Inspection Reports for
Bella Terra Morton Grove

The establishment was found to have multiple violations including failure to properly document and conduct fire drills, incomplete employee orientation and health evaluations, incomplete physician assessments, incomplete resident service plans, and failure to timely conduct TB testing on a resident. The facility was informed of these deficiencies and corrective actions are expected.

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 operating without an active assisted living license, affecting all 41 residents receiving services.

Complaint # not explicitly stated; investigation based on family-provided video showing physical mistreatment of resident R1 by CNAs V6 and V7.

The facility failed to protect a cognitively impaired resident from physical abuse by two CNAs who were rough during care, including pushing the resident's head down and slapping his face. The facility terminated both CNAs and acknowledged failures in training and reporting.

The facility failed to follow its visitation policy restricting 24-hour visitation privileges, resulting in potential impact on all 154 residents. Additional deficiencies include failure to prevent mental abuse to a resident, inadequate investigation of abuse allegations, failure to provide scheduled shower and grooming care to dependent residents, failure to provide ordered splints for a resident with contractures, and insufficient nursing staff leading to delayed call light responses affecting all residents.

The facility was found to have three deficiencies related to notification of medication changes, timely treatment and care for a resident with a language barrier, and infection control practices in the shower room.

The facility failed to provide adequate Certified Nursing Assistant staffing on two units, affecting three residents reviewed and potentially impacting 29 residents. Staffing shortages and reliance on agency CNAs were noted as contributing factors.

The facility failed to ensure fall prevention interventions were utilized for two residents, resulting in injuries including a subdural hematoma and lacerations. Both residents had histories of falls and cognitive or physical impairments contributing to unsafe transfers and ambulation.

The facility was found to have failed to provide effective resident-centered interventions for residents 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 facility was found to have multiple deficiencies including failure to implement pressure ulcer prevention interventions, failure to follow physician orders for restorative care, failure to ensure safe keeping of resident smoking materials, failure to maintain safe feeding tube practices, failure to document reasons for contraindicated gradual dose reductions of psychotropic medications, failure to complete daily refrigerator temperature logs, and failure to perform proper hand hygiene during incontinence care.

Complaint #145198: Section F0689 cited.

The facility failed to ensure that resident R3 wore her prescribed helmet at all times, resulting in a fall and subsequent subdural hematoma. Staff acknowledged the resident's impulsive behavior of removing the helmet and the need for constant redirection and monitoring.

The facility failed to notify the physician of an opened surgical wound for treatment orders, resulting in infection and hospitalization of one resident. The wound care coordinator did not notify the orthopedic surgeon or medical doctor when the wound opened, despite policy requirements.

The facility was found to have failed to protect residents from resident-to-resident physical and verbal abuse, with ongoing arguments and a physical altercation involving two residents.

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 establishment was found in compliance with no health deficiencies cited.

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

The facility was found to have multiple deficiencies including failure to change gastrostomy tube dressings as ordered, inadequate pressure ulcer care and wound management, insufficient supervision leading to falls, and food safety violations related to labeling and cleaning. Corrective actions are required to address these issues.