TRENTON, NJ - Federal inspectors documented serious lapses in basic hygiene care at Belle Care Nursing and Rehabilitation Center after finding residents left in urine-soaked bedding and staff conducting patient rounds in darkness.
Residents Found in Soiled Bedding During Morning Rounds
During an unannounced inspection tour on June 18, 2024, surveyors accompanied by nursing staff discovered Resident #147 lying in bed with a dry incontinence brief, but the fitted sheet underneath was heavily stained with urine and fecal matter. Rather than changing the soiled sheet, staff had placed a protective bed pad directly over the contaminated bedding.
The Unit Manager acknowledged that the nursing assistant assigned to the resident's care "should have changed the resident's sheet when performing incontinence care and should not have left a urine-soaked sheet on the resident's bed." The manager attributed the oversight to an agency nursing assistant from the overnight shift.
Resident #147, who was admitted with chronic respiratory failure and a tracheostomy, required complete assistance with personal hygiene according to the care plan. The comprehensive assessment indicated moderate cognitive deficits and total dependence on staff for hygiene needs.
Staff Conducted Rounds in Darkness, Missing Care Needs
Less than an hour later on the same morning, inspectors found Resident #32 lying in bed with an incontinence brief "very wet with urine" and sheets with a large urine stain that produced a strong odor. The resident, who had experienced a stroke and had severe cognitive deficits, was unable to communicate verbally.
When questioned, the nursing assistant assigned to Resident #32 admitted she had conducted morning rounds "in the dark" and failed to notice the resident's soaked brief or the large urine stain on the bed linens. The assistant acknowledged "it must have been an oversight" and that both the brief and bed linens should have been changed.
The resident's care plan specified that staff should provide incontinence care every two to four hours and that the resident required total dependence and one-person physical assistance with personal hygiene.
Medical Implications of Delayed Incontinence Care
Prolonged contact with urine and fecal matter creates significant health risks for nursing home residents. The moisture and bacteria present in urine can compromise skin integrity within hours, particularly for residents with limited mobility who cannot reposition themselves.
When skin remains in contact with moisture, the outer protective layer breaks down through a process called maceration. This weakened skin becomes vulnerable to friction and pressure, dramatically increasing the risk of pressure ulcers. For residents who already have cognitive impairments and cannot alert staff to their needs, timely incontinence rounds become critical.
The presence of fecal matter creates additional infection risks. Bacteria from bowel movements can cause urinary tract infections, particularly in residents who cannot maintain their own hygiene. For a resident like #147 who had a tracheostomy, maintaining overall infection control was particularly important given the existing vulnerability from the breathing tube.
Failure to Follow Basic Hygiene Protocols
Multiple staff members acknowledged that the care provided fell short of facility standards. The Unit Manager stated that incontinence rounds should occur every two hours and that residents should be clean and dry before breakfast service at 8:00 AM.
A nursing assistant interviewed the following day explained that all incontinent residents should be checked every two hours, with more frequent checks for residents taking diuretics. The assistant emphasized that timely brief changes prevented skin breakdown and that wet bed linens required immediate changing because "leaving urine-soaked bed linen on the bed could also cause odor and skin breakdown."
The assistant added that it was "not appropriate to put clean bed linen over wet bed linen" and that when arriving for a shift, staff should conduct rounds with departing shift staff to ensure all residents were "safe, clean, and dry."
Director of Nursing Acknowledges Unacceptable Practices
The Director of Nursing confirmed that incontinence rounds should begin immediately when staff arrive to the unit to identify priority residents needing care. She stated that even "a drop of urine" on bed linens required changing the sheets and that clean linens should never be placed over soiled ones.
"All residents should be checked on every two hours to ensure that residents were provided incontinence care timely because residents left soiled were at risk for skin breakdown," the director told inspectors.
On June 26, 2024, the Licensed Nursing Home Administrator and Director of Nursing acknowledged it was unacceptable to place protective pads on wet and soiled fitted sheets. The director also acknowledged that conducting care rounds in darkness was inappropriate.
Nail Care Neglected for Multiple Residents
Beyond incontinence care failures, inspectors documented that the facility failed to provide basic nail care for residents. On June 19, 2024, surveyors observed Resident #73 with long, dirty fingernails. When asked if the facility had cleaned or trimmed the nails, the resident stated they had not and that they wanted their nails cut.
The following day, surveyors observed the same resident in the facility lobby biting on their long, dirty fingernails. Resident #73 had been admitted with diabetes mellitus, which makes proper nail care particularly important to prevent infections.
Nursing assistants confirmed they were responsible for nail care, including cleaning and filing nails to a reasonable length. The Registered Nurse stated that nails should appear "clean and short with underneath also clean" and that daily skin checks included examining nails for length and appearance.
Additional Resident Affected by Nail Care Failure
Inspectors also found Resident #60 with long, dirty fingernails. When asked if the facility had provided nail care, the resident stated they had not and requested their nails be cut. This resident had been admitted following a stroke that caused paralysis on one side of the body, along with a documented fungal infection of skin and nails.
When the surveyor questioned staff about Resident #60's fingernail condition on June 20, both the Registered Nurse and Unit Manager confirmed the nails were "long, dirty, and unacceptable." However, when the Director of Nursing observed the same resident five days later on June 25, the fingernails remained long and dirty despite the issue having been previously identified to staff.
The director acknowledged that "nail care was an everyday thing and it should have been addressed by the CNAs" and confirmed the care should have been completed after staff were first alerted to the problem.
Facility Policies Require Regular Hygiene Care
The facility's own Bowel and Bladder Incontinence Care policy, dated May 2023, stated that controlling infections for incontinent residents was part of the overall infection control program and that the facility was committed to providing a safe, healthy environment to minimize or prevent the spread of infections.
The Resident Care-Grooming policy required nursing staff to trim residents' nails using nail clippers and file them to round the tips, and to clean around and under the nails using moistened cotton swabs. The policy specified that nursing staff would provide observation and care of nails for all residents on bath day as needed.
Job descriptions for nursing assistants specifically included responsibilities to bathe residents and "clean and cut fingernails" while ensuring residents receive "the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right."
Implications for Resident Care
The documented failures at Belle Care Nursing and Rehabilitation Center reveal breakdowns in basic activities of daily living assistance. Both incontinence care and nail hygiene represent fundamental nursing home services that protect residents from infection, skin breakdown, and discomfort.
The inspection found that despite having written policies and care plans in place, staff either failed to follow established procedures or conducted care rounds in ways that made it impossible to adequately assess resident needs. The practice of conducting rounds in darkness, acknowledged by staff and management as inappropriate, suggests systemic issues with oversight and accountability.
For residents with cognitive impairments who cannot advocate for themselves or alert staff to their needs, consistent implementation of basic care protocols becomes the primary protection against neglect. The facility's failure to provide these services, despite having appropriate policies and adequate staffing ratios on paper, raises questions about supervision and quality assurance practices.
The complete inspection report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website, where families can review detailed findings and track the facility's compliance history.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Nursing and Rehabilitation Center from 2024-06-26 including all violations, facility responses, and corrective action plans.
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