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
(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 2
Event ID:
145701
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
145701
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Streamwood
815 East Irving Park Road
Streamwood, IL 60107
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145701
If continuation sheet
Page 2 of 2
