emergency Department and diagnosis of comminuted displaced intertrochanteric right femur fracture. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Displaced Intertrochanteric Fracture of Right Femur; Epilepsy; Restlessness and Agitation; Abnormal Posture; Degenerative Disease of Nervous System; Delusional Disorders; Osteoarthritis; Osteophyte Right and Left Hip; and Progressive Vascular Leukoencephalopathy. According to R2's MDS (Minimum Data Set) assessment dated [DATE], under section C, R2 has memory problems and severely impaired decision making. According to R2's MDS (Minimum Data Set) assessment dated [DATE], under section GG, R2 is dependent or requires substantial/maximal assistance with majority of ADLs (activities of daily living). On 08/05/2024 at 12:41 PM, Surveyor interviewed V6 (Licensed Practical Nurse) who stated: On 06/01/2024, before breakfast time, V7 (Wound Care Technician) heard V9 (Certified Nursing Assistant) yelling for help. V7 (Wound Care Technician) stepped into R2's room and saw V9 (CNA) next to R2 who was on the floor, on the floor mat. V7 (Wound Care Technician) came to get me and that's when I went into R2's room. I saw R2 sitting on the floor, on the floor mat with her back towards the bed. I started the assessment. I checked R2's skin, there were no injuries. I also check R2's range of motion, it appeared to be at R2's baseline. I also checked R2's vital signs. It did not appear that R2 had any injury at that time, so me, V9 (CNA), and V7 (Wound Care Technician) put R2 back into the bed via mechanical lift. I kept monitoring R2 for pain as well, which R2 didn't appear to be in pain either. After R2 was placed in bed, I notified V8 (Nurse Supervisor), the doctor, and R2's power of attorney. When I asked V9 (CNA) what happened, she said that she was getting R2 dressed when incident happened. R2 had jerking movements and it was difficult to dress her in supine position, so V9 (CNA) sat R2 up on the edge of the bed, and while she was getting R2 dressed, R2 started leaning forward and V9 (CNA) had to lower R2 to the floor, onto the floor mat. Surveyor asked if R2 was strong enough to sit on the edge of the bed independently, V6 (LPN) said: I'm not sure if R2 had enough strength to be sat on the edge of the bed. I helped other CNA's with R2's transfers and we always used at least two staff and mechanical lift. On 08/05/2024 at 12:56 PM, Surveyor interviewed V2 (Director of Nursing) who said: R2's injury was discovered at nighttime, several hours after R2 fell, that's when R2 started grimacing, pointing to her right hip, and there was a change in R2's right leg appearance, it looked displaced. Surveyor asked if there was anybody else in the room at the time of the fall, V2 (DON) said, R2 had a roommate at the time of the incident but she is not intervieweable. On 08/05/2024 at 1:36 PM, Surveyor interviewed V8 (Nurse Supervisor), who said: I had just started my shift on 06/01/2024, around 7:00 AM, I was notified that R2 had fallen. When I went into R2's (continued on next page) 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 08/08/2024 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)

F 0689 Level of Harm - Actual harm room, she was already in the bed. I was not familiar with R2, but I looked at her extremities, skin, and face, R2 didn't appear to be in distress or pain at the time. V6 (LPN) told me that she knew what to do and didn't need my assistance. I followed up with V6 (LPN) before the end of my shift (3:30 PM) and there were no changes and R2 appeared to be at her baseline. Residents Affected - Few On 08/05/2024 at 2:12 PM, Surveyor interviewed V9 (Certified Nursing Assistant), who said: I went into R2's room, before breakfast, to get her dressed and get her up into the chair. I raised the bed up to my hip level and started with changing R2's brief and putting on her pants. R2 was laying down for that. Then, I attempted to put on R2's top. I sat R2 up on the edge of the bed. I was standing on the side of R2, slipping her arm into the sleeve of the shirt and that's when R2 started to lean forward. As she started to lean to lean forward, I put my arm out, but that didn't prevent R2 from falling off the bed and R2 fell to the floor onto her right hip. The bed was at my hip level, so R2 fell off the hip level height. I took care of R2 before, this was my routine, I always sat R2 up to put on her shirt. Nothing like this has ever happened before. R2 utilized specialty chair, with high back. Surveyor asked if utilizing specialty chair was indicative that R2 didn't have enough strength to sit up independently, V9 (CNA) responded, Yes, that would indicate that. R2 required maximum/two person assist, especially with transfers. R2's ADLs, including getting her dressed, could have been provided by one person, but sometimes, R2 resisted repositioning and then we would need 2 people to get R2 dressed. 08/06/2024 9:37 AM, Surveyor interviewed V11 (Former Fall Coordinator) who said: R2 was in the restorative program at the time of the fall, I saw her for quarterly and annual evaluations. R2 had cognitive deficit and needed maximum assist with toileting and transferring, required mechanical lift for transfers, and total assistance during meals. R2 needed moderate assistance with turning and getting dressed. R2 utilized specialty chair for safety and comfort. Surveyor clarified what does partial/moderate assistance means in regard to getting upper body dressed, V11 (Former Fall Coordinator) said: R2 was able to sit up, in order to assist with dressing. Surveyor asked about V11's (Former Fall Coordinator) fall investigation outcome, V11 (Former Fall Coordinator) said: My investigation revealed that the V9 (CNA) was assisting with changing R2, had R2 sit on the edge of the bed, noticed R2 leaning towards her and was unable to prevent her from falling. It was unusual for R2 to lean forward like that, so the doctor ordered labs after the fall; however, R2 was sent out to the hospital before nurses were able to collect urine sample. After getting labs done at the hospital, it was discovered that R2 had urinary tract infection at the time of the fall. R2 had previous falls and had a urinary tract infection around those times. The conclusion of the investigation was that R2 had an urinary tract infection and the fall was unexpected and unavoidable. On 08/06/2024 at 1:49 PM, Surveyor interviewed V2 (Director of Nursing) who said, Interventions for residents at high fall risk are bed alarms, chair alarms, floor mats, checking labs in case of ongoing infection, and staff education in regard to root-cause of a fall. Each intervention is individual to a resident. R2 didn't require bed alarm because she did not try to get out of bed. R2's fall interventions were: wing mattress due to history of seizures and fall mats. Those were the two main fall prevention interventions for R2. I don't think there was anything more that could have been done to prevent R2's fall. On 08/06/2024 at 2:20 PM, Surveyor interviewed V13 (Family Nurse Practitioner) who said: I am familiar with R2. R2 was alert but not oriented, had dementia. R2 was unable to answer any questions, not able to follow simple directions. R2 was mainly in bed, sometimes was sitting up in the wheelchair. R2 required assistance with all ADLs (activities of daily living). Surveyor asked if it was appropriate for staff to place R2 on the edge of the bed, to provide ADL care based on R2's functional (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 08/08/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few ability, V13 (FNP) said, I'm not sure if it was appropriate, I used to always see her in the dining room, in the wheelchair. Surveyor asked about R2's fall, V13 (FNP) said: I remember R2 had a hip fracture, but I don't remember R2 having a fall. Surveyor asked what would be appropriate fall prevention interventions for R2, V13 (FNP) said: Fall interventions appropriate for R2 would be staff assistance, frequent monitoring, maybe a bed alarm, not sure. R2 was not very alert, I don't think she moved a lot. On 08/06/2024 at 3:28 PM, Surveyor asked V14 (Agency Certified Nurse Assistant) what some of the interventions are appropriate for high fall risk residents, V14 (Agency CNA) said, Some of the interventions for high fall risk residents are bed and chair alarm, bed in the lowest position, and frequent monitoring. Surveyor asked what it means if a resident requires maximal assistance in almost all aspects of ADLs (activities of daily living), V14 (CNA) said: Resident who is assessed to require maximum assistance, needs staff assistance with their ADLs. It means, that their mobility is very limited. Even if one of the resident's ADLs requires partial/moderate assistance, they cannot perform the task independently, and still need staff's assistance. Surveyor asked, would you sit a resident on the edge of the bed to dress them, who's functional ability is assessed as maximum assistance for dressing lower part of the body and partial/moderate assistance for dressing upper part of the body, V14 (Agency CNA) said: I would sit them up in the bed while putting on their shirt, not on the edge of the bed. Some CNAs find it more convenient to sit residents on the edge of the bed, but it is too risky. If a resident requires maximum assistance with all ADLs except dressing upper body, where they need partial/moderate assist, and they require mechanical lift for transfers, that means their mobility is very limited and there is no point to sit them up on the edge of the bed. The facility incident report dated 06/01/2024 reads in part, On 06/01/2024 while (R2) was sitting in the bed and staff were assisting her with dressing, (R2) began to lean forward, causing the staff the need to lower her to the floor on her floor mats. Post 72 (hour) incident follow up, (R2) was noted with swelling to her right hip and facial grimacing. (R2) was sent to the (local) hospital for evaluation where she was admitted with diagnosis of right hip fracture. Per record review, R2 had two prior falls within 6 months, on 01/10/2024 and 03/14/2024, to the fall on 06/1/2024. Fall Risk Evaluation dated 03/14/2024 shows R2 to be at high risk for falls. R2's Change in Condition with SBAR Form dated 06/01/2024 reads in part, The change in condition, symptoms, or signs observed and evaluated are/is: witnessed fall. R2's Post-incident 72 Hours Follow-up dated 06/02/2024 reads in part, Swelling to the right hip; right hip external rotation. Hospital record dated 06/02/2024 written by V15 (Advanced Practical Nurse) reads in part, History of Present Illness: (R2) is nonverbal at baseline and unable to provide any history but per (the facility) staff, (R2) has been exhibiting signs and symptoms of right hip pain. There is no report of any fall or apparent trauma. CT abdomen reported incidental commuted fracture of the intertrochanteric right femur with mild shortening. Hospital record dated 06/02/2024 written by V16 (Medical Doctor) reads in part, (R2's) POA aware of the natural history of this condition. This includes progression of the fracture, worsening pain, possible neurovascular injury due to displacement of the fracture. Possible skin breakdown due to (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 08/08/2024 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)

F 0689 bony protrusions. Level of Harm - Actual harm Hospital record dated 06/02/2024 written by V17 (Physician Assistant) reads in part, (R2) brought to the ER for evaluation and found to have right hip fracture. (R2) also has UTI (Urinary tract infection). (R2) contracted in the fetal position with both hips and knees flexed. Residents Affected - Few R2's Fall care plan dated 12/22/2023 reads in part, (R2) is at high risk for falls related to: Current medication use, Poor safety awareness, Unsteady gait, Disease process (Toxic Encephalopathy, Alzheimer's Disease, Fatigue, Anxiety, Major Depressive disorder). (R2) utilizes a high back wheelchair as primary means for locomotion. (R2) may have hypotensive episodes placing her at high risk for falls/injury. (R2) is at high risk for fall, has had a hx of fall, impaired cognition requiring weight bearing to staff dependent on self-care and mobility. Interventions: ABT (antibiotic) for UTI; Bed alarm on at all times for fall precautions; Low bed with floor mat while in bed; Treat acute Infection with ABT (antibiotic). R2's ADL care plan dated 03/04/2024 reads in part, (R2) l have an ADL self-care deficit due to incomplete performance, weakness and impaired thought process related to diagnosis of Toxic Encephalopathy, Cognitive communication deficit, Lack of coordination, Fatigue, Anxiety, Major Depressive disorder and Alzheimer's disease, therefore requires extensive assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). (R2) has a (specialty) chair for resident comfort and safety and is totally dependent on staff for locomotion. Interventions: Encourage participation in ADL's; Transfers: mechanical full body lift x2 staff assist. No documented intervention regarding getting R2 dressed. The facility Fall Occurrence policy dated 06/06/2024 reads in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for fall will be provided fall interventions. The interventions will be reevaluated and revised as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145835 If continuation sheet Page 8 of 8