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 Page 1 of 3 145701 145701 03/20/2025 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0644 of screening for other facility residents. V9 said, Yes, I have a list of other residents that are to be screened due to having a new diagnosis. Level of Harm - Minimal harm or potential for actual harm R2's OBRA-I Initial Screen: Residents Affected - Few 1. Date: 02/02/2021. 2. No reasonable basis for suspecting DD or MI. 3. Screening indicated nursing facility services were appropriate. 4. Screening certified by Department on Aging. R2's pertinent medical diagnoses after admission include: 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. V9 (Director of Admissions) presented a PASRR Level I screen done 03/19/2025 at 12:56 PM for R2 after being inquired of a PASRR screening. 2.) R78 is [AGE] years of age and was admitted to the facility on [DATE]. Current diagnoses include but are not limited to PTSD (Post Traumatic Stress Disorder) 01/21/2025, Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbance 10/01/2022, Other Specified Depressive Episodes 04/01/2022, Delusional Disorders 08/07/2021. On 03/19/25 at 09:00 AM V1 (Administrator) provided R78's OBRA (Omnibus Budget Reconciliation Act) initial screening from the Illinois Department of healthcare and Family Services from 06/18/2021. Screening indicated nursing facility services are appropriate. The individual has been formally diagnosed with a mental illness verified by a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders 4th Edition) classification which substantially impairs the person's cognitive, emotional and/or behavioral functioning, excluding organic disorders/dementia, developmental disabilities, and alcohol/substance abuse- yes. V9 (Director of Admissions) presented a PASRR Level I screen done 03/19/2025 at 12:56 PM for R78 after being inquired of a PASRR screening. 145701 Page 2 of 3 145701 03/20/2025 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/19/25 at 01:01 PM, V2 (Director of Nursing) was inquired of R78's preadmission screening and resident review. V2 said, We don't have a PASRR for her (R78), only the OBRA. V9 (Director of Admissions) is putting it in now. I didn't know we had to do a PASRR (preadmission screening and resident review) screening. On 03/19/25 at 01:51 PM, V9 (Director of Admissions) was inquired of PASRR screenings for R2 and R78. V9 said, I started in August of 2023 and received training on PASRR screening. Any new admissions from the hospital case managers do the screenings. If the resident has a change in condition, a new mental health diagnosis a PASRR screening would need to be done to see if it triggers a PASRR 2 screening. I didn't know the residents that were already here needed to be screen when the new PASRR screening started. R2 and R78 need to be screened because of their new diagnoses. V9 was inquired of the need of screening for other facility residents. V9 said, Yes, I have a list of other residents that are to be screened due to having a new diagnosis. On 03/19/25 at 2:20 PM, V2 (Director of Nursing) was asked to provide this surveyor a copy of V9 (Director of Admissions) list of other residents that required a PASRR screening for review. There are 18 residents listed as requiring PASRR screening. 145701 Page 3 of 3