Health inspection·March 20, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program by failing to refer a resident with a newly evident or possible serious mental disorder or related condition for a level 2 review due to new mental health diagnoses. This failure applies to two (R2 and R78) of two residents reviewed for PASRR screening. Findings include: 1.) R2 is [AGE] years of age and was admitted to the facility on [DATE]. Current medical diagnoses include but are not limited to 1. Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, 10/18/2024. 2. Nightmare Disorder, 2/27/2024. 3. Generalized Anxiety Disorder, 8/1/2023. 4. Vascular Dementia, Severe, With Psychotic Disturbance, 8/1/2023. 5. Post-Traumatic Stress Disorder, Unspecified, 12/3/2021. 6. Major Depressive Disorder, Recurrent, Unspecified, 2/8/2021. 7. Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition, 2/6/2021. 8. Hallucinations, Unspecified, 2/2/2021. On 03/19/25 at 01:06 PM, V2 (Director of Nursing) was inquired of R2's PASRR (pre-admission screening and resident review) screening. V2 said, They don't have a Maximus PASRR. Since they've been here a long time, OBRA (Omnibus Budget Reconciliation Act) screening was done, instead. I thought OBRA was sufficient. I did not know Maximus had to get done. On 03/19/25 at 01:44 PM, V9 (Director of Admissions) was inquired of R2's PASRR (pre-admission screening and resident review) screening. V9 said, Both (R2 and R78) were admitted before Maximus became enacted. PASRR screenings were not a requirement for admission. If it's a bed hold of ours there is no requirement to return. Case management at hospital will not be necessary to create one. If change in condition or change in mental status, then we do create one. If they are diagnosed with a mental illness while at the facility, then we will order a PASRR screening. V9 was inquired of the need (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: 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 03/20/2025 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)