Bella Terrace Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Bella Terrace Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 29, 2026

  Based on record review, staff interview, review of the facility investigation, review of hospital records, review of police report, and policy review, the facility failed to provide the appropriate supervision for one cognitively impaired resident (Resident #46) who was at high risk for elopement and required the supervision of a secured memory care unit for his safety. Resident #46 eloped from the facility without staff knowledge on 07/05/25. This resulted in Immediate Jeopardy on 07/05/25 at 11:20 A.M. when Resident #46 was taken off the secured memory care unit to go outside with the memory care unit residents who smoke. […]

• Immediate jeopardy, isolatedF622Jun 29, 2022

  Based on observation, closed medical record review, staff interview, family interview, United Health Care (UHC) transportation representative interviews, review of accuweahter.com information and review of the facility policy and procedures titled Discharge Summary and Plan and Discharge Medications, the facility failed to ensure a safe and orderly discharge for one resident (Resident #76), who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy, on 06/07/22 at approximately 5:00 P.M. when the facility arranged for transportation for Resident #76 to be taken to another long-term care facility for long term care placement. […]

• Immediate jeopardy, isolatedF689Jun 7, 2021

  Based on observations, medical record review, review of the policy for Wandering Unsafe Residents, review of the facility investigation and staff interviews, the facility failed to provide adequate supervision to prevent one cognitively impaired resident (Resident #14) from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious injury when Resident #14, who was assessed as a moderate risk for wandering behaviors and early dementia, left the facility unknown to staff, out an unalarmed unlocked back door and was found in a neighboring State (Indiana), 18 hours later the following day. This affected one (#14) of three (#14, #30, and #06) residents reviewed for potential elopement. The facility identified 19 residents who were at risk for elopement. […]

• Actual harm, isolatedF686Aug 30, 2023

  Based on record review, resident and staff interviews, review of hospital records, and facility policy review, the facility failed to timely treat and assess a pressure ulcer and prevent the pressure ulcer from worsening for one resident (Resident #234). Actual Harm occurred on 08/01/23 when Resident #234 was admitted to the facility with a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure wound to her left proximal (back) upper thigh that worsened to a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer without evidence of routine skin assessments or timely treatments. […]

• Actual harm, isolatedF760Aug 30, 2023

  Based on medical record review, staff interview, hospital record review, and facility policy review, the facility failed to complete comprehensive blood glucose monitoring for Resident #65 to ensure insulin was administered per physician order and to meet the resident's total care needs. Actual Harm occurred when the lack of blood glucose monitoring (beginning in June 2023 and continuing through August 2023) and evaluation and/or administration of insulin resulted in ongoing episodes of hyperglycemia. On 08/12/23 Resident #65 had a blood glucose reading above 500 milligrams per deciliter (mg/dL) and was admitted to the hospital with hyperglycemia and acute kidney injury. This affected one resident (#65) of four residents reviewed for quality of care. […]