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 Terra Bloomingdale during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including venous insufficiency and CHF, had a right lower extremity duplex ordered, but the contracted radiology provider did not perform the exam within the 24-hour timeframe required by contract and did not communicate the delay to the facility. The imaging was completed several days after the order, and the results were not read or transmitted until days after the exam, despite the provider’s usual 6–8 hour turnaround. Facility leadership confirmed they did not receive results until days later and only contacted the radiology company after the family asked about the test, and there was no documentation of communication between the facility and the provider regarding the delays.
A nursing home area was not kept free from accident hazards, and staff did not provide adequate supervision to prevent accidents. This resulted in a deficiency related to the facility's failure to ensure a safe environment and proper oversight for residents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Several residents did not receive their prescribed medications at the scheduled times due to a gap in nursing coverage, resulting in medications such as Velphoro, Coreg, Gabapentin, and Budesonide-Formoterol Fumarate inhaler being administered hours late. Residents with complex medical needs, including those on dialysis and with chronic conditions, were affected, and facility policies requiring timely medication administration and documentation were not followed.
Four residents with diabetes did not receive their scheduled insulin doses on time due to a gap in nursing coverage, resulting in insulin being administered several hours late. The facility's failure to follow physician orders and its own medication administration policies led to significant medication errors, as confirmed by EMR review and resident interviews.
Due to a lack of administrative oversight and failure to revise nursing assignments when an agency RN arrived late, multiple residents did not receive their scheduled medications, including insulin and cardiac medications, at the prescribed times. Staff interviews and medical records confirmed that medications were administered several hours late, and no direction was given to other staff to cover the absent nurse's assignment, resulting in delayed nursing care for all affected residents.
During a COVID-19 outbreak, a facility failed to follow its respiratory testing policy by not testing symptomatic residents for both COVID-19 and influenza. Staff also neglected proper infection control practices, such as wearing required PPE and disinfecting glucometers correctly. These lapses affected multiple residents, including those with confirmed COVID-19 cases and those requiring regular blood glucose monitoring.
The facility failed to follow the posted menu, affecting residents on mechanical soft and puree diets. Residents were served different meals than indicated, such as beef instead of pork and ham instead of sausage patties, without prior approval from the dietician. The dietary manager made substitutions due to perceived poor quality, but the registered dietician was not informed, leading to confusion and non-compliance with facility policies.
A resident's bed remained unrepaired despite being reported as broken, with the footboard's plastic cover detached and exposing an electric connector. The facility's policy requires staff to report such issues, but no maintenance work order was found, indicating a failure to maintain a safe environment.
The facility failed to provide adequate grooming and hygiene care for residents requiring assistance with ADLs. A resident with cognitive impairment had untrimmed, dirty fingernails, while another was found with a urine-soaked brief, indicating a lack of timely incontinence care. Additionally, a female resident was observed with facial hair over several days, despite needing assistance with grooming. The facility lacked a specific policy for facial hair grooming, and staff noted that agency staff might overlook such details.
The facility failed to ensure accurate blood glucose testing for residents with diabetes, as nurses used alcohol pads improperly, affecting readings. Additionally, a resident's urinary concerns were not promptly addressed, with delayed sample collection and inadequate communication with the physician. These actions violated the facility's diabetes management and urinary catheter care policies.
The facility failed to implement fall prevention measures for two residents at high risk for falls. One resident, with multiple diagnoses including impaired cognition, lacked a wing mattress and properly positioned alarm pad, leading to recent falls. Another resident with severe cognitive impairment had a call light on the floor and missing floor padding, contrary to care plan requirements. Both residents had documented falls, highlighting a failure to adhere to prescribed interventions.
The facility failed to properly position urinary catheter tubing and drainage bags for three residents, leading to potential infection risks. One resident's catheter tubing was over his pants, and the drainage bag was placed on his bed. Another resident's tubing was looped under his leg, and a third resident's tubing was unsecured, with the drainage bag containing sediment. Facility policy requires securement and proper positioning of catheter equipment, which was not followed.
A facility failed to report a resident fall caused by improper transfer methods, including not using a sit-to-stand machine as required. Additionally, staff did not consistently use gait belts during transfers, and resident transfer statuses were not accurately documented, leading to unsafe practices.
The facility failed to provide showers as scheduled for five residents who required assistance with bathing. Documentation showed significant gaps between showers, contrary to the policy of providing showers twice weekly. The residents had various medical conditions necessitating assistance with ADLs, and the facility did not adhere to its hygiene care procedures.
The facility failed to follow its urinary catheter care policy, resulting in inadequate documentation and assessment of symptoms for three residents with indwelling catheters who developed UTIs. A resident was sent to the hospital with a UTI, but the nurse did not document urine appearance or output. Another resident had a UTI diagnosed without documented symptoms, and antibiotics were prescribed without assessment. A third resident had a change in antibiotic treatment without documented symptoms or lab results. The DON confirmed the expectation for staff to monitor and document urinary output, which was not met.
A resident with dysphagia requiring 1:1 feeding assistance was left unattended with a meal tray, despite needing help from qualified staff. The Activity Director present was not qualified to assist, and a CNA left the tray after the resident refused lunch. The DON confirmed the need for staff assistance, as per the resident's medical records.
A resident was observed receiving thickened water despite an agreement to allow thin liquids and ice chips between meals to prevent dehydration. The speech therapist had recommended this change after evaluating the resident, but the facility failed to implement the updated dietary orders.
The facility failed to ensure a resident's legal representative was fully informed about the use of psychotropic medications. The resident was administered several psychotropic medications without proper consent documentation, and the legal representative expressed concerns about the lack of information and potential side effects. Facility staff confirmed that consent forms were incomplete, failing to provide necessary details.
Failure to Ensure Timely Diagnostic Imaging and Results
Penalty
Summary
The deficiency involves the facility’s failure to obtain and/or ensure timely diagnostic imaging and results for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hydronephrosis, hypertension, type 2 diabetes mellitus, diabetic foot ulcer, venous insufficiency, and congestive heart failure. An order was placed on February 6, 2026, for a right duplex venous scan related to venous insufficiency, and the order indicated the imaging was sent that same day. The radiology company reported that the exam was not actually performed until February 9, 2026, three days after the order, despite a contract requirement that services be provided within 24 business hours or a time be scheduled with notification to the facility if that timeframe could not be met. The radiology company further stated that results are usually available within six to eight hours after imaging, but in this case the exam was not read by a radiologist and the results were not sent to the facility until February 13, 2026. The DON confirmed the facility did not receive the diagnostic imaging results until February 13, 2026, and that she only contacted the radiology company after the resident’s family inquired about the results during a care plan meeting that same day. The radiology company liaison and territory manager acknowledged the delays in both performing the duplex and in resulting the exam, and indicated there was no communication with the facility about these delays, contrary to the contractual obligation to promptly notify the facility if the 24-hour service time could not be met. The facility did not have documentation showing any communication with the radiology company regarding the delayed exam or delayed receipt of results.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in which a nursing home area was not maintained free from accident hazards, and adequate supervision was not provided to prevent accidents. The report notes that the facility failed to ensure the environment was safe and that appropriate oversight was in place to minimize the risk of accidents for residents. This lack of supervision and failure to address potential hazards directly contributed to the deficiency cited by surveyors.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Administer Medications as Ordered and Scheduled
Penalty
Summary
The facility failed to administer medications as ordered by physicians and as scheduled in the electronic medical record (EMR) for five residents. On a specific date, a nurse was late for her shift, resulting in a gap between the departure of the day shift nurse and the arrival of the evening shift nurse. During this period, residents did not receive their scheduled medications on time. One resident, who requires Velphoro to be taken with meals due to dialysis, did not receive the medication with dinner, and both Velphoro and Coreg were administered more than four hours after the scheduled time. The resident expressed frustration, noting that management was aware of the nurse's tardiness but did not arrange alternative coverage to ensure timely medication administration. Other residents were similarly affected by the delay. One resident had to approach the nurse to request a blood sugar check and pain medication, receiving Gabapentin almost two hours late. Another resident with moderate cognitive impairment received Gabapentin over four hours late. Additional residents with complex medical histories, including COPD, diabetes, and heart disease, also experienced delays in receiving scheduled medications such as Gabapentin and Budesonide-Formoterol Fumarate inhaler, with administration occurring up to four hours after the scheduled time. The facility's policies require that medications be administered according to physician orders and documented immediately after administration. The pharmacist confirmed that certain medications, such as Velphoro, must be given with meals for effectiveness, and significant delays in administering medications like Coreg could result in symptomatic changes. The documentation and interviews confirm that the facility did not adhere to its own policies or physician orders regarding medication administration times for multiple residents.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to administer insulin as ordered by physicians for four residents with diabetes, resulting in significant medication errors. On May 17, 2025, there was a gap in nursing coverage when the day shift nurse left at approximately 3:00 PM and the evening shift nurse did not arrive until 5:45 PM. During this period, no other staff were assigned to administer medications, leading to delays in scheduled insulin administration. Residents reported not receiving their medications on time, and electronic medical records confirmed that insulin doses scheduled for the evening meal were administered several hours late. For example, one resident with multiple chronic conditions, including diabetes and heart failure, received their scheduled 5:00 PM insulin dose at 9:14 PM, more than four hours after dinner. Another resident, also with diabetes and other comorbidities, received their 5:00 PM insulin at 6:50 PM and their 4:00 PM sliding scale insulin at 6:50 PM, both significantly delayed. A third resident with moderate cognitive impairment received their 5:00 PM insulin at 9:09 PM, and a fourth resident received their 5:00 PM insulin at 8:42 PM. In all cases, the insulin was ordered to be given with meals or at specific times, but was not administered as scheduled. The facility's own policies require medications and treatments to be administered according to physician orders and federal and state regulations. The pharmacist confirmed that the types of insulin involved are intended to be given with meals or at specific times to maintain stable blood glucose levels, and that significant delays can cause blood sugar fluctuations. The failure to follow physician orders and facility policy resulted in significant medication errors for multiple residents.
Failure to Revise Nursing Assignments Resulting in Delayed Medication Administration
Penalty
Summary
The administration failed to provide adequate oversight and leadership to ensure that nursing care assignments were revised in response to a change in staffing, resulting in residents not receiving nursing care and medications as ordered by their physicians. On a specific day, an agency RN who was scheduled to work the evening shift arrived late, and no arrangements were made to cover her assignment or ensure that her residents received timely care. The staffing coordinator confirmed that the nurse was assigned to care for a group of residents but was not present for the start of her shift, and no other staff were directed to absorb her responsibilities during her absence. Multiple residents reported and records confirmed that scheduled medications, including critical medications for conditions such as diabetes, hypertension, and pain management, were administered several hours late. For example, one resident did not receive his prescribed Velphoro, carvedilol, and insulin at the scheduled time with his meal, which he stated was necessary for the medications to be effective. The electronic medical records showed that these medications were administered more than four hours after the scheduled time. Other residents also experienced delays in receiving their medications, with documentation showing administration times ranging from nearly two to over four hours late. Interviews with staff and residents corroborated that there was a lack of communication and direction from management regarding coverage for the absent nurse. The administrator acknowledged awareness of the nurse's anticipated late arrival but did not provide a reason for the failure to revise assignments or instruct available staff to cover the affected residents. As a result, all residents assigned to the absent nurse experienced delays in receiving necessary nursing care and medications as ordered.
Infection Control and Testing Failures During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to its respiratory testing policy during a COVID-19 outbreak, as evidenced by the improper testing of residents for both COVID-19 and influenza. Despite the facility's policy and guidance from the local health department, symptomatic residents were only tested for COVID-19, not influenza, which was necessary given the co-circulation of both viruses. This oversight affected multiple residents, including those who tested positive for COVID-19, and led to a delay in appropriate testing and management of the outbreak. In addition to testing failures, the facility did not consistently follow infection control practices for residents on transmission-based and enhanced-barrier precautions. Staff members were observed not wearing the required personal protective equipment (PPE), such as N95 masks and face shields, when entering rooms of residents with confirmed COVID-19 cases. Furthermore, staff failed to don gowns when providing care to residents under enhanced-barrier precautions, increasing the risk of spreading infections. The facility also did not properly disinfect glucometers between uses. Staff members were observed wrapping glucometers in bleach wipes without first wiping down the surfaces, contrary to the facility's policy and CDC guidelines. This improper disinfection practice was noted across multiple instances, involving several residents with diabetes who required regular blood glucose monitoring. These deficiencies highlight significant lapses in the facility's infection prevention and control program.
Failure to Follow Posted Menus and Ensure Nutritional Needs
Penalty
Summary
The facility failed to adhere to the posted menu for residents, impacting all 18 residents on non-vegetarian mechanical soft and puree regular diets, and one resident on a vegetarian pureed diet. On the specified date, the menu indicated that roasted pork loin was to be served for lunch, but residents on mechanical soft diets were served beef instead. The dietary server was unsure why beef was prepared instead of pork, despite the pork loin being suitable for mechanical soft diets. Additionally, the dietary department was not provided with an updated list of residents receiving mechanical soft diets, which affected meal preparation. Further discrepancies were observed during breakfast service, where the menu listed sausage patties, but residents were served mechanical soft ham instead. The dietary server was uncertain about the substitution, suggesting it might have been due to a shortage of sausage patties. An unidentified puree item served during breakfast was also not labeled, leading to confusion about its contents. The dietary manager admitted to making substitutions without prior approval from the dietician, citing poor quality and appearance of the original items as reasons for the changes. The registered dietician confirmed that menu substitutions should be approved in advance to ensure nutritional equivalence. However, the dietician was not informed of the changes and was unsure about the items served. The facility's policy mandates that menus be followed as written unless changes are necessary due to preferences, unavailability, or special meals, and that any changes should be approved by the dietician. The failure to follow these protocols resulted in residents not receiving the meals indicated on their meal tickets, highlighting a breakdown in communication and adherence to dietary guidelines.
Failure to Repair Resident's Bed
Penalty
Summary
The facility failed to repair a resident's bed, which was identified as broken by the resident herself. The resident reported that the footboard's plastic cover was detached and broken, and an unidentified male staff member assessed the bed but did not provide a timeline for repair. A Certified Nurse Assistant (CNA) later assessed the issue and stated she would complete a maintenance work order request. However, the resident continued to report that the bed was not fixed, and the plastic cover eventually fell off completely, exposing an electric connector. The facility's administrator reviewed the maintenance work orders and found no record of a request for the resident's broken bed. The facility's policy requires staff to report malfunctioning equipment to the maintenance department, but this procedure was not followed in this case. The lack of a maintenance work order and the continued disrepair of the bed indicate a failure to maintain a safe and comfortable environment for the resident.
Deficiencies in Grooming and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene care for residents who require assistance with Activities of Daily Living (ADLs). One resident, a male with severe cognitive impairment, was observed with long, dirty fingernails and a broken nail, despite the facility's policy that nursing staff should regularly check and trim residents' nails. Another resident, a male with mild cognitive impairment, was found with a urine-soaked incontinent brief and a strong odor of urine, indicating a failure to provide timely incontinence care as per the facility's policy of checking for incontinence every two hours. Additionally, a female resident was observed with noticeable facial hair over several days, despite the expectation that CNAs should address grooming needs during shower times. The resident's care plan indicated a need for assistance with ADLs, including grooming, but there was no documentation of refusal to be groomed. The facility lacked a specific policy for facial hair grooming, and staff acknowledged that agency staff might overlook such details.
Deficiencies in Blood Glucose Testing and Urinary Output Monitoring
Penalty
Summary
The facility failed to ensure accurate blood glucose testing for four residents with diabetes. Observations revealed that agency nurses used alcohol pads to wipe away the first drop of blood without allowing the alcohol to dry, which can affect glucose readings. This practice was observed in multiple instances, leading to potentially inaccurate blood glucose readings for residents with orders to monitor their blood sugar levels closely due to their diabetes diagnoses. Additionally, the facility did not adequately address a resident's concerns regarding urinary output. The resident reported pain and discomfort during urination, which was not promptly addressed by the staff. The resident's urinary output was significantly decreased, and the urine was cloudy, foul-smelling, and contained blood. Despite these symptoms, there was a delay in collecting urine and nephrostomy drainage samples for analysis, and the resident's physician was not immediately informed of the situation. The facility's policies on diabetes management and urinary catheter care were not followed, contributing to these deficiencies. The diabetes management policy required allowing alcohol to dry before testing blood glucose, and the urinary catheter care policy required monitoring and reporting unusual urine appearances and resident complaints. These lapses in following established procedures led to the deficiencies identified in the report.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for two residents with recent histories of falls. Resident R100, who was admitted with multiple diagnoses including nontraumatic intracerebral hemorrhage and impaired cognition, was identified as being at high risk for falls. Despite this, the care plan interventions such as a bed/chair alarm and a wing mattress were not properly implemented. On observation, R100 was found in bed without the wing mattress, and the sensory fall alarm pad was not positioned correctly. R100's wife expressed concern for his safety due to recent falls, and the Director of Nursing acknowledged the expectation for these interventions to be in place. Resident R14, who has severe cognitive impairment, was also identified as being at high risk for falls. However, during observation, the call light was found on the floor, and the floor padding was not in place as required by the care plan. Additionally, the resident's name tag did not have the yellow star indicating a high fall risk. The Director of Nursing confirmed that these interventions should have been implemented according to the facility's fall occurrence policy. Both residents had documented falls prior to these observations, indicating a failure to adhere to the prescribed fall prevention measures.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter tubing and drainage bags to prevent infection for three residents. One resident's catheter tubing was improperly positioned over his pants, and the drainage bag was placed on top of his bed, above the level of his bladder. The securement device for the tubing was ripped and detached, leaving the tubing unsecured. Another resident's catheter tubing was looped underneath his leg and was not secured because the securement device was wrapped around the tubing instead of being attached to his leg. The third resident also had unsecured catheter tubing, as the securement device was not attached to her leg, and her drainage bag contained urine with sediment. The facility's policy on urinary catheter care requires that catheter tubing be secured with a leg strap and that drainage bags be positioned below the bladder to prevent backflow. The Director of Nursing confirmed that catheter tubing should not be positioned over a resident's pants and that drainage bags should be placed below the bladder. The care plans for the residents involved indicated the need for catheter care every shift and proper positioning of the catheter bag and tubing, which was not adhered to in these instances.
Improper Transfer Practices and Inadequate Reporting of Falls
Penalty
Summary
The facility failed to ensure proper reporting and handling of a resident fall incident, which was caused by an improper transfer. A resident with a history of lumbar spinal fusion surgery and mobility issues was improperly transferred by a CNA, who did not use the recommended sit-to-stand machine with a 2-person assist. The CNA did not report the fall to the licensed staff, and the resident was assisted off the floor without a proper assessment. The resident later experienced increased pain and was transferred to the hospital for further evaluation. Additionally, the facility did not consistently use gait belts during resident transfers, as observed with multiple residents. One resident was assisted off the toilet without a gait belt, despite having a care plan indicating the need for such a device due to high fall risk. Another resident self-transferred to the toilet without supervision, and the CNA assisting did not use a gait belt, contrary to the resident's care profile requirements. The facility also failed to ensure that resident transfer statuses were accurately communicated and documented. Several residents had discrepancies between their care profiles and the actual transfer methods used by staff. For instance, two residents were transferred using a sit-to-stand machine, although their care profiles did not reflect this requirement. The lack of accurate documentation and communication regarding transfer statuses contributed to unsafe transfer practices.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers in accordance with its schedule and policy for residents who required assistance with bathing. This deficiency was identified for five residents who were reviewed for showers and baths. The facility's documentation showed that these residents did not receive showers as scheduled, with significant gaps between the showers provided. For instance, one resident did not receive a shower from September 16 to September 26, and another did not receive any shower or complete bed bath during their entire stay from September 21 to October 8. These lapses exceeded the facility's policy of providing showers at least once weekly. The residents involved had various medical conditions, including chronic heart failure, kidney disease, diabetes, dementia, and other health issues, which necessitated assistance with activities of daily living, including bathing. The facility's policy required that residents receive showers twice per week, and any refusals should be documented. However, the documentation provided did not align with this policy, indicating a failure to adhere to the established schedule and procedures for resident hygiene care.
Inadequate Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to adhere to its policy for urinary catheter care, resulting in inadequate documentation and assessment of symptoms for residents with indwelling urinary catheters who developed urinary tract infections (UTIs). Three residents, identified as R1, R2, and R8, were affected by this deficiency. The facility's policy required staff to monitor and document urinary output, including color, clarity, and any unusual appearance, as well as to observe and report signs of UTIs. However, these requirements were not consistently met. Resident R2 was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder and dementia, and had an indwelling urinary catheter. R2 was sent to the hospital with symptoms of lethargy and altered mental status, where a UTI was diagnosed. The nurse, V14, did not document the appearance of R2's urine or the urinary output in the electronic medical record (EMR), despite the facility's policy. Similarly, Resident R8, who was severely cognitively impaired, had a UTI diagnosed based on lab results, but there was no documentation of symptoms or urine characteristics in the progress notes. The physician prescribed antibiotics without a documented assessment of symptoms or response to treatment. Resident R1, with a suprapubic indwelling urinary catheter, had a change in antibiotic treatment for a UTI without documented symptoms or lab results to justify the change. The progress notes lacked documentation of R1's response to the treatment. The Director of Nursing, V2, confirmed the expectation for staff to monitor and document urinary output and characteristics, which was not fulfilled in these cases. The facility's failure to follow its urinary catheter care policy led to inadequate monitoring and documentation, contributing to the deficiency.
Failure to Provide Required Feeding Assistance for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate feeding assistance for a resident diagnosed with dysphagia, who required one-to-one feeding assistance. During an observation, the resident was seen at lunch with a mechanical soft tray and thickened liquids in front of him, attempting to drink the liquids without assistance. The Activity Director present at the table stated she was not qualified to feed residents. A Certified Nursing Assistant (CNA) mentioned that the resident had refused lunch and left the tray in front of him. The Director of Nursing confirmed that residents requiring one-to-one feeding assistance should be helped by a CNA, nurse, or speech therapist, and a tray should not be left unattended in front of such residents. The resident's medical records indicated a diagnosis of dysphagia and specified the need for one-to-one assistance with meals.
Failure to Follow Updated Dietary Orders for Resident
Penalty
Summary
The facility failed to follow dietary orders for a resident, identified as R1, who was on a special diet. On October 2, 2024, R1 was observed sitting near the nursing station with thickened water, which was consistent with his dietary orders. However, the speech therapist, V11, had evaluated R1 on September 24, 2024, and noted that although R1's hospital video swallow did not show aspiration, R1 was coughing on honey thick liquids during the evaluation. A care conference with R1's family on September 27, 2024, resulted in an agreement to allow thin liquids and ice chips between meals to promote hydration, as R1 was at risk for dehydration. Despite this agreement, the facility did not adhere to the updated dietary orders. On October 2, 2024, the Licensed Practical Nurse, V4, provided R1 with thickened water, contrary to the agreed-upon plan of allowing thin liquids and ice chips between meals. The Director of Nursing, V2, acknowledged that speech therapy recommendations should be followed, yet the facility failed to implement the updated dietary plan. The Order Summary Report dated October 2, 2024, confirmed the dietary orders for a regular diet with mechanical soft texture, nectar thick liquid consistency, and allowance for thin water and ice chips between meals, effective from September 27, 2024.
Failure to Inform Legal Representative About Psychotropic Medications
Penalty
Summary
The facility failed to ensure the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. The resident, who has a history of traumatic brain injury, major depressive disorder, and other significant health issues, was administered several psychotropic medications without proper consent documentation. The medications included Lorazepam, Aripiprazole, Escitalopram, and Trileptal. The consent forms for these medications were either incomplete or missing, failing to provide necessary information such as drug classification, targeted behaviors, side effects, and whether the legal representative agreed to the medication use. The resident's father, who is the designated Power of Attorney (POA), was not fully informed about the medications being administered. He expressed concerns about the use of these medications, particularly the mood stabilizer/antiepileptic medication Trileptal, which he believed could have detrimental side effects. The father also indicated that he was not notified about the administration of these medications and showed copies of incomplete consent forms provided by the facility. Interviews with facility staff, including the psychotropic nurse and the attending physician, confirmed that the consent forms should have included detailed information to ensure the POA was fully informed. The facility's policy on psychotropic medications, dated 5/30/2016, mandates adherence to federal regulations and obtaining consent for each psychotropic medication. However, the facility failed to comply with these requirements, leading to the deficiency identified in the report.
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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 Bloomingdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Suburban Nursing & Rehab Center | 1.2 mi | ★★★★★ | 12 | 0 |
| Alden Valley Ridge Rehab & Hcc | 1.7 mi | ★★★★★ | 0 | 0 |
| Abbington Vlge Nrsg & Rhb Ctr | 2 mi | ★★★★★ | 24 | 0 |
| Landmark Of Itasca Rehabilitation And Nursing Cent | 3.6 mi | ★★★★★ | 28 | 2 |
| Pearl Of Elk Grove, The | 3.6 mi | ★★★★★ | 7 | 0 |
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