Bel Air at Teravista

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards or practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 (Resident # 128) residents reviewed for pain management. The facility failed to administer pain medication to Resident #128, who had pancreatic cancer, from the time she was admitted [DATE] at 7:30 p.m. to 6/2/26 at 10:00 a.m. This failure could place the residents at risk of delayed healing, physical, mental, and psychological distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 10 residents (Resident #13, Resident #48, and Resident #86) reviewed for ADL care. The facility failed to ensure, Resident #48, and Resident #86 did not have unwanted facial hair. The facility failed to ensure Resident #13 was changed or toileted every two hours. This failure could place residents at risk of embarrassment and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident, that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 7 residents (Resident #28, Resident #13, and Resident #127) reviewed for quality of care. The facility failed to ensure: Nursing staff weighed Resident #13 and Resident #127 every day according to their care plan and physician's orders due to their CHF diagnosis. Nursing staff provided wound care for Resident #28 according to her care plan and physician's orders. These failures could place the residents at risk of fluid overload, infection, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for all residents who consumed foods orally from the only kitchen in the facility that: The facility failed to provide palatable food that was attractive or appetizing to residents who complained the food did not look or taste good and that it was frequently cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, food borne illnesses, and diminished quality of life. During an interview on 06/02/2026 at 1:05 p.m., it was revealed that Resident #18's only complaint was that her soup was too salty. During an interview on 06/02/2026 at 3:29 p.m., Resident #17 stated his meals were served cold almost every day. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. The facility failed to ensure dietary staff followed proper handwashing and glove use. These deficient practices could place residents at risk for food borne illness. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. The facility failed to ensure dietary staff followed proper handwashing and glove use. These deficient practices could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 5 of 12 residents (Resident #128, Resident #90, Resident #41, Resident #37, and Resident #60) reviewed for infection control. Facility failed to ensure: TN L sanitized the over-the-bed table prior to setting supplies on it for Resident #90's wound care, did not put on PPE (gown) before providing care to Resident #128 and Resident #90 and did not sanitize her hands two times between changing gloves during Resident #90's wound care. MA D sanitized her hands between changing gloves after performing eye drops for Resident #60 and failed to sanitize the blood pressure cuff between Resident #37 and Resident #41. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident had the right to be informed of, his or her treatment which includingrights.ht to be informed in advance, by the physician or other practitioner or professional, of the risk and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 5 residents (Resident #1) reviewed for resident rights .The facility failed to provide information to Resident #1's FM about the change of medication from Lantus (Insulin) to Metformin and its risks and benefits and other alternative options available. This failure could place residents at risk of receiving medications without their prior knowledge or consent.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents (R #1) reviewed for medication administration. The facility failed to administer R#1's physician ordered 4 units of Insulin Lispro Injection solution, prescribed to treat Type 2 Diabetes Mellitus, (elevated blood sugar levels) on 12/19,12/22,12/23,12/24,12/25,12/28,12/29 and 12/30/2025. These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents (R#2), reviewed for pharmaceutical services, in that:The facility failed to ensure Resident #2 had her physician ordered Robaxin (muscle relaxer) 1 500 mg tablet by mouth every 8 hours for pain, available on 01/10/2026. This failure could place residents at risk for not receiving medication as ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of care. The facility failed to ensure Resident #1, Resident #2 , Resident #3, Resident #4, Resident #5's nebulizing masks and/or oxygen canulas were bagged for sanitation when not in use on 11/06/25. This failure could place residents at risk for respiratory infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents review for resident rights. RN A failed to notify Resident #1's family when a new medication order for antibiotics, to treat a urinary tract infection, was initiated on 06/14/2024. This failure put residents at risk for not having their representative notified and aware of their current medical status.

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay and final status of discharge for three of three (Resident #1, Resident #2, Resident #3) reviewed for discharge summary. The facility failed to complete a discharge summary and recapitulation for Resident #1, Resident #2 and Resident #3. This failure could place residents at risk of not having complete records, necessary services, or information after permanent discharge from the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide routine and/or emergency drugs and biologicals to its residents for three of (Resident #21, Resident #345, and Resident #90) four residents reviewed for pharmacy services. The facility failed to ensure Resident #21, Resident #345, and Resident #90's antibiotic medicine were administered daily as ordered. The facility failed to administer antibiotic medicine 02 times and at the correct time 21 times for Resident #21. The facility failed to administer antibiotic medicine 04 times for Resident #345. The facility failed to administer antibiotic #1 medicine 01 time and at the correct time 06 times for Resident #90. The facility failed to administer antibiotic #2 medicine at the correct time 16 times for Resident #90. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. Some food items were not labeled at all. - The grease in the fryer was dirty. - Drawers where the serving utensils were stored were not clean with debris in in the drawer. - Staff serving food in hall 100 were not sanitizing their hands before getting food trays to take to the resident. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regiment review recommendations from the pharmacy consultant were received and acted upon for 1 (Resident # 144) of 4 residents reviewed for drug regimen review. The facility failed to follow their policy regarding the pharmacy consultant and did not follow up on new admission pharmacy consultant recommendations dated 3/28/25. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 7 residents reviewed for accidents and hazards. CNA A failed to transfer Resident #1 received assistance with the mechanical lift on 12/14/2024. This failure could result in residents receiving injuries. The noncompliance was identified as PNC. The IJ began on 12/14/24 and ended on 12/16/24. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) for 1 (Resident #2) of 1 reviewed for pharmaceutical services. MA D left Resident #2's medications with her and walked out without observing Resident #2 taking the medications. This failure could place residents at risk for not receiving a therapeutic effect or another resident getting the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on 08/22/24. She was found less than two hours later approximately one mile away at a gas station on a busy street. She had a fall which resulted in a swollen face and a cheek abrasion. This noncompliance was identified as PNC IJ. The deficient practice began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for, falls, injuries, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences by not ensuring the resident call system was accessible to 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for call systems. - Resident call system was not accessible for Resident #1, Resident #2, and Resident #3. This failure could endanger the health or safety of the resident or other residents if they are not able to call for assistance when needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents' had the right to a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatment and supports for daily living safety for 6 residents (Residents #9, #29, #40, #57, #61 and #68) of 20 residents reviewed for resident rights. The facility failed to ensure resident room water temperature was maintained at a comfortable warm temperature which was at least 100 degrees F. This failure could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the facility's only dry storage were dated and sealed appropriately. 2. The facility failed to ensure food items in the facility's only walk in freezer were dated and sealed appropriately. 3. The facility failed to ensure staff wore proper hair or beard coverings. These failures could place residents at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident # 6 and Resident #75) reviewed for infection control. - LVN B failed to don gloves while assisting Resident #75 with a PICC dressing change. - RN C failed to maintain a sterile field while performing a PICC dressing change for Resident #75. - LVN E failed to perform hand hygiene after changing her gloves failed to change her gloves after they became contaminated and failed to maintain a sterile field during a catheter change for Resident #6. - CNA F failed to change her gloves after they became contaminated while performing perineal care for Resident #6. [...]