Inspection Reports for
Bella Terra Morton Grove

The facility was found operating without an active assisted living license, affecting all 41 residents receiving services. The Executive Director reported waiting for the application to renew the license.

The facility described corrective actions including registration to the Siren notification system, submission of the license renewal application, and steps to avoid future occurrences by contacting the corporate legal team prior to license expiration.

The facility was found to have multiple deficiencies related to mistreatment and abuse of a cognitively impaired resident, failure to implement care plan interventions, and inadequate staff competency in dementia care and behavior management. Two CNAs were terminated following video evidence of rough handling and failure to follow care plans.

The facility was found to have multiple deficiencies including failure to follow visitation policy, failure to prevent abuse and properly investigate abuse allegations, inadequate assistance with activities of daily living, failure to provide ordered rehabilitative care, and insufficient nursing staff to meet resident needs.

The facility was found to have multiple deficiencies including failure to notify family and physician of medication changes, failure to provide timely treatment and care to a resident with a language barrier who refused restorative and shower programs, and failure to maintain a clean shower environment. The facility lacked policies on reporting resident refusal of treatment and aftercare following showers.

The facility failed to provide adequate Certified Nursing Assistant staffing in two units, Suites North and Suites South, affecting three residents reviewed and potentially impacting 29 residents in those units. Staffing shortages and reliance on agency CNAs unfamiliar with residents were noted.

Complaint investigation involving incidents of falls for residents R2 and R3 with documented injuries and hospitalizations.

The facility failed to ensure fall prevention interventions were utilized for two residents, resulting in actual harm including hospitalizations and injuries. Both residents had cognitive or physical impairments contributing to unsafe transfers and falls despite interventions and supervision.

The facility failed to provide effective resident-centered interventions for residents identified to be at high risk for falls, affecting two of three residents reviewed. The findings detail incidents involving residents R1 and R3, including falls, inadequate supervision, and alarm system issues.

The survey identified multiple deficiencies affecting residents related to pressure ulcer prevention, restorative care, safe smoking policy, enteral tube feeding care, psychotropic medication management, food storage, and infection control. The facility failed to implement appropriate interventions such as applying heel protectors and hand splints, ensuring safe storage of smoking materials, positioning residents properly during enteral feeding, documenting reasons for psychotropic dose reductions, completing refrigerator temperature logs, and performing hand hygiene during incontinence care.

The facility failed to follow a resident care plan related to the use of a helmet for one resident (R3) who sustained a right subdural hematoma after a fall. Staff failed to ensure the helmet was worn at all times as required by the care plan, contributing to the injury.

The facility failed to notify the orthopedic physician of an opened surgical wound on resident R1, which led to wound infection with live insect larvae and hospitalization. The wound care coordinator did not notify the physician despite the wound opening and presence of maggots.

Complaint #145198: Resident-to-resident abuse involving physical and verbal altercations.

The facility failed to ensure two of three residents were free from resident-to-resident physical and verbal abuse. The altercation involved one resident hitting another with a plate cover, and staff and family reported ongoing verbal conflicts that were not adequately resolved.

The facility failed to provide adequate supervision to prevent a dependent resident (R3) from falling, resulting in a displaced intertrochanteric fracture requiring surgical intervention. The facility's fall prevention policy was reviewed but not fully implemented to prevent this incident.

The establishment was found in compliance with Part 295. No health deficiencies were cited.

The facility was found to have multiple deficiencies including failure to change gastrostomy tube dressings as ordered, inadequate skin care and wound management, insufficient fall prevention interventions, and food safety violations related to labeling and cleaning.

The facility was found to have multiple deficiencies including failure to accommodate resident needs, prevent abuse, improper use of restraints, inadequate pacemaker monitoring, failure to change gastrostomy tube dressings as ordered, insufficient pressure ulcer care, failure to apply splints for contracture prevention, inadequate fall prevention supervision, medication reconciliation errors, expired medications not removed, food safety violations, lack of hospice care coordination, improper wound care hand hygiene, and failure to offer pneumococcal vaccination to a resident.