Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bella Vita Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and on anticoagulant therapy was found with multiple unexplained injuries, including a head abrasion and lip injury. Although the facility documented the injuries and notified family and medical staff, there was no evidence that the required report was made to the state agency. Staff interviews and policy review confirmed that such incidents should be reported, but the facility did not follow its own procedures or regulatory requirements.
A resident with dementia and on anticoagulant therapy was transferred to the hospital after a family member noticed a bruise and called 911. Only a face sheet was provided during the transfer, and the required documentation, including relevant diagnoses and medical information, was not sent with the resident. Staff interviews revealed a lack of awareness about required transfer documents, and the facility's policy for emergency transfers was not followed.
A resident with multiple comorbidities and high risk for skin breakdown developed a Stage 3 pressure ulcer, suspected deep tissue injuries, a diabetic ulcer, and moisture-associated skin damage despite care plans and physician orders for prevention. Documentation showed repeated skin checks with no issues noted prior to the discovery of multiple wounds, delayed implementation of offloading interventions, inconsistent wound care documentation, and lack of timely weight monitoring after significant weight loss. These actions and inactions resulted in the resident developing multiple wounds that were not present on admission.
The facility did not ensure that residents and their representatives were involved in the discharge or transfer process, as required by policy. Several residents, including those with cognitive impairment and those who wished to remain in the facility, were transferred to other skilled nursing facilities without prior involvement or consent from themselves or their representatives. Staff interviews revealed inconsistencies in the discharge planning process, and documentation did not show evidence of active discharge planning or communication with families.
Two residents were transferred to other facilities without timely written notification or proper involvement of their representatives. In both cases, the representatives reported not receiving advance notice or formal paperwork, and staff interviews revealed inconsistencies and confusion in the discharge notification process.
Two residents were involved in an altercation where one allegedly struck the other, leading to a deficiency in the facility's ability to protect residents from abuse. Despite no injuries being found, the incident was reported to authorities, and staff intervened to separate the residents. The facility's policy on abuse prevention was reviewed, highlighting a failure to maintain a safe environment.
A facility failed to notify the Ombudsman of a resident's discharge to a rehabilitation facility, despite policy requirements. The resident, with moderately impaired cognition, was transferred without the Ombudsman being informed, as confirmed by staff interviews and record reviews.
A resident with muscle weakness and impaired mobility was not provided adequate assistance with ADLs, including showering and dressing, despite a care plan indicating such needs. The resident reported not being offered a shower since admission, and staff interviews revealed inconsistencies in documentation and communication regarding the resident's care. The facility's policy required documentation of ADL care, but this was not consistently followed.
A resident's blood pressure medication, Midodrine HCL, was administered outside the ordered parameters multiple times without documentation or physician notification. The facility's policies on medication administration and documentation were not followed, as revealed in interviews with the ADON and DON.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with medical devices, and staff were observed handling soiled and clean linens improperly, leading to potential contamination. Additionally, a nurse administered medications without using required personal protective equipment, despite EBP signage. These deficiencies indicate systemic issues in infection control practices and staff training.
A resident with mental health issues became aggressive during a shower, leading to a physical altercation with staff. The resident bit a CNA's finger, prompting the CNA to strike the resident in the face twice. Witnesses confirmed the CNA used a closed fist, despite the resident having calmed down. The facility's investigation concluded the actions were not intentional abuse, but this was inconsistent with witness statements.
The facility failed to protect residents from abuse, as evidenced by incidents where one resident with severe cognitive impairment was struck by another with a history of aggression, and another resident was hit during an altercation. Despite staff presence, supervision was inadequate, leading to these incidents.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an injury of unknown origin for a resident to the state agency as required. The resident, who had diagnoses including dementia, borderline personality disorder, and was on anticoagulant therapy, was found with multiple injuries including an abrasion to the lip, redness to the left sclera, and a lump on the back of the head. Documentation showed that the injuries were unwitnessed, and the resident was unable to explain how they occurred due to severe cognitive impairment. The facility's internal records, including care plans and incident reports, documented the injuries and the notifications made to the family, ADON, and physician, but there was no evidence that the incident was reported to the state agency as required by facility policy and regulation. Staff interviews confirmed that the expectation was for injuries of unknown origin to be reported immediately to nursing leadership and, if necessary, to outside agencies. The CNA, LPN, ADON, Social Services Manager, Executive Director, and DON all described the importance of reporting such injuries, especially when the resident cannot communicate what happened. Despite these expectations and the facility's own policies, the incident involving the resident's injuries was not reported to the state agency. The DON stated that the incident did not meet the definition of injury of unknown origin according to their policy, citing documentation that the resident was known to rest her head on the headboard and bite her lip, although this documentation was dated after the incident. A review of the facility's policies confirmed that injuries of unknown source, especially when unwitnessed and unexplained by the resident, are to be reported to the state agency. The facility's incident report log and self-report records did not show any report made for this incident. The failure to report the injury of unknown origin was identified through closed record review, staff interviews, and policy review, establishing that the facility did not follow its own procedures or regulatory requirements in this case.
Failure to Provide Required Documentation During Resident Transfer
Penalty
Summary
The facility failed to provide the required documentation to the receiving facility during the transfer of a resident with multiple diagnoses, including dementia, borderline personality disorder, and a history of falls. The resident, who was on anticoagulant therapy and had documented cognitive impairment and behavioral symptoms, was transferred to the hospital after a family member noticed a bruise and called 911. Upon review, it was found that only a face sheet was provided to the paramedics, and the SNF/NF to Hospital Transfer Form lacked essential information such as relevant diagnoses, vital signs, and pain level. The document checklist on the transfer form was left blank, indicating that no additional documents accompanied the resident during the transfer. Interviews with facility staff revealed a lack of awareness regarding the required documentation for hospital transfers. The Executive Director was unfamiliar with the necessary documents, and the DON stated that only basic information was typically provided. Although a report was called into the hospital, there was no documentation of the specific information relayed. The facility's policy required that a face sheet, advance directives, current physician's orders, and pertinent labs or x-rays be attached during emergency transfers, but this was not followed in the resident's case.
Failure to Prevent and Timely Identify Pressure Ulcers and Deep Tissue Injuries
Penalty
Summary
A resident with multiple comorbidities, including hypertension, diabetes mellitus type 2, schizophrenia, dementia, and a history of cerebrovascular accident with left-sided weakness, was admitted to the facility and assessed as being at high to moderate risk for pressure ulcers according to repeated Braden Scale assessments. The resident was dependent on staff for most activities of daily living, including mobility, hygiene, and toileting, and was always incontinent of urine and bowel. Despite care plans and physician orders that included daily body checks, use of pressure-relieving devices, regular skin evaluations, and application of barrier creams, documentation shows that the resident developed multiple wounds, including a Stage 3 pressure ulcer on the left buttock, suspected deep tissue injuries (DTIs) on the right heel and left iliac crest, a diabetic ulcer on the left medial lower leg, and moisture-associated skin damage (MASD) to the buttocks. The facility's records indicate that, prior to the discovery of these wounds, routine skin checks and shower sheets repeatedly documented no new skin issues, bruises, or open areas. However, on a later date, staff identified multiple wounds during a skin assessment, including a Stage 3 pressure ulcer and DTIs, which were not present on admission. Orders for interventions such as foam boots for offloading were not transcribed until after the wounds were identified, and there were inconsistencies in the documentation of wound care administration. Additionally, despite a significant weight loss noted in a short period and recommendations for weekly weight monitoring, there was a lack of documented weekly weights following the initial identification of weight loss. The resident experienced episodes of lethargy and decreased responsiveness, which were reported to providers and resulted in medication adjustments and hospital transfer. The development of multiple wounds, including pressure ulcers and DTIs, occurred despite the presence of care plans and physician orders intended to prevent such outcomes. The documentation reveals a failure to consistently assess and meet the resident's basic needs for skin integrity and nutrition, leading to the development of avoidable pressure injuries and related complications.
Failure to Involve Residents and Representatives in Discharge Planning
Penalty
Summary
The facility failed to ensure that residents and their representatives were involved in the discharge or transfer process for four out of five sampled residents. In each case, the clinical records and care plans did not reflect any active or ongoing discharge planning prior to the issuance of a notice of proposed transfer or discharge. For example, one resident with severe cognitive impairment was discharged to another skilled nursing facility, and her representative reported being notified only after the transfer had already occurred, with no prior discussion or consent. Another resident, who was cognitively intact, was discharged to another facility without her or her power of attorney's prior knowledge or consent. The representative stated she was not given any formal paperwork or notice and was not consulted about the transfer, despite the resident's wish to remain in the facility. Similarly, another resident's representative was unaware of the transfer, stating that the facility did not reach out to notify her, and the resident herself had short-term memory loss, further complicating communication. Additionally, a resident who wished to remain in the facility was transferred due to renovations, but reported not having a discharge plan or being involved in the process. Interviews with staff revealed inconsistencies in the discharge planning process, with some staff stating that consent should be obtained from residents or their representatives, while others indicated that the process begins with a notice of transfer. The facility's own policy requires keeping residents and families involved in all discharge planning, but documentation and interviews indicate this was not consistently followed.
Failure to Provide Timely Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives prior to transferring or discharging them to another facility. For two sampled residents, there was no evidence of proper discharge planning or notification in the clinical records. In one case, a resident with severe cognitive impairment was transferred to another skilled nursing facility, and the resident's representative reported being notified only after the transfer had already occurred. The representative was not informed of the transfer in advance, nor was she given an explanation regarding the resident's behaviors that were later reported by the receiving facility. In another instance, a resident with no cognitive impairment was discharged to another facility, and the resident's power of attorney stated she was not given any formal paperwork or notice prior to the transfer. The representative learned of the transfer from the receiving facility the day before it occurred and did not provide verbal consent or receive an option regarding the move. The facility's staff interviews revealed inconsistencies in the discharge process, with some staff unsure of how far in advance notifications were provided and others indicating that the process starts with case management and social services, but lacking clear documentation of timely notification. Facility policy requires that residents and families be involved in all discharge planning, and that notifications are typically delivered 30 days before discharge. However, in these cases, there was no documentation of timely written notification or consent from the residents or their representatives prior to the transfers. Staff interviews further indicated confusion regarding access to discharge records and the specific procedures followed for notification.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #214, who had no cognitive impairment, was allegedly struck by another resident, #525, while seated in her wheelchair. The incident occurred in front of station 300, where Resident #525 approached Resident #214, yelled in her face, and allegedly struck her on the right shoulder and mid-back area. Although Resident #214 did not report any pain or discomfort and no physical injuries were found, the incident was reported to the unit secretary, and relevant authorities were notified. Resident #525, who also had no cognitive impairment, was involved in the altercation with Resident #214. He exhibited aggressive behavior by yelling and allegedly striking Resident #214. The facility's staff, including the unit secretary and nursing staff, intervened by separating the residents and conducting a skin assessment on Resident #214, which revealed no injuries. The facility's administration reviewed the incident via camera footage, confirming the altercation. The facility's policy on abuse prevention was reviewed, indicating a failure to maintain a safe environment for the residents.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of the transfer or discharge of a resident, which is a requirement under the State Operations Manual. The resident in question was admitted with acute kidney failure, gastro-esophageal reflux, and multiple rib fractures, and had a moderately impaired cognition as indicated by a BIMS score of 11. Despite a physician's order and a progress note indicating the resident's transfer to a rehabilitation facility, there was no evidence in the facility's records or communications that the Ombudsman was notified of this discharge. Interviews with various staff members, including the Social Services Supervisor, Medical Records Supervisor, Assistant Director of Nursing, Case Manager, and Director of Nursing, confirmed that the resident was not included in the list of transfers or discharges sent to the Ombudsman. The facility's policy requires that such notifications be made, but the oversight resulted in the resident's discharge not being communicated to the Ombudsman. This lapse was identified through a review of the facility's records and interviews with staff, highlighting a failure in the facility's discharge notification process.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, who was admitted with diagnoses including muscle weakness, hemiplegia, hemiparesis, and type 2 diabetes mellitus, had a care plan indicating a need for assistance with ADLs due to general weakness and impaired mobility. Despite this, there was no evidence in the Certified Nursing Assistant (CNA) bathing task log that the resident received a shower from admission until a week later, except for one documented refusal. Interviews with the resident revealed that he had not been offered a shower since admission and expressed a desire to have one. The resident was observed wearing the same clothing over several days, with dried skin flakes noted on his shirt, indicating a lack of assistance with personal hygiene and dressing. The resident reported that a staff member had promised to return to assist with a shower but never did, and he had not refused any showers as documented. Staff interviews confirmed that residents should receive showers twice a week, and refusals should be documented. However, there was inconsistency in the documentation and communication regarding the resident's care. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that showers should be offered according to schedule and preferences, but there was no requirement to document each offer or refusal. The facility's policy stated that ADL care, including dressing and personal hygiene, should be documented, but this was not consistently followed, leading to the deficiency.
Failure to Administer Blood Pressure Medication Within Parameters
Penalty
Summary
The facility failed to ensure that a resident's blood pressure medication, Midodrine HCL, was administered within the ordered parameters. The resident, who was readmitted with diagnoses including dependence on hemodialysis and hypotension, had a care plan that required monitoring and reporting of vital signs. The medication order specified that Midodrine should be held if the systolic blood pressure exceeded 130. However, the Medication Administration Record (MAR) showed that the medication was administered outside of these parameters multiple times over several months, with no documentation justifying the deviation or indicating that the provider was notified. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that there was no order to support administering the medication outside the specified parameters, and no documentation was found to indicate that the physician was contacted regarding these occurrences. The facility's policies on documentation and medication administration emphasize the importance of adhering to prescribed parameters and obtaining clarification when in doubt, which was not followed in this case.
Infection Control Deficiencies in EBP Implementation and Laundry Practices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one of whom had a feeding tube and the other a hemodialysis fistula. Resident #157, who was admitted with a feeding tube, did not have EBP orders or signage in place, and staff were observed assisting the resident without wearing gowns. The Infection Preventionist was unsure if EBP was necessary for the resident, indicating a lack of clarity in the facility's infection control practices. The laundry process at the facility also demonstrated deficiencies in infection control practices. Staff were observed handling soiled linens without wearing gowns, and clean linens were held against their bodies during folding, contrary to facility policy. The Director of Housekeeping acknowledged that these practices could lead to contamination, yet staff continued to handle linens improperly, indicating a systemic issue in adherence to infection control protocols. During medication administration, a Licensed Practical Nurse failed to utilize EBP for a resident with EBP signage, administering medications without the required personal protective equipment. Interviews with staff revealed inconsistencies in understanding and implementing EBP during medication administration, highlighting a gap in training and adherence to infection prevention guidelines.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member, resulting in a deficiency. The incident involved a resident with a history of mental health issues, including Bipolar disorder, Anxiety disorder, and Schizophrenia, who was cognitively intact but experienced hallucinations and aggressive behaviors. On the day of the incident, the resident was being showered by a CNA when they became agitated and aggressive, leading to a physical altercation with the staff. During the altercation, the resident began spitting, cursing, and physically attacking the nurse and CNA present. The situation escalated when the resident bit a CNA's finger, prompting the CNA to strike the resident in the face twice to release the bite. This action was witnessed by other staff members, who confirmed that the CNA used a closed fist to hit the resident, despite the resident having calmed down and being seated at the time. The facility's Director of Nursing conducted an investigation and concluded that the CNA's actions were not intentional abuse but rather an attempt to release the resident's grip. However, this conclusion was inconsistent with witness statements and the facility's own report, which indicated that the CNA's actions were deliberate. The facility's policy on abuse prevention emphasizes that residents have the right to be free from abuse, and the incident was a violation of this policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, as evidenced by incidents involving resident-to-resident aggression. Resident #107, who has severe cognitive impairment, was struck by resident #15, who has moderate cognitive impairment and a history of verbal and physical aggression. The incident occurred when resident #15 approached resident #107 in a wheelchair, yelled at him to move, and then struck him in the face. Despite the presence of staff, the altercation was not prevented, indicating a lapse in supervision and intervention. Another incident involved resident #22, who is cognitively intact, and resident #36, who has severe cognitive impairment and a history of aggressive behavior. Resident #36 struck resident #22 in the face during an altercation in the common area. The staff present, including an LPN, were unable to prevent the incident, as they were occupied with other tasks and did not adequately monitor the residents. The facility's policy requires staff to be present in common areas to monitor residents, but this was not adhered to, contributing to the incident. Interviews with staff, including the DON and ADON, revealed that there was an expectation for staff to supervise residents in common areas, but this was not consistently implemented. The facility's assessment and policies emphasize the need for individualized care and monitoring of residents with behavioral issues, yet these measures were insufficient in preventing the incidents. The lack of adequate supervision and failure to anticipate and manage aggressive behaviors led to the deficiency in protecting residents from abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Place At Glencroft | 3.6 mi | ★★★★★ | 1 | 0 |
| Horizon Post Acute And Rehabilitation Center | 3.7 mi | ★★★★★ | 3 | 0 |
| Haven Of Phoenix | 4.7 mi | ★★★★★ | 12 | 0 |
| The Rehabilitation Center At The Palazzo | 4.8 mi | ★★★★★ | 1 | 0 |
| Beatitudes Campus | 5 mi | ★★★★★ | 5 | 0 |
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