Federal inspectors found the facility failed to provide adequate nursing care during a June complaint investigation, documenting cases where staff ignored basic hygiene needs and medication schedules for vulnerable residents.
Resident 97, who had stage 4 breast cancer that had spread to bones and lungs, missed multiple doses of tramadol in June and July 2023. On June 22, the resident didn't receive their 9 a.m. dose with no explanation documented. Three weeks later, the resident missed three consecutive doses on July 21 — at midnight, 6 a.m., and noon.
The nursing notes show staff called the pharmacy about the missing medication at 1:34 p.m. on July 21, nearly 13 hours after the first missed dose. The pharmacy said they were waiting for a prescription. A nurse called the nurse practitioner, who claimed the prescription was sent the night before. The pharmacy denied receiving it.
Nobody documented whether the physician was notified about the missed doses or whether alternative pain relief was provided. The resident's pain wasn't assessed during the hours without medication.
On July 27, the resident missed another 6 a.m. dose with no documentation explaining why.
The Director of Nursing told inspectors the facility had backup narcotic supplies, but tramadol wasn't included. When inspectors requested medication inventory sheets three times over six days, administrators couldn't locate them. The Assistant Director of Nursing confirmed the resident had cancer when the pain medication wasn't received.
Meanwhile, staff left residents in unsanitary conditions during routine care rounds. On June 18, inspectors found Resident 147 lying on a fitted sheet stained with urine and dried feces. A protective pad had been placed over the soiled sheet rather than changing it.
The Unit Manager told inspectors an agency nursing assistant from the overnight shift "must have left the dirty sheet on the resident's bed" and that the morning aide hadn't made rounds yet. Incontinence checks were supposed to happen every two hours.
The same morning, inspectors found Resident 32 lying in a very wet brief with sheets soaked in urine that gave off "a strong smell." The Licensed Practical Nurse confirmed the brief and entire bed linen should have been changed.
The nursing assistant assigned to Resident 32 told inspectors she made rounds that morning but "conducted rounds on Resident #32 in the dark, and did not see the large urine stain on the resident's bed sheets or notice the resident's brief was soaked with urine."
The Director of Nursing acknowledged to inspectors it was "not appropriate to make care rounds in the dark."
Basic grooming needs went unmet for weeks. Resident 73, who has diabetes and moderately impaired cognition, was observed with long, dirty fingernails on June 19. When asked if staff had cleaned or cut their nails, the resident said no and requested they be trimmed.
The next day, inspectors saw the same resident in the lobby biting their long, dirty fingernails.
Resident 60, a stroke patient with moderate cognitive deficits, was found with similarly neglected nails on June 17. The resident requested nail care but received none. When the Director of Nursing saw the resident's fingernails on June 25, she confirmed they were "long and dirty" and said nail care "should have been addressed by the CNAs."
The facility's own policy required nursing assistants to "clean around and under the nails" and "trim the nails using the nail clipper." Job descriptions specified that CNAs were responsible for cleaning and cutting fingernails.
Both residents required substantial assistance with personal hygiene according to their care assessments.
A Registered Nurse told inspectors that nails should appear "clean and short with underneath also clean" and that staff checked nail length and appearance during weekly bathing. When Resident 60 approached the nursing station during the interview, both the nurse and Unit Manager confirmed the resident's fingernails were "long, dirty, and unacceptable."
The Licensed Nursing Home Administrator acknowledged to inspectors that providing nail care to residents was a facility expectation. The Director of Nursing confirmed residents should be checked every two hours to prevent skin breakdown from prolonged exposure to urine and feces.
The facility's pain management policy required staff to "reassess patients with pain regularly" and revise treatment plans when pain wasn't adequately controlled. The incontinence policy emphasized controlling infections as part of the overall infection control program.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few to some residents at the 150-bed facility on Bellevue Avenue.
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.
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