Providence Nursing And Rehabilitation Center

F-F677

1. According to the Admission Record (AR), Resident #147 was admitted to the facility with the diagnoses which included but not limited to chronic respiratory failure and tracheostomy (hole in the windpipe to facilitate breathing). The most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/10/24, reflected that Resident #147 had moderate cognitive deficits and was dependent on staff for hygiene. Resident #147's individualized comprehensive care plan (ICCP) reflected that the resident required total dependence and one-person physical assistance with personal hygiene.

According to the AR, Resident #32 was admitted to the facility with the diagnoses which included but not limited to cerebral infarction (stroke). The most recent comprehensive MDS dated [DATE REDACTED], reflected that Resident #32 had severe cognitive deficits and was dependent on staff for hygiene. Resident #32's ICCP reflected that the staff provided incontinent care every two to four hours and that the resident required total dependence and one-person physical assistance with personal hygiene.

On 6/18/24 at 8:02 AM, the surveyor conducted an incontinence tour on the Second Floor nursing unit accompanied by the Unit Manager/Licensed Practical Nurse (Um/LPN #1) and observed the following:

The surveyor and UM/LPN #1 entered Resident #147's room who was observed lying in bed. UM/LPN #1 asked the resident if she could check their incontinent brief and the resident gave UM/LPN #1 permission.

The surveyor observed that the resident's incontinent brief was dry and the chuck (protective bed pad) that was directly under the resident was dry, however the fitted sheet located under the chuck had a large brown/yellow stain that smelled like urine and contained some dry brown stains which UM/LPN #1 identified as bowel movement (bm). UM/LPN #1 was interviewed at that time, and stated that the Certified Nursing Aide (CNA) that was assigned to care for Resident #32 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. UM/LPN #1 stated that the Agency CNA that cared for the resident on 11:00 PM to 7:00 AM shift must have left the dirty sheet on the resident's bed because the CNA (CNA #1) that came in that morning just got to the unit and had not made rounds yet. UM/LPN #1 stated that incontinence rounds were completed by the CNA every two hours. The surveyor observed the resident's skin during the tour and the resident's skin was free of skin breakdown.

A review of the CNA Assignment sheet for 6/18/24, revealed that for the resident census of 47, there were five assigned CNAs. CNA #1 had thirteen assigned residents to care for.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 6/18/24 at 8:45 AM, the surveyor conducted an incontinence tour on the First Floor nursing unit with a Licensed Practical Nurse (LPN) and observed the following: Level of Harm - Minimal harm or potential for actual harm On 6/18/24 at 9:00 AM, the surveyor accompanied the LPN into Resident #32's room observed the resident lying in bed and was non-verbal. The resident's incontinence brief was observed to be very wet with urine Residents Affected - Some and the sheets were observed with a large urine stain that had a strong smell of urine. The LPN was interviewed at the time and confirmed that the stain the surveyor observed on the resident's sheet was urine and that the resident's incontinence brief should have been changed and the entire bed linen should have been changed. The resident's skin was observed, and the resident's skin was intact and free of breakdown.

On 6/18/24 at 9:10 AM, the surveyor interviewed UM/LPN #2 for the First Floor nursing unit who stated that CNA #2 who was assigned to care for Resident #32 should have made rounds that morning when she had arrived at the unit and checked the residents to see if any residents were incontinent and needed to be changed right away. UM/LPN #2 could not speak to why Resident #32 was wet including the resident's bed linens. UM/LPN #2 stated it was import to assure that the residents were clean and dry to protect the resident's skin and to keep residents comfortable.

A review of the CNA Assignment sheet for 6/18/24, revealed that for the resident census of 50, there were five assigned CNAs. CNA #2 had eleven assigned residents to care for.

On 6/18/24 at 9:20 AM, the surveyor interviewed the CNA #2 who stated that she made rounds that morning and performed an incontinence check for Resident #32. CNA #2 stated 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 because she did not turn the light on in the resident's room. CNA #2 stated that the resident's incontinence brief and bed linen should have been changed and that it must have been an oversight.

On 6/19/24 at 9:08 AM, the surveyor interviewed CNA #1 who stated that all incontinent residents should be checked every two hours, and if a resident urinated more frequently because the resident was on diuretics, that they should be checked every hour. CNA #1 stated that it was important to assure that residents' incontinent briefs were changed timely so that they did not develop breakdown of skin, as well as bed linen should be changed when the resident wets the bed. CNA #1 explained that leaving urine-soaked bed linen

on the bed could also cause odor and skin breakdown, and it would not be appropriate to put clean bed linen over wet bed linen. CNA #1 stated that when she arrived on the unit, she made rounds with the CNAs from

the previous shift so that she could ensure that all the residents were safe, clean, and dry. CNA #1 stated that breakfast was served at 8:00 AM, so residents should have been clean and dry before they started their meals.

On 6/20/24 at 9:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that incontinence rounds should be done when staff arrived at the unit to ensure that any priority residents should be taken care of. The DON stated that during shift rounds, the staffs responsibility was to identify soiled residents and to ensure that the residents were changed and bed linen were changed when soiled, emphasizing that even if a drop of urine got onto the linen, then the linen should be changed. The DON stated that clean linen should not be put on top of dirty linen, and all residents should be checked on every two hours. The DON explained that it was important to assure that residents were provided incontinence care timely and that residents left soiled were at risk for skin breakdown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 6/25/24 at 10:13 AM, the surveyor interviewed the Staffing Coordinator in the presence of the Licensed Nursing Home Administrator (LNHA), who stated she scheduled nursing staff in accordance with State Level of Harm - Minimal harm or regulation which required one CNA to every eight residents for the morning shift; one CNA for every ten potential for actual harm residents for the evening shift; and one CNA to every fourteen residents for the overnight shift. The Staffing Coordinator stated it was very hard to find staff; that the facility did not always meet the required ratios. Residents Affected - Some

On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, Assistant Director of Nursing (ADON), and survey team acknowledged it was unacceptable to put chuck on a wet and soiled fitted bed sheet. The DON acknowledged it was not appropriate to make care rounds in the dark.

38080

2. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that

the facility relied heavily on Agency staffing. At that time, the surveyor requested the Nurse Staffing Report to be completed for the weeks of 11/6/22 to 11/19/22.

On 6/18/24 at 11:56 AM, the LNHA informed the surveyor that the facility did not have the staffing records for 2022; that they were trying to get the information from the payroll company. The surveyor asked the LNHA if

the facility needed to maintain staffing records, and the LNHA confirmed the facility should have the records.

On 6/25/24 at 10:13 AM, the surveyor reviewed the Nurse Staffing Report sheets completed by the facility for 11/6/22 through 11/19/22 which revealed the following:

On 11/6/22, there was a census of 91 residents with a total of four nurses throughout the twenty-four hour period.

On 11/7/22, there was a census of 91 residents with a total of two nurses throughout the twenty-four hour period with no nurses on the overnight.

On 11/8/22, there was a census of 91 residents with a total of four nurses throughout the twenty-four hour period.

On 11/9/22, there was a census of 93 residents with a total of three nurses throughout the twenty-four hour period with no nurses on the overnight.

On 11/10/22, there was a census of 93 residents with a total of four residents throughout the twenty-four hour period.

On 11/11/22, there was a census of 92 residents with a total of four nurses throughout the twenty-four hour period.

On 11/12/22, there was a census of 93 residents with a total of three nurses throughout the twenty-four hour period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 11/13/22, there was a census of 93 residents with a total of two nurses throughout the twenty-four hour period with no nurses on the evening shift. Level of Harm - Minimal harm or potential for actual harm On 11/14/22, there was a census of 94 residents with a total of two nurses throughout the twenty-four hour period with no nurses on the overnight shift. Residents Affected - Some

On 11/15/22, there was a census of 95 residents with a total of three nurses throughout the twenty-four hour period.

On 11/16/22, there was a census of 95 residents with a total of three nurses throughout the twenty-four hour period with no nurses on the evening shift.

On 11/17/22, there was a census of 93 residents with a total of two nurse throughout the twenty-four hour period with no nurse on the evening shift.

On 11/18/22, there was a census of 94 residents with a total of one nurse throughout the twenty-four hour period with no nurses on the day or evening shifts.

On 11/19/22, there was a census of 93 residents with a total of one nurse throughout the twenty-four hour period with no nurse on the day or evening shifts.

At that time, the LNHA stated that the facility could not locate the November 2022 staffing sheets, and they used payroll documents to complete the staffing report. The LNHA stated the facility relied heavily on Agency staff who were not included in those reports.

On 6/25/24 at 10:17 AM, the surveyor interviewed the Staffing Coordinator in the presence of the LNHA who stated she was not here at the time, and could not locate the staffing sheets for that time. The Staffing Coordinator stated she could reach out to the Agencies to determine the staff provided.

On 6/25/24 at 10:21 AM, the surveyor interviewed the DON in the presence of the LNHA and Staffing Coordinator who acknowledged the staffing sheets needed to be maintained and kept as a reference at all times. The DON stated the unit managers kept records of the assignment sheets, but the sheets cannot be located. The DON acknowledged her role was to oversee the nursing department, and confirmed the staffing levels were not acceptable.

At that time, the surveyor requested the Medication Administration Record with the times medication was administered for five sampled residents (Resident #32, #43, #60, #250, and #252) for the time period of 11/6/22 through 11/19/22.

On 6/25/24 at 12:30 PM, the LNHA provided the surveyor with Administration Documentation Audit Detail Report (ADADR) for the weeks of 11/1/22 to 11/13/22 for Resident #32, #43, and #250. The LNHA stated Resident #252 was discharged from the facility in July of 2022, and Resident #43 was out of the facility at the time so she provided the week of 11/25/24.

On 6/25/24 at 1:30 PM, the surveyor interviewed the DON who stated medication should be administered as ordered; the right person, medication, dose, route, and time. The DON continued medication was to be administered at the time prescribed or one hour before or after the medication was timed for.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 The surveyor reviewed the ADADR reports provided which revealed the following:

Level of Harm - Minimal harm or For the weeks of 11/1/22 through 11/13/22: potential for actual harm For Resident #32, their medications were administered out of the time parameters: for the 8:00 AM dose on Residents Affected - Some 11/2/22, 11/3/22, 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/10/22, 11/11/22, 11/12/22, and 11/13/22; for the 9:00 AM doses on 11/4/22, 11/5/22, 11/11/22, and 11/12/22; for the 12:00 PM doses on 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/10/22, and 11/11/22; for the 5:00 PM doses on 11/2/22, 11/3/22, 11/4/22, and 11/11/22; for the 6:00 PM dose on 11/2/22; and the 10 PM dose on 11/11/22. It was documented the residents tube feeding (nutrition administered through a surgical tube into the stomach) scheduled at 4:00 PM, was administered late on 11/3/22, 11/7/22, 11/8/22, 11/9/22, 11/11/22, and 11/12/22. It was also documented on 11/4/22, that their 8:00 AM medications were administered at 2:04 PM; and their 11/11/22 8:00 AM and 9:00 AM medications were administered at 1:26 PM.

For Resident #60, their medications were administered out of the time parameters: for the 8:00 AM doses on 11/1/22; 11/2/22; 11/3/22; 11/4/22; 11/5/22; 11/6/22; 11/7/22, 11/9/22, 11/11/22, 11/12/22, and 11/13/22; for

the 9:00 AM doses on 11/1/22, 11/4/22, 11/5/22, and 11/12/22 for the 1:00 PM doses on 11/1/22, 11/2/22, 11/3/22, 11/4/22, 11/7/22, 11/8/22, and 11/11/22; for the 5:00 PM doses on 11/2/22, 11/3/22, 11/4/22, 11/7/22, 11/11/22, and 11/12/22; and the 9:00 PM doses on 11/2/22, 11/11/22, 11/12/22, and 11/13/22. It was documented that they received their 11/4/22 9:00 AM medications at 2:18 PM.

For Resident #250, their medications were administered out of the time parameters: for the 8:00 AM dose on 11/11/22; for the 9:00 AM doses on 11/3/22, 11/8/22, 11/9/22, 11/11/22, 11/12/22, and 11/13/22; for the 1:00 PM doses on 11/9/22, 11/10/22, and 11/13/22; and the 5:00 PM doses on 11/3/22, 11/4/22, 11/5/22, and 11/8/22. It was documented the resident's 9:00 AM doses on 11/3/22 were administered at 1:52 PM, and their 5:00 PM doses on 11/5/22 were administered at 10:26 PM.

For the week of 11/25/22 through 11/30/22, Resident #43's medications were administered out of the time parameters: for the 9:00 AM dose on 11/29/22; the 5:00 PM dose on 11/27/22; and the 6:00 PM dose on 11/27/22. It was documented the 9:00 AM medications were administered at 12:06 PM on 11/29/22.

On 6/26/24 at 10:30 AM, the LNHA provided additional staffing for the weeks of 11/6/22 through 11/19/22, which revealed on 11/6/22, there were three nurses for the day shift and one for the overnight; on 11/7/22, there were two nurses for the day and overnight shifts and three for the evening; on 11/8/22 there were three nurses for the evening and two nurses for the overnight shifts; on 11/9/22 four nurses for the day shift, two for the evening and one for the overnight shifts; on 11/10/22 there was four for the day, three for the evening, and two for the overnight shift; for 11/11/22 there was four for the day, three for the evening, and one for the overnight shift; on 11/12/22 there were two nurses for the day four for the evening, and two for the overnight; for 11/13/22 there was three for the day, two for the evening, and one for the overnight; for 11/14/22 there was two for the evening and one for the overnight; for 11/15/22 and 11/16/22 there was two for the evening and overnight; 11/17/22 there were three for the evening and two for the overnight; for 11/18/22 there were three for the evening and one for the overnight; and for 11/19/22 there were two for the evening and one for

the overnight.

On 6/26/24 at 10:34 AM, the LNHA acknowledged these concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 A review of the facility's Bowel and Bladder Incontinence Care policy dated May 2023, included that controlling common infections for incontinent residents was part of the overall infection control program .the Level of Harm - Minimal harm or facility was committed to providing a safe a healthy environment for residents and to minimize or prevent the potential for actual harm spread of infections .

Residents Affected - Some A review of the facility's Nursing and Sufficient Staff policy dated last reviewed July 2023, included it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on

the facility assessment .the facility will supply sufficient numbers of each of the following personnel types on

a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .

NJAC 8:39-25.2 (a); 27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 48964

Residents Affected - Few Complaint NJ #163249; 168809

Based on observation, interview, review of the medical record, and other pertinent facility documents, it was determined that the facility failed to maintain an accurate, complete, and easily accessible medical record.

This deficient practice was identified for 3 of 35 residents' medical records reviewed (Resident #97, #248, and #252), and was evidenced by the following:

1. On 6/17/24 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the investigation for the reportable event to the New Jersey Department of Health (NJDOH) for Resident #248 reported on 4/3/23.

On 6/18/24, the surveyor was provided with a copy of the form submitted to the NJDOH, but was not provided with the investigation. The surveyor requested a copy of the investigation.

A review of the investigation reported to the NJDOH included an Investigation Summary dated 4/3/23, that Resident #248 on 4/3/23 at approximately 1:00 PM was observed by the nurse to be lethargic sitting in their wheelchair. The nurse immediately performed a sternal rub (rubbing the knuckles on the breastbone) and the resident immediately responded physically and verbally. The report did not include any statements or assessments.

On 6/19/24 at 1:25 PM, the surveyor asked for a third time to provide the investigation for the incident that occurred with Resident #248.

On 6/20/24 at 10:12 AM, the surveyor interviewed the Director of Nursing (DON) regarding the investigation process who stated interviews were obtained from staff, residents, and any witnesses; the resident was assessed; and then based on the information gathered, the facility determined what happened and put interventions in place to prevent the incident from reoccurring.

On 6/20/24 at 1:16 PM, the surveyor requested for the fourth time the investigation for the facility reported event. The DON stated regarding the investigation, accident/incident reports, and/or witness statements, We have them but can't find it.

On 6/25/24 at 1:28 PM, the surveyor interviewed the LNHA who confirmed medical records should be easily accessible, complete, and accurate. The LNHA confirmed all medical records that the survey team had requested should be easily accessible, accurate, and maintained.

On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, Assistant Director of Nursing (ADON), and survey team stated the facility was unable to locate the investigation for Resident #248. The LNHA confirmed

the investigation should have included an assessment of the resident; interview of possible witnesses and resident; psychological evaluation if needed; psychosocial if needed with a social worker; summary, conclusion, and interventions put in place so incident would not occur again which was updated in the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 38080

Level of Harm - Minimal harm or 2. According to the Resident Face Sheet (an admission summary) Resident #252 was admitted to the facility potential for actual harm in 2022 with diagnoses kidney failure. The face sheet did not include the resident's discharge date .

Residents Affected - Few A review of the electronic Admissions Record revealed Resident #252 was discharged from the facility in July of 2022.

On 6/19/24 at 12:09 PM, the surveyor interviewed the Medical Records personnel who stated after a resident was discharged from the facility, the facility maintained the medical records for ten years.

On 6/25/24 at 10:33 AM, the surveyor requested for the LNHA a copy of Resident #252's discharge summary. The LNHA stated that at the time of the resident's stay in the facility, the facility utilized paper medical charts and needed to locate the record from medical records.

On 6/25/24 at 1:28 PM, the surveyor requested again from the LNHA a copy of Resident #252's discharge summary. At that time, the LNHA confirmed medical records should be easily accessible, complete, and accurate. The LNHA confirmed all medical records that the survey team had requested should be easily accessible, accurate, and maintained.

On 6/26/24 at 10:14 AM, the LNHA informed the surveyor that there was no discharge summary for the resident. The LNHA stated that staff informed her that one was completed, but the facility was unable to locate it. The surveyor asked why and where the resident was discharged to, and the LNHA was unable to speak to it stating the facility did not have electronic medical records at the time.

On 6/26/24 10:35 AM, the ADON in the presence of the LNHA, DON, and survey team stated Resident #252 was transferred to another facility, and the discharge summary should have been completed, but cannot be located.

3. On 6/20/24 at 9:23 AM, the surveyor reviewed the closed medical record for Resident #97.

A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included malignant neoplasm of unspecified site of left and right [male/female] breast (breast cancer); malignant pleural effusion (a condition that occurs when cancer cells cause abnormal amount of fluid to build up between lung and chest cavity); chest pain; and heart failure.

A review of the June 2023 Medication Administration Record (MAR) revealed a physician's order (PO) dated 6/21/23, for tramadol 50 milligram (mg) tablet; give one tablet three times a day for pain scheduled at 9:00 AM; 1:00 PM; and 5:00 PM. A review of the corresponding administration times revealed the following:

On 6/22/24 at 9:00 AM, an indication for not administered see last section

A review of the corresponding last section indicated on 6/22/23 at 9:00 AM, tramadol not administered and comment not applicable [n/a].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 A review of the corresponding Progress Notes (PN) included a Nursing Note (NN) dated 6/21/23 at 7:53 PM, that the resident was received from the hospital at 4:30 PM, denies pain at this time. The next NN was dated Level of Harm - Minimal harm or 6/21/23 at 2:42 PM, that included the resident continued on tramadol and was observed in no distress. The potential for actual harm note did not include why the resident did not receive their tramadol on 6/22/23 at 9:00 AM.

Residents Affected - Few A review of the July 2023 MAR revealed a PO dated 7/7/23, for tramadol 50 mg tablet; give one tablet by mouth every six hours for pain scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. A review of the corresponding administration times revealed the following:

On 7/21/23 at 12:00 AM, 6:00 AM, and 12:00 PM, tramadol was not administered and to comment (see last section).

On 7/27/23 at 6:00 AM, tramadol was not administered.

A review of the corresponding last section indicated on 7/21/23 at 12:00 AM and 6:00 AM, awaiting medication from pharmacy, and at 12:00 PM, the resident was not in the facility. There was no documentation for the 7/27/23 at 6:00 AM dose.

On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated the facility had a backup narcotic medication supply, but review of the inventory revealed tramadol was not included. At this time, the surveyor requested the resident's tramadol declining inventory sheets for June and July 2023.

On 6/20/24 at 1:24 PM, the surveyor informed the DON and LNHA about the missing doses of tramadol, and requested the resident's June and July 2023 tramadol declining inventory sheets.

On 6/25/24 at 1:22 PM, the surveyor in the presence of the LNHA, DON, and survey team requested for the third time a copy of the resident's June and July 2023 tramadol declining inventory sheet.

On 6/26/24 at 8:45 AM, the surveyor received the resident's Individual Patient Controlled Substance Administration Record for Tramadol dated first dose administered 7/5/23 at 9:00 AM, and the last dose administered 7/20/23 at 12:00 PM. There were no additional declining inventory sheets.

On 6/26/24 at 10:35 AM, DON in the presence of the LNHA, ADON, and survey team stated they were unable to locate any additional declining inventory sheets for tramadol.

A review of the facility provided Medical Record Policy dated last revised 5/1/24, included Purpose: To ensure that each resident's medical record is maintained in accordance with accepted professional standards and practices .

NJAC 8:39-35.2(k)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45209

Residents Affected - Few Complaint NJ #159451; 159539; 159783; 162168

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain resident environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 2 of 2 nursing units (First and Second Floor) and was evidenced by the following:

On 6/19/24 at 9:09 AM, the surveyor observed in the hallway by Resident room [ROOM NUMBER] a wheelchair with brown matter that resembled fecal matter, smeared across the seat cushion and down the leg of the wheelchair onto the wheels.

On 6/20/24 at 10:52 AM, the surveyor observed on the Second Floor nursing unit a strong urine odor while approaching Resident room [ROOM NUMBER]. The surveyor entered the room to discover the floor by Bed B was wet and sticky. In addition, puddles of wetness was observed on the bed.

On 6/20/24 at 11:41 AM, the surveyor requested that Registered Nurse (RN #1) walk with them to Resident room [ROOM NUMBER]. While approaching the room, RN #1 acknowledged the strong urine odor, and confirmed that they were aware of the room's condition.

On 6/20/24 at 11:55 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN #1) confirmed the strong smell of urine and acknowledged that Resident room [ROOM NUMBER] should not be in that condition.

On 6/25/24 at 9:43 AM, the surveyor interviewed the Director of Nursing (DON) who acknowledged that Resident room [ROOM NUMBER] should have been cleaned in a timely fashion; that residents should receive quality of care and living environments.

On 6/26/24 at 10:35 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Assistant Director of Nursing (ADON), and survey team acknowledged that the wheelchair and resident room, which resulted in the urine smell in the hallway, were not acceptable.

A review of the facility's undated Quality of Life- Homelike Environment policy included .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order .e. Pleasant, neutral scents .

A review of the facility's Cleaning and Disinfecting Wheelchairs, [Reclining Chairs, Bedside Commode, & Privacy Curtains policy dated last reviewed March 2024, included . 1. Ensure that wheelchairs and [reclining chairs] are kept clean and in good repair [ .] 4. Designate an area for cleaning wheelchairs, [reclining chairs], and bedside commode. If necessary, use a power spray and clean heavily soiled wheelchairs outside .

NJAC 8:39-4.1 (a), 11

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 315124

F-F725

1. According to the Admission Record (AR), Resident #147 was admitted to the facility with the diagnoses which included but not limited to chronic respiratory failure and tracheostomy (hole in the windpipe to facilitate breathing). The comprehensive Minimum Data Set (MDS), an assessment tool dated 4/10/24, reflected that Resident #147 had moderate cognitive deficits and was dependent on staff for hygiene. Resident #147's individualized comprehensive care plan (ICCP) reflected that the resident required total dependence and one-person physical assistance with personal hygiene.

According to the AR, Resident #32 was admitted to the facility with the diagnoses which included but not limited to cerebral infarction (stroke). The comprehensive MDS dated [DATE REDACTED], reflected that Resident #32 had severe cognitive deficits and was dependent on staff for hygiene. Resident #32's ICCP reflected that the staff provided the resident incontinent care every two to four hours, and that the resident required total dependence and one-person physical assistance with personal hygiene.

On 6/18/24 at 8:02 AM, the surveyor conducted an incontinence tour on the Second Floor nursing unit accompanied by the Unit Manager/Licensed Practical Nurse (UM/LPN #1) and observed the following:

The surveyor and UM/LPN #1 entered Resident #147's room who was observed lying in bed. UM/LPN #1 asked the resident if she could check their incontinent brief and the resident gave UM/LPN #1 permission.

The surveyor observed that the resident's incontinent brief was dry and the chuck (protective bed pad) that was directly under the resident was dry, however the fitted sheet located under the chuck had a large brown/yellow stain that smelled like urine and contained some dry brown stains which UM/LPN #1 identified as bowel movement (bm). UM/LPN #1 was interviewed at this time and stated that the Certified Nursing Assistant (CNA) that was assigned to care for Resident #32 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. UM/LPN #1 stated that the agency CNA that cared for the resident on the 11:00 PM to 7:00 AM shift must have left

the dirty sheet on the resident's bed, because the CNA (CNA #1) that came in this morning just got to the unit and had not made rounds yet. UM/LPN #1 stated that incontinence rounds should be done by the CNA every two hours. The surveyor observed the resident's skin during the tour and the resident's skin was free of skin breakdown.

On 6/18/24 at 8:45 AM, the surveyor conducted an incontinence tour on the First Floor nursing unit with a Licensed Practical Nurse (LPN #1) and observed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 At 9:00 AM, the surveyor accompanied LPN #1 entered Resident #32's room observed the resident lying in bed and the resident was non-verbal. The resident's brief was observed to be very wet with urine and the Level of Harm - Minimal harm or sheets were observed with a large urine stain that had a strong smell of urine. LPN #1 was interviewed at the potential for actual harm time and confirmed that the stain the surveyor observed on the resident's sheet was urine, and that the resident's incontinence brief and the entire bed linen should have been changed. The resident's skin was Residents Affected - Few observed, and the resident's skin was intact and free of breakdown.

On 6/18/24 at 9:10 AM, the surveyor interviewed UM/LPN #2 for the First Floor nursing unit who stated that

the CNA (CNA #2) who was assigned to care for Resident #32 should have made rounds that morning when

she had arrived to the unit and checked the residents to see if any residents were incontinent and needed to be changed right away. UM/LPN #2 could not speak to why Resident #32 was wet including the resident's bed linens. She stated that it was import to ensure that residents were clean and dry to protect their skin and to keep the residents comfortable.

On 6/18/24 at 9:20 AM, the surveyor interviewed CNA #2 who stated that she made rounds that morning and performed an incontinence check for Resident #32. CNA #2 stated that she 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. CNA #2 stated that the resident's brief and bed linen should have been changed and that it must have been an oversight.

On 6/19/24 at 9:08 AM, the surveyor interviewed CNA #1 who stated that all incontinent residents should be checked every two hours, and every hour if they urinated more frequently because the resident was on diuretics. CNA #1 stated that it was important to assure that residents' incontinent briefs were changed timely, so that they did not develop breakdown of skin. CNA #2 stated that bed linen should also be changed when the resident wets the bed because leaving urine-soaked bed linen on the bed could also cause odor and skin breakdown, and it was not appropriate to put clean bed linen over wet bed linen. CNA #1 stated that when she arrived on the unit, she made rounds with the CNAs from the previous shift so that she could ensure that all the residents were safe, clean, and dry. CNA #1 stated that breakfast was served at 8:00 AM, so residents should be clean and dry before they start their meals.

On 6/20/24 at 9:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that incontinent rounds should be done when staff arrived to the unit to ensure that any priority residents should be taken care of. The DON stated that during shift rounds, the staffs responsibility was to identify soiled residents, change them, and ensure bed linen was changed when soiled; even if a drop of urine got onto the linen, then

the linen should be changed. The DON stated that clean linen should not be put on top of dirty linen. The DON stated that 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.

On 6/26/24 at 10:36 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and survey team acknowledged it was unacceptable to put chuck on a wet and soiled fitted bed sheet. The DON acknowledged it was not appropriate to make care rounds in the dark.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A review of the facility's Bowel and Bladder Incontinence Care policy dated May 2023, included controlling common infections for incontinent residents was part of the overall infection control program .the facility was Level of Harm - Minimal harm or committed to providing a safe a healthy environment for residents and to minimize or prevent the spread of potential for actual harm infections .

Residents Affected - Few 45209

2. On 6/19/24 at 10:01 AM, the surveyor observed Resident #73 in their room with their fingernails as long and dirty. When asked if their nails have been cleaned or cut by the facility, Resident #73 denied and voiced that they do not like them long and would like them cut.

On 6/20/24 at 9:25 AM, the surveyor observed Resident #73 the facility's lobby biting on their long and dirty fingernails.

The surveyor reviewed the medical record for Resident #73.

A review of the Order Summary Report revealed that Resident #73 was admitted to the facility with diagnosis that included, but not limited to diabetes mellitus, mood disorder, and hypertension (high blood pressure).

A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 5/3/24, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. Section GG (Functional Abilities and Goals) of the MDS identified the resident as requiring Substantial/Maximal Assistance with Personal Hygiene.

A review of the individualized comprehensive care plan (ICCP) included a focus area dated 10/11/23, for activities of daily living (ADL) Functional/Rehabilitation (Rehab) Potential with interventions that included to have all my needs met.

On 6/19/24 at 10:20 AM, the surveyor interviewed CNA #2 and #3 who both confirmed that they were responsible for nail care, which included cleaning and filing the nail to a reasonable length.

On 6/20/24 at 11:23 AM, the surveyor interviewed the Registered Nurse who stated that the CNAs were responsible for assisting in residents' ADLs which included nail care. When asked how resident nails are supposed to appear, the RN responded, clean and short with underneath also clean. The RN further explained that skin checks were completed by the CNA daily and weekly by the nurse during bathing, in which nails were checked for length and appearance.

On 6/26/24 at 10:35 AM, the LNHA, in the presence of the DON, Regional Nurse, ADON, and survey team acknowledged that it was the expectation of the facility that nail care was completed on the residents.

2. On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. The surveyor observed Resident #60's nails were long and dirty. When asked if their nails have been cleaned or cut by the facility, Resident #60 denied and stated they would their nails cut.

The surveyor reviewed the medical record for Resident #60.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to

the facility with diagnosis that included, but not limited to hemiplegia (paralysis of one side of the body) and Level of Harm - Minimal harm or hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left potential for actual harm dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder.

Residents Affected - Few A review of the most recent quarterly MDS dated [DATE REDACTED], reflected a BIMS score of 12 out of 15, which indicated a moderately impaired cognition.

A review of the ICCP included a focus area dated 7/13/22, for ADL Functional/Rehab Potential with interventions that included personal hygiene expected with limited assistance of one person physical assist.

On 6/19/24 at 10:20 AM, the surveyor interviewed CNA #2 and #3 who both confirmed that they were responsible for nail care, which included cleaning and filing the nail to a reasonable length.

On 6/20/24 at 11:23 AM, the surveyor interviewed the RN who stated that the CNAs were responsible for assisting in residents' ADLs which included nail care. When asked how residents' nails were supposed to appear, the RN responded, clean and short with underneath also being clean. The RN further explained that skin checks were completed by the CNA daily and weekly by the nurse during bathing, in which nails were checked for length and appearance. At that time, Resident #60 approached the nursing station, and the surveyor questioned the length and appearance of the resident's fingernails. Both the RN and UM/LPN #1 confirmed that they were long, dirty, and unacceptable.

On 6/25/24 at 9:43 AM, the surveyor and DON passed Resident #60 in the hallway. At that time, the DON confirmed that their fingernails were long and dirty, and stated that nail care was an everyday thing and it should have been addressed by the CNAs. The surveyor informed the DON that Resident #60's fingernails were previously addressed with the RN and UM/LPN #1 on 6/20/24, and the DON confirmed that the nail care should have been completed at that time.

On 6/26/24 at 10:35 AM, the LNHA, in the presence of the DON, ADON, Regional Nurse, and survey team acknowledged that it was the expectation of the facility that nail care was completed on the residents.

A review of the facility's Resident Care- Grooming policy dated last reviewed January 2023, included .6. Trim

the nails using the nail clipper and file to round the tips of the nails. 7. Clean around and under the nails using a moistened cotton swab. Essential Points: the nursing staff will provide observation and care of nails for all residents on bath day as needed .

A review of the facility's undated Certified Nurse Aide Position document included .5. Bathes the resident in bed, tub or shower, combs hair, cleans and cut fingernails and gives shampoos .22. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right .

A review of the facility's undated Licensed Practical Nurse Position document included .9. Supervises and coordinates nursing personnel in providing direct resident care in adherence with state and federal regulations. 10. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A review of the facility's undated Registered Nurse Position document included .2. 9. Supervises and coordinates nursing personnel in providing direct resident care in adherence with state and federal Level of Harm - Minimal harm or regulations. potential for actual harm

A review of the facility's undated Unit Manager/Director Nurse Position document included .4. Assesses the Residents Affected - Few work performance of nursing personnel as it relates to their job description, unit standards of care and goals of the individual 6. Encourages nursing staff to perform their jobs to the fullest of their potential .

NJAC 8:39-27.2 (g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38080 potential for actual harm NJ Complaint #166769 Residents Affected - Some Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who received daily pain management a.) received their pain medications as order and b.) ensure the resident's pain was being assessed and monitored every shift. This deficient practice was identified for 1 of 1 residents reviewed for pain management (Resident #97), and was evidenced by the following:

On 6/20/24 at 9:23 AM, the surveyor reviewed the closed medical record for Resident #97.

A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included malignant neoplasm of unspecified site of left and right [male/female] breast (breast cancer); malignant pleural effusion (a condition that occurs when cancer cells cause abnormal amount of fluid to build up between lung and chest cavity); chest pain; and heart failure.

A review of the individualized comprehensive care plan (ICCP) included a focus area dated 6/14/23 for pain with a goal to be free from pain, and interventions which included assess for signs and symptoms of pain; establish baseline pain through pain assessment. An additional focus are dated 1/7/23, for breast cancer as evidenced by visible lumps/tumors; pain and weight loss with an invasive carcinoma (cancerous tumor) grade two to the right breast and stage 4 that metastasized (spread from one part of the body to another) to

the left proximal humerous (upper arm bone); right middle lobe (lung); lytic lesions (bone damage appearing as holes) to bilateral ilia and lumbar vertebrea (upper hip and lower spine) with no interventions exist for this focus.

A review of the June 2023 Medication Administration Record (MAR) revealed a physician's order (PO) dated 6/21/23, for tramadol 50 milligram (mg) tablet; give one tablet three times a day for pain scheduled at 9:00 AM; 1:00 PM; and 5:00 PM. A review of the corresponding administration times revealed the following:

On 6/22/24 at 9:00 AM, an indication for not administered see last section

A review of the corresponding last section indicated on 6/22/23 at 9:00 AM, tramadol not administered and comment not applicable [n/a].

A review of the corresponding Progress Notes (PN) included a Nursing Note (NN) dated 6/21/23 at 7:53 PM, that the resident was received from the hospital at 4:30 PM, denies pain at this time. The next NN was dated 6/21/23 at 2:42 PM, that included the resident continued on tramadol and was observed in no distress. The note did not include why the resident did not receive their tramadol on 6/22/23 at 9:00 AM.

A further review on the June 2023 MAR, revealed a PO dated 6/21/23, for pain assessment every shift; use pain scale 0-10. A review of the corresponding pain assessment for 6/22/23 during the 7:00 AM to 3:00 PM shift; reflected the resident was in no pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 A review of the July 2023 MAR revealed a PO dated 7/7/23, for tramadol 50 mg tablet; give one tablet by mouth every six hours for pain scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. A review of the Level of Harm - Minimal harm or corresponding administration times revealed the following: potential for actual harm

On 7/21/23 at 12:00 AM, 6:00 AM, and 12:00 PM, tramadol was not administered and to comment (see last Residents Affected - Some section).

On 7/27/23 at 6:00 AM, tramadol was not administered.

A review of the corresponding last section indicated on 7/21/23 at 12:00 AM and 6:00 AM, awaiting medication from pharmacy, and at 12:00 PM, the resident was not in the facility. There was no documentation for the 7/27/23 at 6:00 AM dose.

A further review of the July 2023 MAR included no PO for pain scale every shift as previously documented in June 2023.

A review of the Progress Notes for 7/21/23, included a NN at 1:34 PM, that call was placed to the Pharmacy to be made aware of the need for tramadol, and the Pharmacy stated they were awaiting a prescription. The nurse documented they called the Nurse Practitioner (NP) who stated a prescription was sent over the night before, and nurse called Pharmacy to relay information who denied having prescription. The nurse documented they made NP aware. An additional note dated 7/21/23 at 1:37 PM, that resident was out of the facility at 9:05 AM to go to oncology (cancer doctor) with no distress observed. There was no documentation

on 7/21/23, that either the physician or NP was made aware the resident did not receive their tramadol for three scheduled administrations or any alternative. There was no documentation of the resident's pain for the missed 12:00 AM and 6:00 AM doses.

A further review of the Progress Notes did not include any documentation as to why the resident did not receive the tramadol on 7/27/23 at 6:00 AM.

A review of the comprehensive Minimum Data Set (MDS) dated [DATE REDACTED], revealed the resident had a brief

interview for mental status (BIMS) score of a 14 out of 15, which indicated a fully intact cognition. A further

review revealed the resident received routine pain medication.

On 6/20/24 at 9:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated pain was monitored for all residents on the MAR using a pain scale every shift. The DON stated if the resident did not receive their scheduled pain medication, the nurse documented why it was not received. The DON stated the facility had a backup narcotic medication supply, but review of the inventory revealed tramadol was not included. At this time, the surveyor requested the resident's tramadol declining inventory sheets for June and July 2023.

On 6/20/24 at 1:24 PM, the surveyor informed the DON and Licensed Nursing Home Administrator (LNHA) about the missing doses of tramadol. The surveyor requested any additional information for what was done for those shifts; pain scale; and the resident's June and July 2023 tramadol declining inventory sheets.

On 6/25/24 at 1:22 PM, the surveyor in the presence of the LNHA, DON, and survey team requested for the third time a copy of the resident's June and July 2023 tramadol declining inventory sheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 6/26/24 at 8:45 AM, the surveyor received the resident's Individual Patient Controlled Substance Administration Record for Tramadol dated first dose administered 7/5/23 at 9:00 AM, and the last dose Level of Harm - Minimal harm or administered 7/20/23 at 12:00 PM. There were no additional declining inventory sheets. potential for actual harm

On 6/26/24 at 10:35 AM, DON in the presence of the LNHA, Assistant Director of Nursing (ADON), and Residents Affected - Some survey team stated they were unable to locate any additional declining inventory sheets for tramadol. The DON was unable to provide any additional information regarding the missing doses, but confirmed medication should be administered as ordered. The DON acknowledged the facility should have assessed

the resident's pain every shift, and if medication was unavailable, the physician was immediately notified and asked if another medication should be given instead. The DON confirmed the resident was on pain medications and it was important to monitor their pain to ensure the medication prescribed was effective.

At that time, the ADON confirmed the resident had cancer at the time the pain medication was not received.

A review of the facility's Pain Management policy dated reviewed February 2024, included the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences .reassess patients with pain regularly based on facility's established intervals. If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated .

NJAC 8:39-27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 315124 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315124 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belle Care Nursing and Rehabilitation Center 439 Bellevue Avenue Trenton, NJ 08618

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33106

Residents Affected - Some Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide sufficient nursing staff to ensure residents were provided with care to achieve their highest practical wellbeing by failing to ensure a.) incontinence care was provided for 2 out of 7 residents observed

during incontinence rounds (Resident #32 and Resident #147) and b.) medications were administered according to physician's orders for 4 of 4 residents reviewed for medication administration timing (Resident #32, #43, #60, and #250). This deficient practice was evidenced by the following:

Refer