Inadequate Investigation of Resident-to-Resident Violence
The most serious violation occurred when facility administrators failed to properly investigate an incident where one resident allegedly struck another resident multiple times in the head. On May 9, 2025, at approximately 6:30 AM, staff witnessed what appeared to be a physical altercation between two residents in the hallway.
According to witness statements from nursing assistants, the incident involved a resident who had been in a motorcycle accident and could not speak, and another resident who was hard of hearing. Multiple staff members observed the first resident "punching" and "hitting" the second resident "across the head" and "on the head."
One certified nursing assistant provided this account: "So around 6 o'clock I was coming out of the bathroom I see (R401) trying to push (R402) to the wall me and (V11, CNA) stopped him, I put (R401) back in his room and moved (R402) off the hall. I go back in the bathroom to wash hands only to see (R401) hitting (R402) on the head."
Despite multiple staff witnesses, facility administrators concluded they could not substantiate whether abuse occurred. The administrator's reasoning was concerning: when asked whether the striking involved an open or closed hand, staff could not provide specific details. The administrator stated, "I felt the staff were inconsistent with their statements, so it was impossible to determine if abuse occurred. I know some of my staff will lie."
This investigation approach falls far short of industry standards for protecting vulnerable residents. When potential abuse is witnessed by multiple staff members, facilities are required to conduct thorough investigations, document all evidence, and implement protective measures regardless of whether every detail can be confirmed. The failure to substantiate obvious physical contact between residents creates an unsafe environment where aggressive behavior may continue unchecked.
The incident is particularly concerning because both residents had communication limitations that made them especially vulnerable. The aggressor could not verbally communicate due to his injuries, while the victim had hearing impairments. Staff noted that the residents were roommates and that food theft had been an ongoing issue between them, suggesting the facility was aware of tension but failed to address it proactively.
Critical Nursing Leadership Vacancy Compromises Patient Care
Belleville Healthcare Center operated without a Director of Nurses for over 13 months, from February 11, 2024, through the March 2025 inspection. This represents a fundamental breakdown in nursing oversight for the facility's 126 residents.
The Director of Nurses position is not optional - it's a federal requirement for nursing homes. This role serves as the clinical leader responsible for overseeing all nursing care, ensuring proper staffing levels, maintaining quality standards, and coordinating with physicians and other healthcare providers. Without this critical leadership position filled, nursing staff lacked proper supervision and clinical guidance.
During the inspection, a registered nurse consultant confirmed the facility had no Director of Nurses and that an Assistant Director of Nurses had just started working the day before the inspection. This means residents were without proper nursing leadership oversight for more than a year during a critical period when the facility was managing complex medical conditions and rehabilitation needs.
The absence of a Director of Nurses creates cascading problems throughout the facility's operations. Nursing protocols may not be properly implemented, staff training can become inconsistent, and quality assurance measures may be inadequately monitored. This leadership gap likely contributed to other violations found during the inspection, as there was no qualified nursing professional ensuring compliance with medical standards and regulations.
Federal regulations require facilities with more than 60 residents to have a full-time Director of Nurses who cannot serve as a charge nurse. With 126 residents, Belleville Healthcare Center was well above this threshold and should have prioritized filling this essential position immediately after the previous director's departure.
Pressure Ulcer Care Failures Result in Wound Deterioration
The facility failed to properly assess and treat a resident's pressure ulcer, allowing it to worsen from a Stage II to Stage III wound. This deterioration occurred because staff did not conduct a complete skin assessment when the resident returned from the hospital, missing critical changes in the wound's condition.
The resident was readmitted to the facility on August 14, 2024, with a documented Stage II sacral pressure ulcer from her hospital discharge paperwork. However, nursing staff failed to perform the required comprehensive skin assessment upon readmission. A nurse's note mentioned "breakdown to her right butt" but provided no detailed wound evaluation or staging.
Six days later, wound assessment revealed the pressure ulcer had progressed to Stage III, measuring 6.11 centimeters by 3.01 centimeters by 2.77 centimeters. The wound bed showed 60% slough and 40% eschar, indicating significant tissue death and poor healing conditions.
Pressure ulcers are serious medical conditions that can lead to life-threatening complications if not properly managed. Stage II ulcers involve partial-thickness skin loss, while Stage III ulcers extend into deeper tissue layers, including fat. This progression represents a significant decline in the resident's condition and increases risks for infection, sepsis, and prolonged healing times.
The facility's own policy required skin assessments within 24 hours of admission, including completion of the Braden Scale for Predicting Pressure Ulcer Risk and nursing admission observations. These assessments are critical for identifying at-risk residents and implementing appropriate preventive measures such as specialized mattresses, positioning schedules, and nutritional support.
Additionally, dietary staff recommended Prostat supplements twice daily for wound healing, but no physician's order was obtained until September 4, 2024 - three weeks after the recommendation. This delay in obtaining proper nutritional support likely contributed to poor wound healing and the ulcer's progression to a more serious stage.
Improper Waste Management Creates Health Hazards
Inspectors found the facility's garbage disposal practices violated health and safety standards, with dumpster lids missing or left open, creating potential disease transmission risks and pest attraction problems.
During the March 11, 2025 inspection, both garbage dumpsters behind the kitchen were found improperly secured. One dumpster was missing its lid entirely, while the second dumpster's lid was completely open despite being half-full of garbage bags and other waste materials.
A dietary aide confirmed the observation was inappropriate, stating: "These lids should be closed. That is how we keep the animals out of the trash." The administrator explained that a garbage truck operator had damaged one lid and promised replacement, but the facility continued operating with exposed waste for an undetermined period.
Proper waste containment is essential in healthcare settings to prevent disease transmission, control odors, and prevent pest infestations. Open garbage containers can attract rodents, insects, and other vectors that may carry pathogens into food preparation areas and resident living spaces. The kitchen's proximity to the exposed waste creates particular risks for foodborne illness transmission.
The facility's own policy required garbage containers to be "in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lids and covered." This violation represents a basic failure to maintain sanitary conditions that protect both residents and staff from environmental health hazards.
Medical Context and Industry Standards
These violations reflect fundamental breakdowns in nursing home operations that directly impact resident safety and wellbeing. Proper abuse investigation protocols exist because nursing home residents are among the most vulnerable populations, often unable to defend themselves or report incidents due to cognitive impairments, physical limitations, or communication barriers.
Nursing home standards require facilities to maintain adequate staffing levels and leadership structures specifically because residents depend entirely on staff for their medical care, safety, and daily needs. The Director of Nurses position exists to ensure clinical standards are maintained and that nursing staff receive proper guidance and oversight.
Pressure ulcer prevention and treatment require skilled nursing assessment and intervention. These wounds can progress rapidly without proper care, leading to serious complications including osteomyelitis (bone infection), sepsis, and death. Facilities must implement evidence-based prevention strategies and respond quickly when wounds develop or worsen.
Environmental health standards in nursing homes serve to protect immunocompromised residents who may be more susceptible to infections and disease transmission than the general population. Proper waste management is a basic requirement that supports overall infection control efforts.
Additional Issues Identified
The inspection also revealed problems with medication administration documentation, where dietary staff recommended wound healing supplements that were not properly ordered by physicians for three weeks. Treatment administration records showed inconsistencies in wound care documentation, and the facility's abuse investigation files were incomplete, missing statements from some staff members who witnessed the alleged incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Integrity Hc of Belleville from 2025-03-14 including all violations, facility responses, and corrective action plans.
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