Safety Report: Terra Bella Health and Wellness Suites
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
8Immediate jeopardy citations (severity J–L)
4Actual harm citations (severity G–I)
12Requirements cited on more than one inspection
H
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F580
K
Government finding: Provide appropriate foot care.
Quality of Life and Care Deficiencies · Tag F687
K
Government finding: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F656
K
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
K
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
H
Government finding: Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Tag F677
K
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
K
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
K
Government finding: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F755
K
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
Citations by topic
2Abuse, neglect & exploitation
3Infection control
7Medications & pharmacy
3Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (13) than in the cycle before (15).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 4 | August 5, 2026; July 21, 2025; January 18, 2024; October 10, 2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 3 | June 9, 2026; May 23, 2026; November 26, 2025 |
| Provide and implement an infection prevention and control program. (F880) | 3 | January 13, 2026; February 7, 2025; January 18, 2024 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 3 | February 24, 2025; August 29, 2024; October 10, 2023 |
| Provide timely, quality laboratory services/tests to meet the needs of residents. (F770) | 2 | August 5, 2026; October 28, 2023 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580) | 2 | May 23, 2026; October 28, 2023 |
| Ensure medication error rates are not 5 percent or greater. (F759) | 2 | March 26, 2026; October 28, 2023 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | November 20, 2025; November 14, 2023 |
| Ensure each resident receives an accurate assessment. (F641) | 2 | July 21, 2025; August 29, 2024 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 2 | February 24, 2025; January 18, 2024 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | December 23, 2024; October 28, 2023 |
| Ensure that residents are free from significant medication errors. (F760) | 2 | November 14, 2023; October 28, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| May 23, 2026 | Fine | $22,780 |
| July 21, 2025 | Fine | $45,679 |
| February 7, 2025 | Fine | $26,943 |
| January 18, 2024 | Fine | $38,705 |
| November 14, 2023 | Fine | $32,548 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 5, 2026 — 2 citations · complaint investigation
D
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F770 · complaint · corrected August 14, 2026
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected August 14, 2026
June 9, 2026 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 24, 2026
May 23, 2026 — 4 citations (includes serious) · complaint investigation
H
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to residents (not immediate jeopardy) · Pattern · Quality of Life and Care Deficiencies · F697 · complaint · corrected June 19, 2026
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 19, 2026
G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Actual harm to a resident (not immediate jeopardy) · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected June 19, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected June 19, 2026
March 26, 2026 — 1 citation
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected April 20, 2026
January 13, 2026 — 2 citations · complaint investigation
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected January 23, 2026
D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F726 · complaint · corrected January 23, 2026
November 26, 2025 — 2 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected December 1, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected December 1, 2025
November 20, 2025 — 1 citation · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected December 11, 2025
July 21, 2025 — 5 citations (includes serious) · complaint investigation
K
Provide appropriate foot care.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F687 · complaint · corrected August 8, 2025
K
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Immediate jeopardy to resident health or safety · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected August 8, 2025
K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected August 8, 2025
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · complaint · corrected August 8, 2025
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected August 8, 2025
April 25, 2025 — 1 citation · complaint investigation
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · complaint · corrected May 10, 2025
February 24, 2025 — 2 citations (includes serious) · complaint investigation
K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected March 14, 2025
H
Provide care and assistance to perform activities of daily living for any resident who is unable.
Actual harm to residents (not immediate jeopardy) · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected March 14, 2025
February 7, 2025 — 2 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected March 3, 2025
D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected March 3, 2025
December 23, 2024 — 4 citations
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · complaint · corrected January 17, 2025
D
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F814 · complaint · corrected January 17, 2025
D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected January 17, 2025
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · complaint · corrected January 17, 2025
November 14, 2024 — 1 citation · complaint investigation
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · complaint · corrected November 14, 2024
August 29, 2024 — 3 citations · complaint investigation
E
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected September 27, 2024
D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · complaint · corrected September 27, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected September 27, 2024
June 10, 2024 — 1 citation · complaint investigation
D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F921 · complaint · corrected June 24, 2024
January 18, 2024 — 4 citations (includes serious) · complaint investigation
K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected January 21, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected January 21, 2024
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · complaint · corrected January 21, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected January 21, 2024
November 14, 2023 — 2 citations (includes serious) · complaint investigation
K
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected November 24, 2023
K
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F755 · complaint · corrected November 24, 2023
October 28, 2023 — 6 citations (includes serious)
K
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected November 10, 2023
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected November 10, 2023
E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · complaint · corrected November 10, 2023
D
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F770 · complaint · corrected November 10, 2023
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected November 10, 2023
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected November 10, 2023
October 10, 2023 — 2 citations · complaint investigation
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected October 30, 2023
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected October 30, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare