Bella Terra Lombard

In the surveyor’s words

From the most serious findings on record at Bella Terra Lombard, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 25, 2026

  Based on observation, interview, and record review the facility failed to prevent the development of a facility acquired stage 3 pressure ulcer. This failure resulted in R1 developing a facility-acquired stage 3 sacral pressure ulcer. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in sample 5. The findings include:1.The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes, multiple sclerosis, hypertension, gastroesophageal reflux disease, low back pain, difficulty in walking, unsteadiness on feet and dementia. The MDS (Minimum Data Set), dated May 11, 2026, showed R1 was cognitively impaired and dependent on staff for toileting, hygiene, bathing and transfers. […]

• Actual harm, isolatedF677Aug 24, 2023

  Based on observation, interview, and record review, the facility failed to provide incontinence care to residents' dependent on staff for care for 5 of 5 residents (R1-R5) reviewed for incontinence care in the sample of 5. This failure resulted in psychosocial harm as evidenced by R2 being upset and angry for lying in a soiled incontinence brief for over four hours and stating it makes her pissed and disgusted, R1sitting in a soiled incontinent brief for over six hours and stating he felt like a second class citizen, and R4 stated in the morning she is soaked through to the bed linens and can't feel like a person when this happens. The findings include: 1. […]

• Actual harm, isolatedF689Apr 19, 2022

  Based on observation, interview, and record review, the facility failed to follow their policy for transferring residents using a gait belt or mechanical lift device. This failure resulted in R8 sustaining an arm fracture (left humerus fracture) following a fall, due to an improper transfer. This applies to 3 of 3 residents (R2, R6, and R8) in the sample of 9. The findings include: 1. On April 14, 2022, at 9:16 AM, R8 was sitting in his bed. R8 had an arm sling loosely hanging over his left arm. R8's left arm hung limp at his side. Bruising was visible on R8's upper left arm. R8 said he has a history of a stroke and has no use of his left arm. R8 demonstrated his inability to use his left arm and used his right hand and arm to reposition his left arm to a comfortable position. […]

• No harm, potential for more than minimal, widespreadF812Jun 26, 2024

  Based on observation, interview, and record review the facility failed to ensure food preparation equipment was sanitized prior to preparing food. This has the potential to affect all 138 residents receiving food from the kitchen. The findings include: The CMS 671 dated 6/24/24 shows there are 139 residents residing in the facility. Facility provided Diet Type Report shows that there is only one resident with an order of NPO (nothing by mouth) and does not receive food from the kitchen. On 6/24/24 at 10:37 AM, V18 (Chef) said that he had just finished pureeing the chicken for lunch and had to finish pureeing the noodles and broccoli. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to properly label, date, seal and store food items and practice proper sanitation in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated 7/18/23 documents that the total census was 129 residents. On 7/18/23 at 3:39 PM, V2 (DON/Director of Nursing) said 3 residents are NPO (Nothing By Mouth) and do not eat from the facility kitchen. […]