Inspection Reports for
Bella Terra Morton Grove

The facility was found to be operating without an active assisted living license, as the license expired on 2025-06-25. The facility was providing services to 41 residents at the time of the survey.

The complaint involved allegations of physical abuse and mistreatment of a cognitively and visually impaired resident (R1) by two CNAs during care, including rough handling, threats, and slapping. The complaint was substantiated with video evidence and interviews. The facility suspended and terminated the CNAs involved and notified police. The facility's internal incident report failed to fully document the resident's distress and abuse.

The facility failed to ensure that R1 was treated with respect and dignity, resulting in physical and emotional harm due to rough handling, including pushing the resident's head down, slapping the resident's face, and failing to follow care plan interventions for behavior management. The two CNAs involved were suspended and terminated. The facility also failed to report all aspects of the incident accurately and did not provide adequate training or monitoring of staff regarding dementia care and behavior de-escalation.

The complaint investigation involved multiple issues including visitation restrictions, mental abuse and threats to a resident (R113), failure to investigate abuse allegations properly, inadequate ADL care including showering and grooming for several residents, failure to apply ordered splints for contracture prevention for resident R129, and insufficient nursing staff leading to delayed call light responses affecting many residents. Substantiation status is not explicitly stated.

The facility failed to follow its visitation policy allowing 24-hour visitation, resulting in restricted visiting hours. There was failure to protect a resident from mental abuse and threats, and failure to properly investigate the abuse allegation. The facility also failed to provide scheduled shower and grooming care, failed to apply ordered splints for contracture prevention, and failed to provide sufficient nursing staff to ensure timely response to call lights and adequate care.

The complaint investigation revealed failures in notification to family and physician regarding medication changes, inadequate pain management and treatment for a resident with a language barrier after a fall, and poor infection control practices in the shower room.

The facility failed to notify a resident's family and physician about discontinuation of hypertensive medication, failed to provide timely treatment and care to a resident with a language barrier who refused restorative care and complained of severe pain after a fall, and failed to ensure proper infection control practices in the shower room by leaving soiled clothes and towels on the floor.

The facility failed to provide appropriate CNA staffing in Suites North and Suites South units, affecting three residents reviewed and potentially impacting 29 residents in those units. Staffing schedules showed only one CNA per unit per shift despite census numbers exceeding recommended CNA-to-resident ratios, leading to delays in care and reliance on agency staff unfamiliar with residents.

The investigation was complaint-related, focusing on falls involving residents R2 and R3. R3 sustained a subdural hematoma and died in the hospital. R2 sustained a laceration requiring sutures. Both residents had cognitive or physical impairments and histories of multiple falls. The facility failed to provide adequate supervision and fall prevention measures despite known risks and prior incidents.

The facility failed to ensure fall prevention interventions such as nonskid footwear and adequate assistance during transfers for residents R2 and R3. These failures resulted in actual harm, including lacerations requiring sutures and a subdural hematoma leading to hospitalization and death of R3. Both residents had histories of falls and cognitive or physical impairments contributing to their risk.

The facility failed to provide effective resident-centered interventions for residents at high risk for falls, affecting two of three residents reviewed (R1 and R3). Deficiencies included inadequate supervision, improper use and monitoring of assistive devices and alarms, and failure to ensure staff awareness of resident needs and safety equipment.

The facility was found deficient in multiple areas including failure to implement pressure ulcer prevention interventions, failure to follow physician orders for restorative care, unsafe handling of resident smoking materials, improper positioning and feeding tube management during enteral feeding, lack of documentation for gradual dose reduction contraindications for psychotropic medications, failure to complete daily refrigerator temperature logs, and failure to perform proper hand hygiene during incontinence care.

The investigation was complaint-driven, substantiated by findings that the resident was not wearing the helmet at the time of the fall, despite care plans and staff awareness of the resident's impulsive behavior and need for helmet use.

The facility failed to ensure that resident R3 wore a protective helmet as required by her care plan, leading to a fall that caused a right subdural hematoma and forehead laceration. Staff interviews and record reviews confirmed the resident's impulsive behavior and history of falls, and that staff did not adequately supervise or redirect the resident to wear the helmet at all times.

The complaint investigation found that the facility did not notify the orthopedic surgeon or medical doctor when resident R1's surgical wound opened on 9.19.23. This failure resulted in the wound becoming infected with maggots and the resident being sent to the hospital for evaluation and treatment. The facility's change in condition policy requires immediate notification of the physician and family in such cases.

The facility failed to follow its change in condition policy by not notifying the orthopedic surgeon or medical doctor about the opened surgical wound on resident R1, which led to the wound becoming infected with live insect larvae (maggots) and required hospital evaluation and treatment.

The complaint investigation found substantiated resident-to-resident abuse involving physical hitting and verbal name-calling. Staff and family members reported frequent arguments and attempts to deescalate, but the residents were not separated until after the physical incident occurred.

The facility failed to ensure that two of three residents were free from resident-to-resident physical and verbal abuse. The investigation found that R2 hit R1 on the leg with a lunch lid during an argument about the air-conditioning, and both residents frequently argued and called each other names. Staff were aware of the ongoing conflict but did not separate the residents in time to prevent the incident.

The complaint investigation found that the facility failed to supervise resident R3 adequately, who was at high risk for falls due to cognitive impairment, impulsivity, and poor safety awareness. The resident fell on 7/9/23 while using the bathroom, sustaining a hip fracture that required surgical repair. Staff interviews confirmed the resident's impulsivity and the partial closure of the bathroom door for privacy contributed to the incident.

The facility failed to provide adequate supervision to a dependent resident (R3) with severe cognitive impairment and a history of falls, resulting in the resident falling in the bathroom and sustaining a displaced intertrochanteric fracture of the right femur requiring surgical intervention. The investigation revealed that the resident was assisted to the bathroom but was given partial privacy, and the fall occurred quickly despite staff presence nearby.

The facility was found deficient in multiple areas including failure to change gastrostomy tube dressings as ordered, inadequate pressure ulcer care and failure to update care plans, insufficient supervision leading to resident falls and injuries, and food safety violations such as unlabeled food items and improper cleaning of ice scoop holders.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach, failure to prevent resident-to-resident abuse, improper use of physical restraints, inadequate pacemaker follow-up, failure to change gastrostomy tube dressings as ordered, failure to provide pressure ulcer care and follow mattress usage guidelines, failure to apply hand splints to prevent contractures, inadequate supervision to prevent falls resulting in hospitalization, failure to reconcile controlled medications, expired medications and undated inhalers found, failure to maintain food safety and cleanliness standards, failure to coordinate hospice care, failure to perform hand hygiene during wound care, and failure to offer pneumococcal vaccination as required.