Health inspection·December 5, 2025

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145701 If continuation sheet Page 2 of 3 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 12/05/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 145701 If continuation sheet Page 3 of 3