Bella Terra Bloomingdale

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from abuse. This failure resulted in R1 experiencing a broken arm after R2 struck R1 with a plate cover. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the diet spreadsheet and standardized recipes to ensure satisfactory taste and palatability for residents. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a qualified staff member performed wound care as prescribed for a resident (R93) with a stage 3 pressure ulcer to the right buttock. This applies to 1 of 3 residents (R93) reviewed for nursing services in a sample of 24.

Inspectors wroteBased on the interview and record review, the facility failed to ensure physician's orders were in place for using the two ports on a resident's gastrojejunostomy tube (GJ tube). This applies to 1 of 2 residents (R102) who were reviewed for tube feeding in a sample of 24. On 04/08/2024, around 10:15 AM, V21(Family member) reported that R102 has a gastrojejunostomy tube (GJ tube) and the feeding should be given through the jejunal port, and medication administration through the gastric port. V21(R102's family) said the staff is not following the physicians' order, and R102 went to the hospital multiple times for the replacement of the GJ tube due to clogging. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain timely diagnostic imaging. This applies to 1 of 3 residents (R1) reviewed for diagnostic imaging in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident with a mechanical lift. This failure resulted in R1 sustaining a closed fracture of the distal end of his right femur and requiring surgery. This applies to 1 of 4 residents (R1) reviewed for transfers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for accidents in the sample of 9. This failure resulted in R1 receiving stitches to a left leg laceration. This past noncompliance occurred from 6/3/25 to 6/9/25.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician and as scheduled in the EMR (Electronic Medical Record). This applies to 5 of 16 residents (R1, R2, R3, R13, R15) reviewed for quality of care in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin as ordered by the physician. This applies to 4 of 16 residents (R1, R2, R3, R4) reviewed for quality of care in the sample of 16.

Inspectors wroteBased on interview and record review, the administration failed to provide oversight and leadership to ensure resident nursing care assignments were revised due to a change in staffing to ensure residents received nursing care and medications as ordered by the physician. This applies to 16 of 16 residents (R1- R16) reviewed for quality of care and administration in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and serve the posted menu for residents. This applies to all 18 residents (R8, R11, R18, R14, R41, R54, R55, R57, R59, R62, R70, R76, R82, R96, R357, R360, R361, R362) who receive non-vegetarian mechanical soft and puree regular diets, and 1 resident (R22) who receives a vegetarian pureed diet from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its respiratory testing policy for the management of its COVID-19 outbreak. The facility also failed to follow infection control practices for residents on transmission-based and enhanced-barrier precautions and failed to thoroughly disinfect glucometers. This applies to 13 of 13 residents (R23, R53, R307, R96, R32, R359, R103, R358, R48, R157, R26, R21, and R98) reviewed for infection control in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to repair a resident's bed. This applies to 1 out of 3 (R103) residents reviewed for environment in a sample of 31.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide residents with grooming and incontinent/hygeine care for residents who require assistance with ADLs (Activities of Daily Living) This applies to 3 of 3 residents (R14, R43, and R46) reviewed for ADL cares in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure blood glucose testing was performed as accurately as possible and failed to follow up on resident concerns with characteristics of urinary output. This applies to 4 of 4 residents (R26, R96, R98, R157) reviewed for quality of nursing care in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls for residents with recent histories of falls. This applies to 2 of 2 residents reviewed (R14, R100) for fall and injury in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to to ensure urinary catheter tubing and drainage bags were positiond in a manner to prevent infection. This applies to 3 out of 4 (R358, R96, and R95) residents reviewed for urinary catheters in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a Resident fall (caused by an improper transfer) to licensed staff before assisting the Resident up from the floor, failed to transfer residents using gait belts, and failed to ensure resident tranfer status was clearly communicated. This applies to 5 out of 5 residents (R1-R5) reviewed for accidents.

Inspectors wroteBased on interview and record review the facility failed to provide showers in accordance with the facility schedule and policy for residents identified as needing assistance with showers. This applies to 5 of 5 residents (R1, R2, R3, R7, R8) reviewed for showers/baths in the sample of 8.

Inspectors wroteBased on interview and record review the facility did not follow their policy for Urinary Catheter Care and failed to document the assessment of symptoms for residents with indwelling urinary catheters who developed UTIs (Urinary Tract Infections) This applies to 3 of 4 residents (R1, R2 and R8) reviewed for indwelling urinary catheter care and UTI in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide feeding assistance for a resident with a dysphagia diagnosis, requiring 1 to 1 feeding assistance. This applies to 1 of 4 (R1) residents reviewed for feeding assistance reviewed for safety supervision in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow dietary orders for a resident. This applies to 1 of 4 (R1) residents reviewed for special diets in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. This applies to 1 of 4 residents (R1) reviewed for psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care to a resident that needs extensive assistance for activities of daily of livings (ADL's) for 1 of 9 residents (R17) reviewed for ADL's in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prescription glasses to a resident to maintain vision for 1 of 1 resident (R35) reviewed for vision services in the sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to treat pressure injuries by not ensuring pressure relieving devices/ interventions were in place for a resident with a pressure injury. This applies to 1 of 6 residents (R63) reviewed for pressure injuries in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident with a history of falls. This applies to 1 of 19 residents (R7) reviewed for safety in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fortified supplements for a resident with significant weight loss. This applies to 1 of 8 residents (R47) reviewed for weight loss in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times) There were 32 opportunities with 3 errors resulting in a 9.32% error rate. This applies to 2 of 4 residents (R66, R7) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to separate COVID-19 positive and COVID-19 negative residents to prevent the transmission of COVID-19 when the residents shared the same room, and failed to ensure staff wear PPE (Personal Protective Equipment) when entering a COVID-19 positive room. This applies to 6 of 27 residents (R1, R2, R8- R11) reviewed for COVID-19 infection.

Inspectors wroteBased on interview and record review, the facility failed to assess, supervise, and implement safety measures for a resident who voiced homicidal and suicidal threats for 1 of 1 resident (R2) reviewed for safety and supervison in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was administered the correct medication for 1 of 4 residents (R1) reviewed for medication administration in the sample of 5.