Belle Care Nursing: Medication Safety Failures - NJ
The registered nurse told inspectors on June 18 that she "had to borrow a password" from the unit manager because she was locked out of the system after entering her own password incorrectly three times. She had already given morning medications to ten residents but waited hours to sign the electronic records, using someone else's login credentials to do it.
"I shouldn't have pre-signed," the nurse admitted when inspectors caught her signing off on medications she planned to give later that day.
The password sharing was just one of multiple medication safety breakdowns inspectors documented during their visit to the 439 Bellevue Avenue facility. Nurses administered wrong medication doses, failed to maintain proper records of controlled substances, and left gaps in narcotic inventory logs spanning multiple shifts in June.
Meanwhile, residents with severe cognitive deficits lay in beds soaked with urine and feces while understaffed nursing assistants made rounds in the dark.
Resident 147, who required total assistance with personal hygiene due to moderate cognitive deficits and a tracheostomy, was found lying on a fitted sheet with large brown and yellow stains that smelled like urine and contained dried feces. The unit manager identified the brown stains as bowel movement and said the certified nursing aide "should have changed the resident's sheet when performing incontinence care."
On the first floor, Resident 32 — a stroke patient with severe cognitive deficits — was discovered lying in an incontinence brief "very wet with urine" while his sheets were stained and had "a strong smell of urine." The licensed practical nurse confirmed the resident's brief should have been changed and the entire bed linen replaced.
The nursing aide assigned to Resident 32 told inspectors she had made rounds that morning but "did not see the large urine stain on the resident's bed sheets" because "she did not turn the light on in the resident's room." She called it "an oversight."
Both residents' skin remained intact without breakdown, but the Director of Nursing acknowledged that leaving residents soiled puts them "at risk for skin breakdown." She emphasized that "even if a drop of urine got onto the linen, then the linen should be changed."
The facility's staffing problems extended far beyond individual oversights. Records from November 2022 revealed dangerous nurse-to-patient ratios, with some shifts having no nurses at all on certain units.
On November 7, 2022, the facility housed 91 residents but had only two nurses working across all three shifts, with no nursing coverage during the overnight hours. November 18 and 19 saw even worse conditions — 94 residents cared for by just one nurse per day, with no nurses working day or evening shifts.
"The facility relied heavily on Agency staffing," the administrator told inspectors, acknowledging they "did not always meet the required ratios" of one aide for every eight residents during morning shifts.
The medication errors were equally troubling. On June 18, inspectors watched a registered nurse prepare eight medications for Resident 5, including a 125-milligram tablet of Depakote for bipolar disorder. The nurse administered seven medications but gave only part of the prescribed dose.
Physician orders required Resident 5 to receive 625 milligrams of Depakote daily — a combination of 125-milligram and 500-milligram tablets taken together. But when the facility switched computer systems on June 11, the 500-milligram dose was incorrectly programmed to start on June 30 instead of immediately.
For a full week, Resident 5 received less than one-fifth of the prescribed mood-stabilizing medication. The unit manager discovered the error only after inspectors questioned the dosage, admitting the order "was entered incorrectly" and "should have been started on 6/11/24."
Controlled substance management proved equally problematic. Inspectors found missing signatures on narcotic count sheets for six different shifts in June, including the morning of their visit when the agency nurse forgot to sign after completing her inventory count.
The methadone records for Resident 51 showed similar gaps. On June 17, no nurse signed the custody record when the medication was removed from inventory, even though electronic records showed it was administered. The Assistant Director of Nursing, who gave the medication, told inspectors she "had not realized she was supposed to sign the record."
Individual patient logs for controlled substances contained multiple missing entries. Resident 51's pregabalin records lacked nurse signatures for doses given on June 14. Resident 9's tramadol log was missing administration time documentation from May 30.
The facility's policies required nurses to document controlled substance administration immediately, with both incoming and outgoing nurses signing inventory sheets at every shift change. "Both nurses are responsible for the count and must sign the inventory count form," the policy stated.
But the consultant pharmacist, who started in March 2024, told inspectors she had not yet conducted any medication administration observations or training sessions for nurses.
The Human Resources coordinator confirmed that agency nurses received individual login passwords and should never share them. When the registered nurse was locked out on June 18, administrative staff could have unlocked her account or provided a new password instead of allowing her to use someone else's credentials.
"The login corresponded to the nurse's signature," the Director of Nursing explained. Using another person's password meant the medication records falsely showed the unit manager had administered drugs she never touched.
The facility had changed its electronic charting system just one week before the inspection, but administrators said nursing procedures should have remained the same. Medications were supposed to be documented "immediately after the medication was administered," not hours later using borrowed passwords.
State regulations require one certified nursing aide for every eight residents during morning shifts, every ten residents during evening shifts, and every fourteen residents overnight. The staffing coordinator acknowledged these ratios were "very hard" to maintain and that "the facility did not always meet the required ratios."
For residents like 147 and 32, who depended entirely on staff for basic hygiene, the understaffing meant lying in their own waste while aides rushed between rooms or made rounds without turning on lights.
The facility's own policies emphasized the importance of infection control and maintaining "a safe and healthy environment for residents." But inspectors found the reality fell far short of those standards, with residents left soiled and medications administered incorrectly or not at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belle Care Nursing and Rehabilitation Center from 2024-06-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BELLE CARE NURSING AND REHABILITATION CENTER in TRENTON, NJ was cited for violations during a health inspection on June 26, 2024.
She had already given morning medications to ten residents but waited hours to sign the electronic records, using someone else's login credentials to do it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.