Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure that a resident was free from misappropriation of
prescribed narcotic medication.
Residents Affected - Few
This applied to 1 of 4 residents (R1) reviewed for narcotic/controlled medications.
The findings include:
The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that included
dementia, alcohol dependence, bipolar disorder, pain in left shoulder, low back pain, fractured left femur,
obstructive and reflux uropathy, limitation of activities due to disability, and cardiac arrythmias. R1 was
admitted to the facility on [DATE].
The MDS (Minimum Data Set) dated 5/3/2024 showed that R1's cognition was severely impaired with BIMS
(Brief Interview Mental Status) score of 6/15.
The care plan dated 4/27/2024 showed an intervention to provide prescribed pain medications to R1 for
pain management. The care plan also identified R1 with impaired cognitive function, impaired thought
processes related to dementia, bipolar disorder, alcohol dependence, major depressive disorder.
The POS (Physician Order Sheet) for the month of 7/2024 showed a physician order dated 5/24/2024 for
R1 to have Norco 5/325 mg. (controlled/narcotic medication) 1 tablet every 4 hours as needed for pain
management. The order was changed on 7/8/2024 for Norco 5/325 mg. to every 6 hours as needed from
the original order of every 4 hours.
The pharmacy manifest list showed that the facility had received 30 tablets of Norco 5/325 mg on 6/8/2024
and another 30 tablets on 6/28/2024 for R1.
The EMAR (Electronic Medication Administration Record) for the month of 6/2024 and 7/1-7/2024 were
reviewed. The EMAR showed that for the month of 6/2024, R1 had received 11 tablets of Norco 5/325. The
month of 7/1 through 7/7 of 2024 showed that R1 had received 11 tablets of Norco 5/325 mg. This showed
that there should still be available Norco for R1 with 60 tablets supplied and 22 tablets used.
The facility's incident report dated 7/13/2024 showed that an incident of misappropriation of R1's Norco
5/325 mg. was identified on 7/7/2024 at 11:45 P.M. The report also showed that V4(LPN/Licensed Practical
Nurse/routinely scheduled staff night on the dementia unit floor, (where R1 resides) had reported that R1's
Hydrocodone 5/325 mg. (Norco) was identified missing during the change of shift
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145511
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145511
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Lombard
2100 South Finley Road
Lombard, IL 60148
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
narcotic count between her and V3 (RN/Registered Nurse from agency staffing). The facility incident report
also showed that V3 was narrowed down as the alleged perpetuator. The incident report also documents
that the facility notified the local police, public health and replaced the missing medication for R1.
Review of the staffing schedule on 7/6/2024 and 7/7/2024 showed the following nurses on duty on the third
floor. They were same nurses for the 2 days that took care of R1.
-7/6/2024 and 7/7/2024 for day shift (7:00 A.M.- 3:00 P.M.) was V5 (RN/Registered Nurse/in house
staff/routinely assigned to R1)
-7/6/2024 and 7/7/2024 for evening shift (3:00 P.M. -11:00 P.M.) was V3 (RN/ from agency staffing)
-7/6/2024 and 7/7/2024 for night shift (11:00 P.M. -7:00 A.M.) was V4 (LPN/Licensed Practical Nurse/in
house staff/ routinely assigned to R1)
On 7/16/2024 at 1:58 P.M., V5 said that she was routinely scheduled to the dementia unit and assigned to
R1 during the day shift. V5 said she was scheduled day shift on 7/6 and 7/7 of 2024. V5 said that during the
change of shift narcotic count with V3, R1's Norco 5/325 mg. of 7-9 tablets were accounted for based from
the narcotic count sheet. V5 said that on 7/7/2024, at changed of shift at 3:00 P.M. again with V3, narcotic
count was done. V5 said that R1's Norco was accounted and there were approximately 7-8 tablets. V5 said
that since she was regularly assigned to R1, she knows how R1 was being managed with pain which was
Norco daily given around early morning. V5 said it was really weird when narcotic count held at the change
of shift between her and V4 on 7/7/2024 night/morning shift. V5 said that both of them (V4 and V5) have
noticed that (R1) narcotic count sheet showed that (V3) signed off indicating that V3 took 3 tablets of R1's
Norco 5/325 the evening of 7/6/2024 at 3:00 P.M., 7:00 P.M. and 10:45 P.M. V5 added that between change
of shift on 7/6 and 7/7/2024, it was only the three of us (V3 and V4, V5) that have the access for the
narcotic box where (R1's) Norco was placed. It was identified by (V4) that (R1's) Norco 5/325 mg. tablets
and the Norco narcotic count sheet form were missing. This was identified during the narcotic count sheet
between (V3) and (V4). I believe (V3) took (R1's) Norco but she said she does not know. How could (V3)
not know if (V3) was the only one who had the access to the narcotic box prior to being noted it was
missing. V5 also said that she did not administer Norco medication to R1 on 7/6 and 7/7 of 2024 during the
day shift.
On 7/16/2024 at 2:00 P.M., V4 said that she was routinely scheduled to the dementia unit and was
assigned to R1 during the night shift. V4 said she was scheduled night shift on 7/6 and 7/7 of 2024. V4 said
that during the change of shift with V3 on 7/6 at 11:00 P.M., both counted R1's Norco tablets in the narcotic
box. V4 said they both counted the Norco tablets and checked with the Norco narcotic count sheet. V4 said
there were approximately 7 tablets of Norco. V4 said she had noticed that R1's narcotic count sheet showed
that V3 signed off indicating that she took R1's Norco 3 tablets at 3:00 P.M., 7:00 P.M. and 10:45 P.M. V4
said that she was well aware of R1's routine of taking Norco which was only once a day and was usually
given early morning. V4 said it was very unusual that (V3) took 3 tablets of Norco) from (R1) based on the
narcotic count sheet. This was very unusual that (R1) had Norco every 4 hours. (R1) was only having daily
Norco and was comfortable with a pain patch only. V4 said that during the narcotic count at the change of
shift on 7/7/2024 at 11:45 P.M. with V3, V4 noted that R1's Norco tablets and Norco narcotic count sheet
were both missing. V4 said she had asked V3 what happened to R1's Norco tablets and the narcotic count
sheet. V4 said that V3 kept saying follow your policy, I don't know, I don't know what happened. V4 said she
immediately called V2 (Assistant Director of Nursing) due to missing controlled medication. V4 said (V3)
might deny that she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145511
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145511
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bella Terra Lombard
2100 South Finley Road
Lombard, IL 60148
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0602
Level of Harm - Minimal harm
or potential for actual harm
took the Norco, but she was the only one who had the access to the narcotic box and no one else, so how
would she not know what happened to (R1's) Norco. Obviously, she took (R1's) Norco since she was the
only responsible staff for that specific narcotic box during her shift. It was already strange the day before
when (V5) and I have noticed that (V3) signed off from (R1's) Norco narcotic count sheet indicating she
took 3 Norco tablets on 7/6/2024.
Residents Affected - Few
On 7/16/2024 at 11:24 P.M. V2 said that she had received a call from V4 on 7/7/2024 at around 11:45-11:50
P.M. V2 said that V4 had reported to her that R1's Norco tablets and Norco narcotic count sheet were
missing which V4 discovered during the narcotic count with (V3) during the change of shift. V2 said that she
immediately called V1 (Administrator), and she had started asking the assigned nurses that took care of R1
(V4 and V5). V2 said that V3 left the building and did not answer her phone despite multiple attempts from
V2 to contact her. V2 said that finally with staffing agency's help, V3 had called the facility on 7/9/2024 and
said that (V3) kept saying I don't know, I don't know. V2 added that based on interviews, and V3's response
it tells a lot without saying anything.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145511
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F602 - The resident has the right to be free from abuse, neglect, misappropriation of re
Protect each resident from the wrongful use of the resident's belongings or money.
FAQ · About this visit
Common questions about this visit
What happened during the July 17, 2024 survey of BELLA TERRA LOMBARD?
This was a inspection survey of BELLA TERRA LOMBARD on July 17, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BELLA TERRA LOMBARD on July 17, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from the wrongful use of the resident's belongings or money."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.