The aide, assigned to care for eleven residents on the first floor, told inspectors on June 18 that she "did not see the large urine stain on the resident's bed sheets and did not notice that the resident's incontinence brief was soaked with urine" during her morning rounds. She called it "an oversight."
Inspectors discovered Resident #32, a stroke patient with severe cognitive deficits, lying in bed with an incontinence brief "very wet with urine" and sheets with "a large urine stain that had a strong smell of urine." The resident was non-verbal and completely dependent on staff for hygiene care.
On the second floor, inspectors found another resident lying on a fitted sheet with "a large brown/yellow stain that smelled like urine and contained some dry brown stains" that staff identified as bowel movement. The unit manager said the overnight agency aide "must have left the dirty sheet on the resident's bed" rather than changing it during incontinence care.
Both residents' skin remained intact without breakdown, but the Director of Nursing acknowledged that "residents left soiled were at risk for skin breakdown."
The facility's staffing problems extended far beyond individual oversights. Belle Care could not produce basic staffing records for a two-week period in November 2022, despite federal requirements to maintain such documentation. When inspectors requested the records, administrators said they were "trying to get the information from the payroll company."
The records they eventually provided revealed severe understaffing. On November 7, 2022, the facility operated with just two nurses for 91 residents across all three shifts, with no nurses working overnight. On November 18 and 19, the facility had only one nurse for the entire 24-hour period, with no nurses on day or evening shifts.
"The staffing levels were not acceptable," the Director of Nursing admitted during the inspection.
These staffing shortages had direct consequences for patient care. Medication administration records showed residents routinely received medications hours late. One resident's 8:00 AM medications were administered at 2:04 PM. Another resident's 9:00 AM dose was given at 1:52 PM, and their 5:00 PM medications weren't administered until 10:26 PM.
The facility's record-keeping failures went beyond staffing sheets. Administrators could not locate a complete investigation for a reportable incident involving Resident #248, who was found lethargic in their wheelchair in April 2023. Despite multiple requests over several days, the facility told inspectors, "We have them but can't find it."
They also could not produce a discharge summary for Resident #252, who left the facility in July 2022. "Staff informed her that one was completed, but the facility was unable to locate it," the Licensed Nursing Home Administrator told inspectors.
The facility's environmental problems were equally troubling. Inspectors observed a wheelchair in the hallway with "brown matter that resembled fecal matter, smeared across the seat cushion and down the leg of the wheelchair onto the wheels."
In one resident room, inspectors found "a strong urine odor" with floors that were "wet and sticky" and "puddles of wetness" on the bed. A registered nurse acknowledged being aware of the room's condition, and the unit manager confirmed "that Resident room should not be in that condition."
The facility's own policies required staff to ensure cleanliness and "pleasant, neutral scents" throughout the building. The wheelchair cleaning policy specifically called for power-spraying heavily soiled equipment outside if necessary.
Belle Care relied heavily on agency staff to fill gaps in coverage, administrators told inspectors. The staffing coordinator said it was "very hard to find staff" and that "the facility did not always meet the required ratios" under state regulations.
New Jersey regulations require one certified nursing aide for every eight residents during morning shifts, one for every ten residents during evenings, and one for every fourteen residents overnight. The facility's own policy committed to providing "sufficient staff with appropriate competencies and skill sets to assure resident safety."
The Director of Nursing told inspectors that staff should check incontinent residents every two hours, or every hour for those on diuretics. She emphasized that "even if a drop of urine got onto the linen, then the linen should be changed" and that "clean linen should not be put on top of dirty linen."
But the morning aide who conducted rounds in darkness had thirteen residents under her care. She told inspectors that "all residents should be clean and dry before they started their meals" at 8:00 AM.
The Licensed Nursing Home Administrator acknowledged to inspectors that the facility's practices were "unacceptable," including putting protective pads "on a wet and soiled fitted bed sheet" and making "care rounds in the dark."
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
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