Terra Bella Health and Wellness Suites

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible and residents received adequate supervision to prevent accidents for 1 out of 5 residents (Resident # 1) reviewed for quality of care. The facility failed to ensure Resident # 1's head of bed was upright and elevated, and that Resident # 1 was closely supervised during and after administration of oral medications on 5/23/26. This failure places residents at risk of aspiration and choking when administering oral medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 9 residents (Resident #1) reviewed for pain management. The facility failed to timely identify Resident #1's pain following a fall as a change in condition, failed to appropriately assess the pain, and failed to ensure ongoing monitoring and communication of the resident's pain status. Resident #1 was observed yelling in pain during care and received pain medication for more than 24 hours before the pain was fully assessed and later required hospital evaluation, a pain management regimen, and experienced a decline in functional abilities. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 9 residents (Resident #1) reviewed for notification of changes. The facility failed to timely consult Resident #1's physician after she reported right leg/knee pain following a fall. Resident #1 complained of pain the evening of the fall and again the following morning; however, the physician was not consulted until more than 24 hours after the initial complaint. Resident #1 later required hospital evaluation, changes to her pain management regimen, and experienced a decline in functional abilities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible for 1 of 9 (Resident #1) reviewed for accidents, in that Resident #1 was lowered to the floor when staff attempted to transfer Resident #1 while she remained wet from her shower and utilized an inappropriate transfer technique. Following the incident, Resident #1 complained of knee pain, required hospital evaluation, was placed on a pain management regimen, and experienced a decline in functional abilities. This failure placed residents at risk for falls, injury, increased pain, hospitalization, and further decline in functional abilities.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 9 residents (CR #3) reviewed for resident rights. The facility failed to provide CR #3 a hot meal upon admission to the facility. CR #3 requested to receive the hot dinner meal being served to other residents; however, the facility did not provide the requested meal and later offered a sandwich and snacks, which she declined. As a result, CR #3's family had to provide her with a hot meal. This failure placed the resident at risk for loss of dignity, unmet nutritional needs, emotional distress, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was not five percent or greater for 2 residents (Resident #10 and Resident #3) of 6 residents observed for Medication Pass. -Resident #10 was administered 9 medications that were prescribed to Resident #107. -Surveyor intervention prevented Resident #3 from receiving one medication that was prescribed to Resident #103. -The medication pass observation yielded 10 errors of 27 opportunities and resulted in a 37% error rate. The failure placed residents at risk of having harmful effects from being administered the wrong medications.

Inspectors wroteBased on interview and record review, the facility failed to establish and 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 one resident (Resident #1) of four residents reviewed for infection control. -Staff providing incontinent care for Resident #1 threw wet and/or soiled incontinent pads onto the floor. The failure placed the resident, visitors and staff at risk for acquiring infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one resident (Resident #1) of four residents reviewed for dietary services. -CNA C was in her first day of orientation and was assigned to assist Resident #1 with eating with no supervision. -Resident #1 had a diagnosis of dysphagia (difficulty swallowing). The failure placed Resident #1 at risk for choking and/or aspiration. Findings Include:Record review of the Face Sheet (no date) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident that one resident (Resident #1) of four residents reviewed for quality of care received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #1 had a wound dressing that was wet during a shower procedure and was not changed prior to being sent to an appointment. The failure could place the resident at risk for not receiving necessary care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) of four residents reviewed received adequate supervision and assistance devices to prevent accidents, in that:Resident #2 was lifted in a mechanical lift by a single staff, although the lift requires two people. Resident #2 was suspended in the air in the and moved by a single staff. The resident was swinging, with her weight shifting side to side. The failure could place residents at increased risk for inadequate supervision.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of 1 of 1 (Resident # 1) reviewed for enteral medication administration. LVN A failed to administer Resident # 1's enteral medications according to physician's order. This failure could place residents at risk for a clogged peg tube, adverse reaction, metabolic abnormalities and a decline in health.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 residents (CR #1) reviewed for neglect.-The facility failed to have structures and processes in place to ensure CR #1's wound was identified, and interventions were implemented. CR #1, who had PAD (a specific form of PVD in which there is narrowing of blood vessels taking blood to the extremities, leading to low or no oxygen), diabetes and a previous right-side AKA, did not receive podiatry services and nail care from admission on [DATE] until she discharged to the hospital on [DATE] (9 months). CR #1's had a wound to her left big toe documented in weekly skin assessments from 01/29/25 until 06/17/25, and there were no interventions implemented prior to hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 Residents (CR #1 ) reviewed for care plans. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (CR #1) reviewed for foot care - The facility failed to provide foot care or attain podiatry services for CR #1, a diabetic patient with severe PAD (a form of PVD in which narrowing of the blood vessels limit blood flow to the limbs) and a history of AKA from admission on [DATE] till she discharged on 06/17/25 to the hospital where she was diagnosed with osteomyelitis (a bone infection) that needed antibiotics, an AKA was recommended resulting in the family [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents (CR #1) reviewed for accuracy of assessments. - The facility failed to identify CR # 1's diagnosis of vascular diseases (narrowing of the blood vessels that result in oxygen not getting sent to the limbs also called PVD) and document it in her MDS(s) which resulted in CR #1 not having a plan of care for her diagnosis. These failures could place residents at risk of a compromised plan of care, worsening of health conditions, infection, injury, and amputation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 medication carts (100 Hall Nurse Cart) reviewed for medication storage . - LVN D failed to ensure the 100-200 Hall Nursing cart was locked when not under direct supervision of authorized staff. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 (Resident #1) of 17 residents reviewed for food form. The facility failed to ensure Resident #1 was served a pureed (blended or mashed to a smooth pudding like consistency) lunch tray on 03/28/2025 as ordered by her physician. Resident #1 was served a mechanical soft (soft chopped, ground foods) lunch tray. This failure could place residents at risk of consuming foods that could cause aspiration (food or liquids enter the airway) or choking.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent ulcers and not develop pressure ulcers for 1 of 8 residents, CR #1, reviewed for pressure ulcers. 1. [...]

Inspectors wroteBased on observations, interviews, 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 grooming for 1 of 8 residents (CR #1) reviewed for ADL's. 1. The facility failed to ensure CR #1's hair was adequately washed and combed for an unknown period and resulted in a thick accumulation of a brown, flakey substance on her entire scalp, and a large amount of matted hair in the back of her head which had to be cut off. 2. The facility failed to ensure CR #1's nails were cut and appropriately groomed which resulted in an accumulation of a dark brown/black substance underneath the nails. 3. The facility failed to notify CR #1's RP and physician that she had matted hair and an accumulation of a brown, flakey substance on her scalp which resulted in a delay in treatment/care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, for 1 (Resident #1) of 5 reviewed for privacy and dignity in that: The wound care nurse announced outside of Resident #1's door that she needed to go in to do wound care on his sacrum. This failure could place residents at risk for embarrassment and lower self-esteem. Findings Included: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses : [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 one of five residents (Resident #1) reviewed for infection control and prevention, in that: -The facility failed to ensure the Wound Care Nurse properly performed clean wound treatment for Resident #1 on 02/07/2025. This failure placed residents with pressure ulcers at risk for infection, prolonged healing, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 for 1 kitchen . A 13.7 quart container of brown sugar was not labeled and not sealed in the facility kitchen. This deficient practice could place 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 coordination of assessments with the Pre-admission Screening and Resident Review (PASRR) program was provided for 1 of 4 residents reviewed for PASRR screenings (Resident #104). The facility did not correctly identify Resident #104 as having mental illness in her PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #85) of 6 residents that were reviewed for feeding tubes. The facility failed to ensure RN A verified G-tube (Gastrostomy tube a surgically placed tube directly into the stomach to deliver food and medicine) placement. RN A failed to aspirate (the act of withdrawing fluid from the stomach to check G-tube placement and measure stomach content) prior to administering water flushes and medications. RN A failed to administer G-tube water flushes and medications by gravity (the use of gravity to move the water flushes and medications through the G-tube into the resident). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for garbage disposal. The facility failed to ensure 1 of 2 dumpster lids was secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 1 (Residents #1) of 5 residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen tubing was labeled and dated. The facility failed to make sure Resident #1's oxygen humidifier was connected to his oxygen port on his side of the room. These failures could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure assessments accurately reflected the resident status for 2 of 6 residents (Resident #1 and Resident #2) reviewed for MDS assessment accuracy. The facility failed to ensure Resident #1, and Resident #2's behaviors were not accurately coded on their quarterly MDS assessments. This failure could place residents at risk for not receiving care and services to meet their needs.

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 grooming, and personal hygiene for one of six residents (Residents #1) reviewed for ADL care. The facility failed to ensure staff provided consistent care with grooming and hygiene for Resident #1. This failure could place residents who were dependent on staff for ADL care at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #1) of six residents reviewed for range of motion. The facility failed to have interventions in place to address Resident #1's hand contracture. This failure could place residents with ROM issues at risk for decline in range of motion, decreased mobility, and worsening contractures.

Inspectors wroteBased on interviews and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 (Resident #1) residents reviewed for environmental concerns in that: The facility failed to provide a safe, clean and sanitary resident room and wheelchair for Resident #1 on 04/20/24 when family member reported a strong smell of ammonia in the room. Resident's family member noticed the underlay that belonged in the resident's bed, and the resident's night gown were lying on the resident's wheelchair, soaking wet with urine. These failures place residents at risk of infection and safety hazards due to an unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 14 residents (Resident#3 and #4) reviewed for pressure ulcers. -The facility failed to provide adequate treatment services to heal pressure ulcers for Resident #3's wound infection on the right buttock, stage 4 pressure ulcer injury that was noted on doctor's order for 12/29/2023. -The facility failed to ensure supplies were available for the ADON to provide adequate wound care treatment to Residents #3 and #4 on 1/14/2024. The ADON made her own dry dressing while providing treatment to Residents #3's and Resident #4's pressure ulcer by using gauze and tape. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident ##3 and #4) observed for urinary incontinence. -CNA A did not practice proper technique while providing incontinent care for Resident #4. -ADON A placed catheter bag on the bed while performing wound care on Resident #4. -Resident #3 did not have the strap to his catheter that keeps the catheter from dislodging during an observation with the Interviewer on 1/13/2024, who was initially checking on residents who had pressure ulcers. These failures placed residents with indwelling catheters at risk for increased infections and hospitalization.

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 #3 and #4) and 2 of 4 staff (ADON A and CNA A) reviewed for infection control, in that: -The facility failed to ensure ADON A performed hand hygiene when moving from a dirty to clean site, while performing Resident #3's wound care on 01/14/2023. -CNA A failed to properly change gloves and wash or sanitize her hands when moving from a dirty area to a clean area when incontinent care was provided to Resident #4 on 01/14/2023. These failures could place residents at risk for cross contamination, infections, delay in treatment and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #3) reviewed for care plans in that: -The facility failed to ensure Resident #3 received Bactroban and Calcium Alginate as ordered by the Wound Care Doctor on 01/11/2024. This failure could place residents at-risk of not receiving needed medication and delay necessary medical treatment.

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) to meet the needs of 1 resident (Resident #1) of 5 residents reviewed for pharmacy services, in that: -Resident #1's Lacosamide (anticonvulsant) medication was not refilled when needed. -Resident #1's Lacosamide medication ran out. -Resident #1 missed 9 doses of Lacosamide (anticonvulsant medication) that lead to Resident #1 having a tonic-clonic seizure (uncontrolled tightening and loosening of muscles that cause convulsions) and resulted in hospitalization. An Immediate Jeopardy (IJ) was identified on 11/13/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed for medications was free of any significant medication errors, in that: -Resident #1's Lacosamide (anticonvulsant) medication was not refilled when needed. -Resident #1's Lacosamide medication ran out. -Resident #1 missed 9 doses of Lacosamide (anticonvulsant medication) that lead to Resident #1 having a tonic-clonic seizure (uncontrolled tightening and loosening of muscles that cause convulsions) and resulted in hospitalization. An Immediate Jeopardy (IJ) was identified on 11/13/2023. While the IJ was removed on 11/14/2023, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident (Resident #8) of 8 residents was free of any significant medication errors, in that: -Resident #8's thyroid medication was discontinued without a physician order. -Resident #8 missed 30 daily doses of the thyroid medication. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 08/23/23 and ended on 09/28/23. The facility corrected the noncompliance before the survey began. The failure led to Resident #8 having a TSH lab value that was Critical High.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the RP of 1 resident (Resident #8) of 8 residents reviewed for medications when there was a need to alter a treatment (medication) significantly, in that: -Resident #8's RP was not notified when her thyroid medication was discontinued. The failure placed the resident at risk for the RP not knowing the resident's course of treatment.

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 in 1 of 1 kitchen reviewed for food service. -A basket for the deep fryer contained fried food residue from the previous evening meal preparation. -Frozen food items that were opened were not labelled or dated. The failure placed all residents who ate food prepared by the kitchen at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation involving an event not resulting in bodily injury was reported not later than 24 hours of the incident to the state survey agency in accordance with state law through established procedures for 1 of 18 residents reviewed for reporting of allegations, in that (CR#1). -Facility failed to report to the state survey agency within 24 hours when CR#1's family member had a firearm in the resident's room This failure placed residents at risk for their health and safety due to the facility not reporting incidents as/when required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6 % based on 2 errors out of 30 opportunities, which involved one of nine residents (Resident # 93) and one of four employees (MA A) reviewed for medication errors, in that:. MA A failed to administer metformin (medication for diabetes) with a meal as recommended by pharmacy. MA A failed to ensure Resident #93 had a physician's order for Vitamin C 500 Mg prior to administering. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of 1 (Resident #8) of 4 residents reviewed for laboratory services. -The facility did not follow up on Resident #8's TSH lab ordered by the physician on 10/24/23. The failure placed the resident at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the resident's medical, nursing, mental, and psychosocial needs for 1 of 4 residents (CR #1) reviewed for care plans. Facility failed to careplan CR #1 for weight loss. This failure could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (CR #1) out of 4 residents reviewed for ADL care. Facility failed to provide oral hygiene and hydration for CR #1. CR #1 had a change in condition and was sent to the hospital. This failure could place residents who were dependent on staff to perform personal hygiene at risk of poor personal hygiene, decreased self-esteem, or decreased quality of life.