Inspection·April 24, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 ensure the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. This applies to 1 of 4 residents (R1) reviewed for psychotropic medications. Residents Affected - Few The findings include: The EMR (Electronic Medical Record) showed R1 is [AGE] years old, with diagnoses that included but not limited to unspecified focal traumatic brain injury, insomnia, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, epileptic seizures related to external causes, not intractable, without status epilepticus, encounter for gastrostomy, catatonic disorder, spondylosis with myelopathy to the cervical region, Vitamin D deficiency, Parkinsonism, quadriplegia, hypertension, and unspecified tremor. The MDS (Minimum Data Set), dated 3/12/2024, showed R1 was moderately impaired with cognition with a BIMS (Brief Interview Mental Status) score of 12/15. The neuropsychology consultation notes, dated 12/20/2021, showed, (R1) neurocognitive profile indicate profound to severe decline in working memory, memory and executive functioning . The consultation notes also showed R1 was identified with diagnoses of major depressive disorder. severe, and major neurocognitive impairment exacerbated by depression. The POA (Power of Attorney) Form, dated 8/30/2021, showed V7 (R1's father) was the designated legal representative/POA of R1. The EMR (Electronic Medical Record) including the POS (Physician Order Sheet) was reviewed with V4 (Psychotropic Nurse). The following psychotropic medications that R1 was administered were identified. V4 also provided copies of psychotropic consents forms for R1. The timeline of psychotropic and antiseizure medications were the following: -Lorazepam 1 mg twice a day; with original order dated 5/6/2022 and with latest order dated 10/5/2023, with same dose. The consent for Ativan was taken on 5/6/2022. The Psychotropic Medication Consent dated 5/6/2022 did not reflect the whether Ativan was anti-anxiety, antidepressant, anti-manic, antipsychotic, hypnotic /sedative. The consent also showed no documentation what specific behaviors that Ativan was used for. The consent form showed whether the consent was obtained via verbal or written and if the POA had agreed with the medications or not. V7 not fully informed for the use of this psychotropic medication since the form were not filled up. The consent form also required the nurse who provided the information; however, the nurse name/signature was blank and did not identify who (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: 145638 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 145638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Bloomingdale 165 South Bloomingdale Road Bloomingdale, IL 60108 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)