The June inspection revealed a pattern of infection control breakdowns affecting dozens of residents. Oxygen tubing went unchanged for weeks beyond safety limits, nurses violated basic sanitation protocols during medication administration, and management failed to address repeated violations from previous inspections.
During morning medication rounds on June 18, inspectors watched a registered nurse prepare eight medications for a resident, including Cosopt eye drops for glaucoma. The nurse told inspectors she had no tissues on her medication cart. With gloved hands, she walked into the resident's bathroom and pulled toilet paper from the roll hanging on the wall.
The nurse folded the toilet paper into a small wad and used it to dab the resident's right eye after administering one drop of Cosopt. She then turned the toilet paper over and used the other side to dab the left eye after the second drop.
When questioned 14 minutes later, the nurse defended her actions, stating "she felt the toilet tissue was clean." She explained she was an agency nurse unfamiliar with the medication cart's supplies, making it "difficult to know what was stocked."
The Director of Nursing later confirmed to inspectors that toilet paper from bathrooms should never be used during medication administration because "it was not sanitary." She stated boxes of tissues were provided for medication carts.
On the facility's second floor, inspectors found Resident #80 using oxygen tubing that hadn't been changed in over two weeks. The resident, who has chronic obstructive pulmonary disease, morbid obesity, and anemia, was receiving humidified oxygen through nasal cannula tubing marked with tape dated June 5.
When inspectors returned two days later, the same dated tubing remained in use. The resident told them, "They change my oxygen tubing when I ask the nurse, and the last time it was done was about two weeks ago."
A physician's order from June 12 specifically required changing oxygen cannula and tubing weekly on Wednesday during the night shift. Licensed Practical Nurse #1 confirmed to inspectors that tubing should be changed weekly and that residents "should not be using nasal tubing that was more than seven days old."
The Director of Nursing acknowledged the infection control risk, stating nasal tubing "should not be used past seven days because it was an infection control issue."
Facility policy required replacing masks and cannula "within seven days and as needed when obviously contaminated."
A Unit Manager and Licensed Practical Nurse was observed multiple times with manicured acrylic nails over an inch long and curled. When an inspector commented on the nail length on June 25, the staff member "hid their nails and replied not to look at them."
The unit manager initially claimed she didn't provide resident care, but the Director of Nursing explained that unit managers assist with care during staffing shortages and confirmed that "administering residents' medications was considered resident care."
Both the Licensed Nursing Home Administrator and Director of Nursing acknowledged the nail length was inappropriate. The Director of Nursing stated the nails were "too long which could result in bacterial growth underneath as well as resident care issues."
The facility's dress code policy required nail length to be "reasonable so as not to interfere with resident care."
These infection control failures occurred across multiple nursing units and involved different shifts. The facility had no Infection Preventionist on staff during the inspection period.
The violations represented a continuation of problems identified in previous inspections. During the survey team's meeting with administrators on June 20, inspectors noted "repeated concerns from the last standard survey which included MDS assessments, medication storage, acting on consultant pharmacy reports, antibiotic stewardship program, facility assessment, and QAPI."
When asked what the facility had implemented to ensure sustainability of improvements, the Licensed Nursing Home Administrator acknowledged she had been present for quarterly quality meetings and reviewed previous violation reports since starting in April 2024. The Director of Nursing stated the facility "educated staff and completed reports."
No additional information was provided about specific corrective measures.
The facility also failed to properly assess its resident population for quality assurance purposes. Administrators confirmed Belle Care houses registered sex offenders and inmates from the local county jail, but these special populations were not included in the facility's required assessment documents updated in September 2023.
The inspection found the facility's quality assurance program relied primarily on addressing violations cited in previous federal surveys rather than proactive identification of safety risks. When asked where the facility obtained concerns for their quality program, the administrator stated they "utilized the CMS statement of deficiencies from previous surveys."
Belle Care operates on Bellevue Avenue and serves residents requiring various levels of medical care and rehabilitation services.
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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