Bella Terrace Rehabilitation and Nursing Center

Inspectors wroteBased on record review, staff interview, review of the facility investigation, review of hospital records, review of police report, and policy review, the facility failed to provide the appropriate supervision for one cognitively impaired resident (Resident #46) who was at high risk for elopement and required the supervision of a secured memory care unit for his safety. Resident #46 eloped from the facility without staff knowledge on 07/05/25. This resulted in Immediate Jeopardy on 07/05/25 at 11:20 A.M. when Resident #46 was taken off the secured memory care unit to go outside with the memory care unit residents who smoke. Resident #46 was brought back in the building and left unattended at the elevator in the lobby on the first floor by Certified Nursing Assistant (CNA) #501, after being outside with the smoke group. Resident #46 was not discovered missing until 12:37 P.M. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure a safe, sanitary and home-like environment. This had the potential to affect all 85 residents in the facility. Facility census was 85.

Inspectors wroteBased on observation, interview and review of work orders, the facility failed to maintain an environment free from a pest's infestation. This had potential to affect all 82 residents.

Inspectors wroteBased on medical record reviews and interview the facility failed to ensure physician's orders were followed when administering medications. This affected two (Residents # 56 and # 94) of five residents reviewed for medication administration. Facility census was 82.

Inspectors wroteBased on observation, interview, sanitizing instructions, and policy review, the facility failed to ensure the staff were properly trained on how to check the sanitization level in the dishwasher. This had the potential to affect all 90 residents. Facility census was 90.

Inspectors wroteBased on review of the facility's antibiotic stewardship program and staff interviews the facility failed to ensure the facility's antibiotic stewardship program was completed by a certified infection control preventionist (ICP). This had the potential to affect all residents residing in the facility. The facility's census was 90. Findings Include: A review of the facility's antibiotic stewardship program dated 05/01/25 to 06/30/25 revealed the monthly tracking logs, trending maps, and the antibiotic criteria forms (McGeers) being completed by the facility's Director of Nursing (DON). There was no signatures on the monthly tracking logs to reflect an ICP was monitoring the program. A review of the facility's infection control program revealed the facility's ICP is the Regional Director of Clinical Services (RDCS) #601. RDCS #601's ICP certification was received in 12/21/19. [...]

Inspectors wroteBased on observation, work orders, policy and interview, the facility failed to ensure cool air temperatures, functional sinks, functional shower rooms, maintenance of ceilings, walls, floors, window seals and vanities, furniture, mattress, toilet paper holders, and functional hand sanitizer dispensers. This affected 24 (Resident's #24, #26, #27, #28, #32, #37, #38. #39, #40, #49, #52, #53, #56, #57, #58, #59, #60, #68, #73, #75, #76, #78, #185, and #285) of 90 residents in the facility.

Inspectors wroteBased on observation, interviews, work orders, and policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This had the potential to affect all 90 residents. Facility census was 90.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure resident representatives were invited to care conferences. This affected two residents (#56, #61) of two residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide barber services for Resident #38. This affected one resident (#38) of four residents reviewed for activities of daily living. Facility census was 90.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure medical records contained accurate advance directives. This affected two residents (#39, #61) of 24 residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate assessment was completed for Resident #68. This affected one (Resident #68) out of 28 resident record reviews. Facility census was 90.

Inspectors wroteBased on medical record review, staff interview and review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) manual the facility failed to complete a significant change MDS required for a resident admitted to hospice services. This affected one resident (Resident #2) of two residents reviewed for hospice services. The facility census was 90. Findings Include: A review of Resident #2's medical record revealed admission date 12/05/23 with the following diagnoses including but not limited to depression, high blood pressure, heart failure, anxiety, and schizoaffective disorder. Resident #2 had impaired cognition and required assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #2's physician orders revealed a revised order dated 03/13/25 to be admitted to Hospice with the diagnosis of metabolic encephalopathy. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure assessments were accurately completed. This affected two (Resident #5 and Residents #40 ) of twenty eight residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 90.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) review was completed with a new psychiatric diagnosis. This affected one (Resident #61) of two residents reviewed for PASARR. The census was 90.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop a dental plan of care and identify triggers for Post Traumatic Stress Disorder (PTSD). This affected two (Resident #10 and #40) of 27 residents reviewed. The census was 90.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure Resident #60, #68, and #72 had comprehensive care plans addressing preferences. This affected three (Residents #60, #68, and #72) out of 28 records reviewed. Facility census was 90.

Inspectors wroteBased on observation, record review, policy and interview, the facility failed to ensure nail care was provided to dependent residents. This affected two (Resident #61 and #78) of four residents reviewed for activities of daily living. The census was 90.

Inspectors wroteBased on record review, policy and interview, the facility also failed to remove a resident's surgical staples and administer antibiotics to meet professional standards. This affected two residents (#134 and #234) out of 29 residents reviewed for appropriate care and services. Facility census was 90.

Inspectors wrote2. Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She has minimal difficulty hearing with no hearing aide, had the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. Interview 06/24/25 at 10:34 A.M. with Resident #61 revealed she wore glasses for distance vision but had not seen an eye doctor since she was admitted to the facility. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide a comprehensive, resident centered treatment plan for the prevention and/or management of pressure ulcers. This affected one (Resident #68) out of two residents reviewed for pressure ulcer care.

Inspectors wroteBased on record review, interview, observation and policy review the facility failed to provide a comprehensive, resident centered fall prevention plan and failed to adequately assess residents after a fall. This affected two (Resident #5 and #135) of three residents reviewed for appropriate care and services. Facility census was 90.

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to store respiratory equipment in a safe and sanitary manner. This affected one resident (Resident #80) of two residents reviewed for respiratory care. The facility census was 90. Findings Include: A review of Resident #80's medical record reviewed admission date 05/30/25 with the following diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, high blood pressure, and type two diabetes. Resident #80 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a resident was provided with identified pain was provided with adequate pain control. This affected one resident (#78) of 29 residents reviewed for care and treatment. The facility census was 90.

Inspectors wroteBased on medical record review, observation, interview and review of facility policy the facility failed to ensure medications were stored securely and failed to remove expired medications from the third-floor medication storage room. This affected one resident (Resident #80) of six residents reviewed for medication administration and the potential to affect 46 residents residing on the third floor. The facility census was 90. Findings Include: 1. A review of Resident #80's medical record reviewed admission date 05/30/25 with the following diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, high blood pressure, and type two diabetes. Resident #80 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide routine dental care. This affected one (Resident #61) of three residents reviewed for dental care.

Inspectors wroteBased on medical record review, staff interviews and facility policy review, the facility failed to initiate therapy services for skilled residents. This affected two residents (#5, #285) out of two residents reviewed for rehab and restorative services. The facility's census was 90. Findings Include: 1. A review of the medical record for Resident #285 revealed admission date 06/18/25 with the following diagnoses including but not limited to aftercare following joint replacement of left hip, high blood pressure, and depression. Resident #285 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #285's physician orders revealed an order dated 06/19/25 to be admitted to skilled level of care. [...]

Inspectors wroteBased on record review, facility documentation review, and staff interview the facility failed to ensure resident activity documentation was accurate. This affected one resident (#72) of one resident reviewed for activities. Facility census was 90.

Inspectors wrote2. Review of Resident #10's medical record revealed a 05/21/24 admission with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, asthma, epileptic seizures, mood disorder, dysthymic disorder, post-traumatic stress disorder, macular degeneration, major depressive disorder, neuropathy, arthritis, malignant neoplasm of lung and bronchus, chronic obstructive pulmonary disease, hyperlipidemia, history of malignant neoplasm of pancreas, insomnia, gastroesophageal reflux disease, and nicotine dependence. On 02/15/25 at 5:01 P.M. the emergency squad arrived at the facility stating they received a 911 call from the resident due to nausea, vomiting and diarrhea. The resident's temperature was normal 98.6 degrees Fahrenheit on discharge. The resident was admitted with a diagnosis of diarrhea. The resident was readmitted to the facility 02/19/25 at 8:00 P.M. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to perform hand hygiene during medication administration. This deficient practice affected three residents (Resident #7, #26, and #42) of three residents observed for medication administration. The facility census was 81. Findings Include: Observation on 11/25/24 from 8:10 A.M. to 8:35 A.M. revealed Licensed Practical Nurse (LPN) #381 completing morning medication administration for the third floor unit of the facility. LPN #381 prepared medications for Resident #7. LPN #381 did not wash or sanitize their hands prior to removal of the medications into the medication cup. LPN #381 then entered Resident #7's room and administered the medications, exited the room and returned to the medication cart without washing or sanitizing their hands. [...]

Inspectors wroteBased on medical record review, family interview, staff interview, and facility policy review, the facility failed to timely notify all resident representatives/guardians of a temporary discharge. This affected 61 residents (#83, #84, #85, #82, #87, #86, #62, #51, #55, #56, #6, #88, #29, #12, #63, #50, #73, #3, #28, #20, #75, #89, #61, #46, #90, #24, #32, #34, #35, #52, #15, #22, #23, #68, #91, #2, #76, #16, #36, #69, #39, #33, #7, #78, #60, #4, #5, #17, #13, #11, #79, #19, #14, #43, #41, #42, #8, #57, #92, #40, and #9) of 91 residents residing in the facility at the time of the emergency temporary discharge. Findings Include: Interview with Administrator on 07/30/24 at approximately 10:30 A.M. revealed the facility had an emergency which resulted in the temporary evacuation of all residents beginning on 07/22/24 around 12:30 P.M. due to the electricity to the facility being shut off. [...]

Inspectors wroteBased on observations, review of the facility policy, staff interviews, and review of the health departments' food inspection reports, the facility failed to ensure the kitchen was in a sanitary condition. This had the potential to affect all 95 residents who received food from the kitchen. The facility identified one resident (#32) who received nothing by mouth. The facility census was 96.

Inspectors wroteBased on observations, family and staff interviews, review of the facility's policy, review of the State of Ohio Food Inspection Report, and record review of work orders and pest control report, the facility failed to maintain an effective pest control program to ensure it was reasonably free from cockroaches. This had the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on medical record review, staff interview, and resident interview, the facility failed to ensure residents who were dependent on staff assistance received baths/showers as scheduled/requested. This affected two (Residents #68 and #73) of three residents reviewed for bathing. The census was 89.

Inspectors wroteBased on record review and interview, the facility failed to provide radiology services as ordered for Resident #5. This affected one resident (#5) of three residents reviewed for the provision of outside/diagnostic services. The census was 90.

Inspectors wroteBased on record review, resident and staff interviews, review of hospital records, and facility policy review, the facility failed to timely treat and assess a pressure ulcer and prevent the pressure ulcer from worsening for one resident (Resident #234). Actual Harm occurred on 08/01/23 when Resident #234 was admitted to the facility with a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure wound to her left proximal (back) upper thigh that worsened to a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer without evidence of routine skin assessments or timely treatments. This affected one resident (Resident #234) out of two residents reviewed for pressure ulcers. The facility census was 82. Findings Include: [...]

Inspectors wroteBased on medical record review, staff interview, hospital record review, and facility policy review, the facility failed to complete comprehensive blood glucose monitoring for Resident #65 to ensure insulin was administered per physician order and to meet the resident's total care needs. Actual Harm occurred when the lack of blood glucose monitoring (beginning in June 2023 and continuing through August 2023) and evaluation and/or administration of insulin resulted in ongoing episodes of hyperglycemia. On 08/12/23 Resident #65 had a blood glucose reading above 500 milligrams per deciliter (mg/dL) and was admitted to the hospital with hyperglycemia and acute kidney injury. This affected one resident (#65) of four residents reviewed for quality of care. The facility census was 82.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to update Preadmission Screening and Resident Review (PASARR)'s for residents with new mental health diagnoses. This affected four (Residents #50, #52, #59, and #65) of the four residents reviewed for accurate PASARRs. The facility census was 82.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop and/or implement care plans for five (Residents #19, #47, #66, #67, and #284) of the seven residents reviewed. The facility census was 82.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to revise comprehensive care plans for four (Residents #20, #66, #284, and #289) out of the five residents reviewed. The facility census was 82. 1. Review of the medical record for Resident #66, revealed an admission date of 06/07/22. Diagnoses included: fusion of the spine in the cervical region, cord compression, alcohol abuse with intoxication, nicotine dependence with cigarettes and unspecified mood affective disorder with a code status of full code with no known allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. [...]

Inspectors wroteBased on observation, record review, review of facility accident investigations, review of the facility incident/accident log, review of hospital records, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (Resident #30) was supervised while smoking, the facility failed to complete neurological checks following an unwitnessed fall for one resident (Resident #56), the facility failed to complete a comprehensive investigation when one resident (Resident #67) required the administration of Narcan (a medication to reverse the effects from a drug overdose), the facility failed to ensure fall interventions were in place for one resident (Resident #47), the facility failed to reassess the effectiveness of fall interventions following multiple falls for one resident (Resident #289), and the facility failed to complete a through investigation [...]

Inspectors wroteBased on staff interviews, medical record reviews, and the facility policy, the facility failed to offer non-pharmacological interventions and/or pain descriptions prior to administration of pain medications. This affected five residents (#50, #66, #67, #71, and #289) out of the five residents receiving pain medication reviewed. The facility census was 82.

Inspectors wroteBased on interview and record review the facility failed to provide appropriate diagnoses or monitoring for the use of psychotropic medications for Resident #19, #47, #66, #71, and #284. This affected five residents (#19, #47, #66, #71, and #284) of seven residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to notify the physician when one resident's (Resident #6) blood sugar levels were over 400 as ordered. The facility also failed to notify the physician and resident representative of a change in condition for one resident (Resident #284). This affected two residents (Residents #6 and #284) of two reviewed for notification of changes. The facility census was 82. Findings Include: 1. Review of the medical record for Resident #6 revealed an admission date on 12/06/22. Medical diagnoses included type II diabetes mellitus, obesity, hypertension (high blood pressure), anxiety disorder, and major depressive disorder-recurrent. Review of the physician orders dated August 2023 revealed Resident #6 had an order to notify the physician if blood sugar (BS) was under 60 or over 400. [...]

Inspectors wroteBased on interview and record review the facility failed to timely complete and provide written transfer notices for Resident #47 and Resident #284 who were hospitalized . This affected two (Resident #47 and #284) of three residents reviewed for transfers. The facility census was 82.

Inspectors wroteBased on record review and interview the facility failed to provide timely follow up treatment for Hepatitis C for Resident #49 and failed to ensure timely wound monitoring and care for Resident #47's leg wound. This affected two residents (#47 and #49) of four residents reviewed for quality of care. The facility census was 82.

Inspectors wroteBased on observation, interview, and medical record review revealed the facility failed to ensure Resident #47 saw podiatry in a timely manner. This affected one resident (#47) of two residents reviewed for activities of daily living. The facility census was 82.

Inspectors wroteBased on medical record review, staff interview, review of dialysis communication forms, and review of facility policy, this facility failed to ensure post dialysis weights were obtained as per order. This affected one (Resident #15) of one residents reviewed for dialysis services. Facility census was 82.

Inspectors wroteBased on interview, review of resident medical records and pharmacy recommendations revealed the facility failed to timely address pharmacy recommendations for Resident #19 and #71. This affected two residents (#19 and #71) of seven residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on interview and record review the facility failed to monitor blood pressure consistently prior to administering medications for Resident #20 and #47 additionally they failed to monitor for side effects of medications for Resident #289. This affected three residents (#20, #47 and #289) of seven residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on interview and record review the facility failed to ensure current hospice plan of care and documentation was on site. This had the affected one resident (#20) of one resident reviewed for hospice. The facility census was 82.

Inspectors wroteBased on record review and interview the facility failed to ensure care plans were revised for residents following a change in condition/status. This affected four residents (#10, #11, #23 and #32) of 14 residents reviewed for comprehensive care plans.

Inspectors wroteBased on observation, record review and interview the facility failed to promote the dignity of Resident #20 by not removing a hospital identification bracelet upon readmission to the facility. This affected one resident (#20) of one resident reviewed for dignity.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #11's privacy was maintained while receiving care and Resident #28's room had window curtains to provide privacy. This affected two residents (#11 and #28) of two residents reviewed for privacy.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive and individualized dental care plan for Resident #7. This affected one resident (#7) of three residents reviewed for dental care.

Inspectors wroteBased on record review and interview the facility failed to ensure ordered dental treatment was provided to Resident #7. This affected one resident (#7) of three residents reviewed for dental care.

Inspectors wroteBased on record review and interview the facility failed to timely implement a pharmacy recommendation for Resident #23 that was approved by the physician related to a psychotropic medication. This affected one resident of six residents reviewed for unnecessary medication use.

Inspectors wroteBased on closed record review and staff interview the facility failed to ensure a psychoactive medication, administered to Resident #24 was justified and ordered by the physician at the time of administration. This affected one resident (#24) of six residents reviewed for unnecessary medication use.