Health inspection·December 5, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor a resident's (R4) right to refuse medication by crushing the medication and putting it into the R4's food without R4 being aware for one out of three residents reviewed for resident rights in a total sample of eight. Findings Include: R4 has the following diagnosis: generalized anxiety disorder, auditory hallucinations, catatonic disorder, noncompliance with medical treatment, and paranoid schizophrenia. On 12/2/25 at 2:18PM, R4 was sitting alone at a table in the dining room participating in the scheduled activity. R4 requested to stay in the dining room for the interview. R4 was alert and oriented times three. R4 denied any issues with medications or medication regimen. When asked if the facility forces, R4 to take scheduled medications, R4 said, no. The surveyor then asked if R4 ever found medications crushed up in R4's food and R4 said, Yes, it happened one time. R4 stated it occurred sometime in October but was unable to give an exact date or even a date range. R4 reported it happened at the lunch meal. R4 stated one day R4's food tasted funny so R4 thought the staff put R4's medication in the food. R4 report R4 saw crushed pills in the food. R4 denied reporting this allegation to anyone at the facility but called R4's guardian and the police. R4 reported R4 refuses medications because R4 doesn't need them. When asked how this makes R4 feel, R4 stated it makes R4 angry because if R4 doesn't want to take a medication then R4 shouldn't have to take it. R4 denied any other concerns at the facility. On 12/3/25 at 12:46PM, V4 (Psychotropic Nurse) stated R4 is on psychotropic medication for a diagnosis of schizophrenia but has a behavior of refusing the medications. V4 reported R4 doesn't have a reason for refusing and staff will educate or will offer the medication again to R4 if R4 refuses. V4 stated the facility never expects nurses to crush the medication and put it in food if a resident refuses. V4 reported it is a resident's right to refuse a medication. On 12/3/25 at 1:21PM, V7 (Registered Nurse/RN) stated R4 has a habit of refusing medication so V7 will offer the medication again to R4 later in the shift. V7 denied ever putting crushed medications into R4's food. V7 reported R4 is alert but has a guardian since R4 has psych diagnoses. V7 stated R4 doesn't have any behaviors if R4 refuses the medication and V7 will call to update the guardian if R4 refuses the medication. On 12/3/25 at 2:44PM, V10 (R4's Guardian) stated on 10/14/25, V10 spoke with R4 on the phone and R4 alleged a nurse crushed medications and put it in R4's food after R4 refused the medication. V10 stated V10 then called V7 and V7 admitted to crushing all the scheduled medications the day before and putting them in R4's food. V10 stated V10 told V7 that if R4 refuses the medication then they shouldn't be given to R4. V10 reported V7 apologized and told V10 that it won't happen again. The surveyor then interviewed V7 (RN) on 12/3/25 at 3:03PM to clarify statement in the previous interview. The surveyor made V7 aware of V10 statements of V7 admitting to putting the medications in food. V7 then admitted to crushing medications and putting them in R4's breakfast on 10/13/25 or 10/14/25. V7 stated V7 doesn't like when R4 refuses the scheduled medication and V7 found a way to get R4 to still take the Page 1 of 3 145701 145701 12/05/2025 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication. V7 reported that morning R4 refused the medication when offered earlier so all morning medications were crushed and put into oatmeal. V7 denied being aware how much of the oatmeal R4 ate. V7 reported if a resident refuses a medication, then staff should offer the medication again at a later time. V7 stated V10 spoke with V7 on the phone about consent and V7 told V10 that V7 will not put medications in R4's food again. The surveyor asked V7 what the seven rights of medication pass are and V7 was able to name five rights that were the right person, route, meds, reason, and dosage. The surveyor asked if a resident should be aware of what they are taking at all times and V7 said, yes. On 12/3/25 at 3:17PM, V11 (Administrator) stated V11 didn't make any notes about V7 giving crushed medications in food because V11 didn't think of it that way. V11 reported the facility does not teach staff to put medications in resident food if they refuse. V11 stated V11 hasn't looked at the medication policy in a while so V11 was unaware of what the medication rights were but reported R4 has a right to refuse medication. On 12/3/25 at 3:43PM, V12 (Director of Nursing) stated the facility crushed medications and put them in R4's food one time in August after getting clearance from the guardian (The guardian was not V10 at that time), but it was only one time. V12 reported the guardian's instructions were to only put the medication in the food one time then allow R4 to refuse the medication if R4 does not want to take them. V12 stated the facility cannot force a resident to take medications if they refuse. V12 reported R4 is alert and oriented but is delusional. V12 denied being aware of R4 being given any medication in food in October. On 12/3/25 at 4:03PM, V7 (RN) stated V7 called the guardian in August to get clearance to put the medication in the food then but it was only for one time. V7 reported R4 didn't notice the medication in the food in August but did notice the medication in the food when V7 did it in October. V7 said, I hope you see where I was trying to come from. I was just trying to make sure he took his meds. V7 stated V7 didn't go back and chart R4 took the medication on the Medication Administration Record because V7 didn't know how much medication R4 consumed. A General Progress note dated 8/28/25 documents R4 refused to take medication as ordered. Staff notified the state guardian and ask to call back. A state guardian called back and was made aware. The guardian gave verbal consent that medication may be mixed with food on this day.A General Progress note dated 10/13/25 documents R4 was alert but confused. R4 refused to take all medications after the nurse offered many times. R4 was educated in the importance of taking all medication but still refused. The nurse practitioner was made aware.A General Progress note dated 10/14/25 documents R4 refused all morning medication. The state guardian was made aware.A Psychotropic note dated 10/30/25 documents no behavior or mood concerns were reported by staff. R4 has had no deviations from baseline. R4 is intermittently noncompliant with medication. Today R4 was cooperative with prompting and reported doing fine. The Care Plan dated 12/25/24 documents R4 required psychotropic medication to help manage and alleviate agitation, aggressive behavior, and anxiety. An intervention includes to have the nurse carry out medication management regimen as prescribed and report any changes or complications to the physician or psychiatrist as appropriate.The Care Plan dated 7/10/25 documents R4 is challenged by mental illness and experiences psychosis. The Care Plan dated 10/14/25 documents R4 demonstrates cognitive impairment related to a diagnosis of mental illness and medical complexities. R4 has a guardian. An intervention includes staff will coordinate requests made by my guardian and will contact my guardian for appropriate treatment consent/authorization. The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment).The Physician Order Summary documents ordered medications. An order was placed that nurses may crush medications if appropriate and mix with soft food. There is no order that medications must be put in food if R4 refuses to take the medication.The Medication Administration Record (MAR) dated 10/2025 145701 Page 2 of 3 145701 12/05/2025 Bella Terra Streamwood 815 East Irving Park Road Streamwood, IL 60107

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documents R4 had a total of five times during the month where R4 refused the medication. On 10/13/25, the morning or 9AM scheduled medications were Risperdal 1 mg tablet, Xarelto 20 mg tablet, senna-plus 8.6-50 mg tablet, and Ativan 0.5 mg tablet, and it is charted as DR- drug refused. The Psychotropic Management Program Comprehensive Evaluation date 10/27/25 documents R4 currently takes two psychotropic medications daily. R4 has poor medication compliance. Non-pharmacological interventions that should be attempted are redirect R4, remove R4 from a situation to ensure safety, allow venting, and activity involvement.The State Guardian Letter dated 1/24/25 documents R4 needs a state guardian for care management which will be permanent.The policy titled, Medication Pass, dated 7/2/25 documents, Policy Statement: it is the policy of the facility to adhere to all federal and State regulations with medication pass procedures. Procedures.7. PO meds:.b. Crushed medications must now be done separately. Each pill is crushed in an individual cup, applesauce added, and given to the resident. The cup must be completely cleaned out or it is considered an incomplete dose.e. After medication is administered to each resident, sign MAR that it was given.The State of Illinois Department on Aging Resident's Rights for People in Long-term Care Facilities was provided by the facility and documents, Your facility must make reasonable arrangements to meet your needs and choices.V12 denied having a policy that included the seven medications rights or a different policy on resident rights. 145701 Page 3 of 3