Health inspection·January 10, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a resident was free from significant medication error for 1 of 3 residents (R3) reviewed for medications in the sample of 8. Residents Affected - Few The findings include: R3's Physician order sheet (POS) dated 1/25 show R3 has diagnoses that include anxiety, rheumatoid arthritis, depression, and bipolar disorder. The same POS show R3 has an order of Lorazepam (Ativan) 0.5 milligram (mg) give 1 tablet every 8 hours at: 6AM, 2PM and 10 PM for anxiety. On 1/10/25 at 9:15 AM, R3 was in bed alert and pleasant. R3 said she had missed her Ativan medications in the past. R3 said she has anxiety. On 1/10/25 at 9AM, V12 (Registered Nurse/RN) said on 1/4/25 she was R3's morning shift nurse. V12 (RN) said she got in report that R3 missed her 6AM dose of Ativan on 1/4/25. V12 said the pharmacy was wanting a signed script. V12 said she took care of the issue that day. R3's Ativan came around 4PM on 1/4/25. R3 got her Ativan dose of 2PM at 4PM (when the medication was finally delivered.) V12 (RN) who was with this surveyor reviewed R3's Electronic Medication Administration record (EMAR). R3's EMAR show on 1/3/25 timed at 2200 (10PM), R3's Ativan was marked as UV-(unavailable) R3's EMAR show on 1/4/25 timed at 0600 (6AM) marked as UV-unavailable. V12 said unavailable means the medication (Ativan) was not available, therefore the resident did not receive her anti-anxiety medications. On 1/10/25 9:49 AM, V13 (License Practical Nurse/LPN) said he was the night nurse last 1/3/25. V13 said he got in report that R3's Ativan was not available. R3 did not get her 10 PM dose. At around midnight (1/4/25), he was surprised that paramedics arrived at the facility looking for R3. R3 called 911 due to not receiving her Ativan dose. R3 said she was having withdrawals and was wanting to be sent to the hospital. R3 also said she had a full-blown anxiety attack months ago due to not taking her Ativan and she was afraid this can happen again. R3 was then brought to the emergency room (ER) via 911. R3 was discharged back to the facility in the morning of 1/4/25. On 1/10/25 at 8:50 AM, V13 (local Emergency Response Team/EMS) said he was one of the CMS that responded to R3's call. They were at the facility last 1/4/25 past midnight responding a call from a resident (R3). R3 called 911 herself and said she was having anxiety attack due to not receiving her Page 1 of 2 145701 145701 01/10/2025 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0760 Level of Harm - Minimal harm or potential for actual harm anti-anxiety medications. R3 was anxious, nervous, and tense. R3 wanted to go to the hospital. R3 was taken to the ER for treatment. R3's Emergency Notes dated 1/4/25 show R3 was diagnosed with generalized anxiety disorder. R3 was discharged back to the facility. Discharge instructions include refill R3's antianxiety medications (Ativan). Residents Affected - Few On 1/10/25 at 1PM. V2 (Director of Nursing) said staff should ensure residents medications including antianxiety were reordered with script timely. R3's care plan dated 12/13/24 show (R3) requires psychotropic medication (Lorazepam) .to help manage and alleviate anxiety and depression with bipolar disorder. The facility policy entitled Medication Pass dated 8/16/24 show, it is the policy of the facility to adhere to all Federal and State Regulations with medications. 145701 Page 2 of 2