Bella Terra Lombard

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident rooms free of mold. This applies to 15 of 17 residents (R1, R7-R12, and R15-R22) reviewed for facility environment in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the development of a facility acquired stage 3 pressure ulcer. This failure resulted in R1 developing a facility-acquired stage 3 sacral pressure ulcer. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in sample 5.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to obtain measurements of a pressure injury during a wound evaluation. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's bed had protective pieces in place for the resident's safety. This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 6.

Inspectors wroteBased on interview and record review the facility staff failed to promptly report a resident's allegation of abuse to the facility's abuse coordinator in accordance with facility policy. This applies to 1 of 3 residents (R1) reviewed for abuse allegation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 2 of 4 residents (R4 and R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R4 is an [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R4 is dependent on toilet hygiene. On 3/7/25 at 10:05 AM, R4 stated, They changed me this morning at around 4:30 AM. I want to be changed now. The CNA is supposed to come and change me. On 3/7/25 at 10:10 AM, V5 (CNA) stated, I started 6:00 AM today and am on my way to change R4. We should provide incontinent care to dependent residents every two hours. I was passing breakfast trays. On 3/7/25 at 10:10 AM, R4 was observed with a urine-soaked incontinent brief with brownish discoloration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician orders to provide wound care to a stage 4 sacral pressure ulcer. This applies to 1 of 3 (R1) residents reviewed for pressure ulcer and treatment in a sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for activities of daily (ADL) care in a sample of 4. The Findings Include: 1. R2 is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. MDS also indicates that R2 is dependent on toilet hygiene. On 7/19/24 at 9:45 AM, R2 stated, I was changed at 5:00 AM today. I am a little wet now. On 7/19/24 at 10:05 AM, per the surveyor's request, V5 (Certified Nursing Assistant/CNA) checked on R2 for incontinence and found R2 with a urine-soaked diaper and urine smell in the room. On 7/19/24 at 10:05 AM, V5 stated, I started my shift at 6:00 AM, and I didn't change her today. We should check residents every two hours for incontinent care. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident was free from misappropriation of prescribed narcotic medication. This applied to 1 of 4 residents (R1) reviewed for narcotic/controlled medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food preparation equipment was sanitized prior to preparing food. This has the potential to affect all 138 residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a wound was assessed and the wound nurse practitioner notified of a new wound. The facility failed to ensure pressure relieving interventions were in place for residents who are at risk for pressure ulcer for 4 of 5 residents (R98, R105, R121 and R240) reviewed for pressure injuries in the sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received their range of motion (ROM) exercises as ordered and failed to ensure splints were placed for a resident with contractures as ordered for 4 of 10 residents (R5, R14, R28 and R79) reviewed for restorative services in the sample of 29.

Inspectors wroteBased on interview and record review the facility failed to treat a resident in a dignified manner. This applies to 1 of 29 residents (R9) reviewed for dignity in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were in place for residents with a history of falls for 2 of 29 residents (R108, R33) reviewed for safety in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident nebulizer equipment was stored in a manner to prevent cross contamination for 3 of 6 residents (R3, R26, R69) reviewed for oxygen in the sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to reorder a resident's medication. This applies to 1 of 29 residents (R340) in the sample of 29 reviewed for pharmacy services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff wore personal protective equipment (PPE) when providing direct resident care for residents on enhanced barrier precautions (EBP) for 2 of 29 residents (R28 and R97) reviewed for infection control in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 4 of 5 residents (R1, R3, R4, and R5) reviewed for activities of daily (ADL) care in a sample of 9. The Findings Include: 1. R1 is a [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R1 is dependent on toilet hygiene. On 4/9/24 at 9:22 AM, R1 was observed with V5 (Certified Nursing Assistant/CNA) and R1 was observed with an inner liner inside an incontinent brief soaked with urine and feces. V5 stated on 4/9/24 at 9:22AM, I started my shift at 6:00 AM, and I checked her around 6:20 AM, and R1 was dry then. We are supposed to check residents for incontinence every two hours. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 4 (R1) residents reviewed for activities of daily living in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to re-assess and allow a resident to return to the facility during an involuntary discharge appeal for 1 of 1 resident in a sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, seal and store food items and practice proper sanitation in the kitchen. 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 maintain a safe, comfortable, and homelike environment. This applies to 6 of 6 residents (R9, R10, R14, R82, R110, R178) reviewed for environment in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure a metal oxygen tank in a holder in the resident's room and failed to safely position residents in proper sitting positions while eating meals in bed. This applies to 7 of 33 residents (R29, R38, R39, R54, R57, R68, and R115) reviewed for accidents and supervision in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to don appropriate personal protective equipment (PPE) for residents under Enhanced Barrier Precautions (EBP) while providing high contact patient care. This affects 4 of 4 residents (R25, R71, R96, and R111) reviewed for infection control in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for self-administering medications and obtain physician orders to have meds stored in resident rooms. This applies to 2 of 6 residents (R23, R179) reviewed for medications in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times or in ordered dosage). There were 27 opportunities with 4 errors resulting in a 14.81% error rate. This applies to 2 of 4 residents (R88, R99) observed in the medication pass.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was in good working condition for a dependent resident. This applies to 1 of 1 resident (R28) reviewed for call lights system.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents medications were administered after it was prepared to prevent medication error and the facility failed to ensure that controlled pain medication was not borrowed from another resident. This applies to 13 of 13 residents (R5, R8, R16, R17, R19, R21, R31, R40, R48, R62, R69, R73, R107) observed during medication cart observation in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and incontinence care. This applies to 5 of 5 residents (R13, R31, R32, R33 and R62) reviewed for ADL (activities of daily living) in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bladder and urinary indwelling catheter care in a manner that would prevent urinary tract infection. This applies to 4 of 8 residents (R13, R33, R60, R61) reviewed for bladder and urinary catheter care in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pharmacy instructions/recommendation of how to store medications. The facility also failed to ensure that an expired medication is removed from the refrigerator where it was mixed with other medications. This applies to 4 of 4 residents (R66, R82, R99, R111) reviewed for medication storage and labeling in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide double portions of entrée and milk for residents with a diet order or preference for the same. This applies to 4 of 4 residents (R8, R34, R81,R100) reviewed for dining in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve mechanical soft roast beef portions for the lunch meal. This applies to 4 of 4 residents (R8, R22, R36, R48) reviewed for mechanical soft diets in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter bag was covered. This applies to 3 of 6 residents (R61, R72, R368) reviewed for urinary catheter in the sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident received foot care and treatment for overgrown, thick toenails. This applies to 1 of 1 resident (R13) reviewed for foot care and services in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall precautions were implemented for a resident with a history of multiple falls. This applies to 1 of 2 residents (R61) reviewed for falls in a total sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor resident behaviors who were receiving psychotropic medications. This applies to 2 of 5 residents (R24 and R61) reviewed for psychotropic medications in a total sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control process with regards to hand hygiene and changing of gloves during provisions of care. The facility also failed to ensure that a catheter tubing and bag is not directly touching the floor. This applies to 3 of the 8 residents (R13, R33, R60) reviewed for infection control in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all staff were fully vaccinated for COVID-19. This has the potential to affect all 120 residents residing in the facility.