Providence Nursing And Rehabilitation Center
Inspection Findings
F-Tag F677
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 57 of107 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 58 of107 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 59 of107 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 60 of107 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 61 of107 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 62 of107 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 34033
Residents Affected - Some Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) the accurate documentation of medication administration during the 6/18/24 medication administration
observation for ten residents by 1 of 2 nurses; b.) accurate documentation of the administration of a medication (Depakote) according to physician's orders from 6/11/24 until surveyor inquiry; c.) accurate inventory documentation of a controlled medication (methadone) administered on 6/17/24; d.) maintain accurate documentation for signing the controlled drug shift-to-shift inventory counts of the controlled medications on the morning shift of 6/18/24 by 1 of 2 nurses observed during the medication administration
observation and an additional six shifts in June for one 1 of 2 medication carts inspected; and e.) accountability of the narcotic shift count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications identified on 2 of 2 medication carts and was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for
the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for
the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under
the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
The deficient practices were evidenced by the following:
1. On 6/18/24 at 7:57 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN #1) entering electronic signatures for the medications that she had administered to Resident #89 in the electronic Medication Administration Record (eMAR).
On 6/18/24 at 8:13 AM, RN #1 stated I had to borrow a password, explaining that she was using the login password for the Unit Manager/Licensed Practical Nurse (UM/LPN #1) because she was an agency nurse, and she had a problem with her login.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of107 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 0755 On 6/18/24 at 8:21 AM, the surveyor observed RN #1 entering electronic signatures for the 8:00 AM (8 AM) and 9:00 AM (9 AM) medications for four sampled residents, (Resident #32, #61, #79, and #84), and six Level of Harm - Minimal harm or unsampled residents, (unsampled Resident #1, #2, #3, #4, #5, #6). RN #1 stated that she had already potential for actual harm administered the morning medications to those residents and needed to sign the eMAR. RN #1 explained that she administered morning medications to the residents earlier because they were a priority since the Residents Affected - Some residents were either diabetic, on dialysis or had a feeding tube (surgical tube inserted into the stomach), and she had not had a chance to sign the eMAR.
On 6/18/24 at 8:45 AM, the surveyor observed RN #1 administer and electronically sign for medications that were administered to Resident #51.
A review of the eMARs for Resident #89, #51, #32, #61, #79, #84 and the six unsampled residents revealed that the initials for the 8 AM and 9 AM medications on 6/18/24 had the electronic signature initials for UM/LPN #1.
On 6/18/24 at 11:27 AM, the surveyor interviewed UM/LPN #1 at the nurse's station, who stated that she had given RN #1 her login because there was a problem this morning. In addition, UM/LPN #1 stated that medications should be signed for immediately after administering them to the resident.
At that time, the Assistant Director of Nursing (ADON) was at the nurse's station and confirmed UM/LPN #1 should not have given RN #1 her login password. The ADON stated that when the computer system changed on 6/11/24, the staff were trained on how to use the system, but that agency nurses were already familiar with the system.
On 6/18/24 at 12:12 PM, the surveyor interviewed the Human Resources/Staff Coordinator (HR/SC) who stated that she was responsible for providing the login passwords for the agency nurses. The HR/SC also stated that each nurse had their own login password, and that she had tested RN #1's login password at 7:45 AM that morning, but that RN #1 had entered the password wrong three times and was locked out.
On 6/19/24 at 8:30 AM, the surveyor interviewed the Director of Nursing (DON) who stated that every nurse had their own login password and were not to use another nurse's login. The DON added that UM/LPN #1 should not have given her login password to RN #1 because the login corresponded to the nurse's signature.
The DON explained that the administrative staff which included the UM had the capability to unlock the RN's login or provide a new one. The DON also stated that the computer system was changed on 6/11/24, but that nursing procedures were still to be followed. The DON explained that the eMAR was to be signed immediately after the medication was administered.
On 6/19/24 at 3:50 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she had started as the CP in March of 2024, and she had not done any medication passes on nurses or inservices for medication administration yet.
On 6/20/24 at 1:21 PM, the survey team met with the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that there were no medication administration observations performed with RN #1, and the facility had not done any inservices on medication administration recently.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of107 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 0755 A review of the facility's Medication Administration Policy dated 12/23/2, included that after medication administration document necessary medication administration/treatment information (e.g. (for example), Level of Harm - Minimal harm or when medications are administered, medication injection site, refused medications, and reason, prn (as potential for actual harm needed) medications, etc.) on appropriate forms .
Residents Affected - Some 2. On 6/18/24 at 8:59 AM, during the morning medication administration pass, the surveyor, observed RN #2 preparing eight medications for Resident #5 which included a 125 milligram (MG) tablet of divalproex sodium delayed release (Depakote) (a medication used for mood stabilization).
On 6/18/24 at 9:08 AM, the surveyor observed RN #2 administer seven medications to Resident #5 which included the Depakote 125 MG tablet. Upon returning to the medication cart, the surveyor observed RN #2 electronically sign the eMAR for Resident #5 for all the highlighted medications that were due for 9 AM.
The surveyor reviewed the medical record for Resident #5.
A review of the Admission Record face sheet (admission summary) revealed diagnoses that included bipolar disorder (a mental health disorder) and generalized anxiety disorder.
A review of the Order Summary Report revealed a physician's order (PO) with a start date of 6/6/24, for Depakote 125 MG tablet, give 1 tablet orally two times a day for bipolar disorder. Give with 500 MG for a total dose of 625 MG.
Further review of the Order Summary Report revealed PO with an active date of 4/29/24, and a start date of 6/30/24, for Depakote 500 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 125 MG for a total dose of 625 MG.
A review of the June eMAR revealed the above PO for Depakote 125 MG. In addition, the eMAR revealed a PO dated 6/30/24, for Depakote 500 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 125 MG for a total dose of 625 MG. The eMAR reflected all June dates with an X until 6/30/24.
There was no documentation that Depakote 500 MG was administered from 6/11/24 until surveyor inquiry.
On 6/18/24 at 12:23 PM, the surveyor interviewed UM/LPN #2 regarding the dose of Depakote that was to be administered at 9:00 AM (9 AM) to Resident #5. UM/LPN #2 checked the electronic records for Resident #5 and stated that the facility had changed electronic charting systems recently and was checking both systems. UM/LPN #2 then verified that the dose of Depakote that Resident #5 was to receive at 9 AM was a total of 625 MG. UM/LPN #2 explained that there was a PO for Depakote 125 MG and Depakote 500 MG to be administered together for a total dose of 625 MG. UM/LPN #2 then reviewed the current eMAR and stated that the Depakote 500 MG order was entered incorrectly because the PO had a start date of 6/30/24, and should have been started on 6/11/24, with the Depakote 125 MG PO. UM/LPN #2 added that the Depakote 125 MG PO had instructions regarding the total dose, but that when the electronic system started on 6/11/24,
the Depakote 500 MG dose would not be highlighted for administration at 9 AM until 6/30/24. UM/LPN #2 was unable to speak to how the PO was entered incorrectly.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of107 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 0755 A review of the previous computer system Physician's Orders revealed a PO dated 9/13/22, for Depakote 125 MG tablet, delayed release; give 1 tablet (125 MG) by oral route 2 times per day. Take with 500 MG for Level of Harm - Minimal harm or a total of 625 MG. In addition, a PO dated 9/13/22, for Depakote 500 MG tablet; give 1 tablet (125 MG) by potential for actual harm oral route 2 times per day. Take with 500 MG for a total of 625 MG.
Residents Affected - Some A review of the previous computer system eMAR reflected the administration of Depakote 125 MG and Depakote 500 MG together at 9 AM for a total dose of 625 MG.
On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the facility had changed computer systems on 6/11/24, and that all PO were transferred to the new computer system.
On 6/20/24 at 10:45 AM, the survey team met with the DON who acknowledged that there was an error in
the dosage of Depakote for Resident #5 that occurred on 6/18/24. The DON added that she was continuing to investigate how the entry error occurred. The DON added that she was reviewing with each nurse that administered medications regarding the Depakote PO for the total dose of 625 MG.
A review of the facility's Medication Administration policy dated effective 12/23/23, included prior to medication administration Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER . Verify that the MAR reflects the most recent medication order .
3. On 6/18/24 at 8:45 AM, the surveyor observed RN #1 preparing to administer medications to Resident #51 which included 50 milliliters (ML) of methadone (a controlled medication used for opioid addiction) liquid with
a concentration of 10 milligrams/10 ml. RN #1 stated that the methadone was obtained by the nursing supervisors from the methadone clinic on a weekly basis. RN #1 explained that the methadone was a controlled drug and had an inventory sheet (Methadone Chain of Custody Record) that was provided by the methadone clinic and had to be signed by the nurse and the resident for the appropriate date and all empty bottles were returned back to the clinic.
At that time, the surveyor, with RN #1 reviewed the resident's Methadone Chain of Custody Record and the methadone bottles. RN #1 stated that there were seven bottles in a bag for Resident #51. RN #1 added that four were empty and three contained 50 ML of methadone. RN #1 stated that she was removing one bottle and signing the record for 6/18/24. The Methadone Chain of Custody Record revealed that on 6/17/24, there was no signature by a nurse for the removal of the methadone.
At that time, RN #1 stated that she thought the Assistant Director of Nursing (ADON) was supposed to sign
the form on 6/17/24. Resident #51 stated that they thought they had taken their methadone on 6/17/24, and had not remembered signing.
A review of the eMAR for Resident #51 for Methadone administration on 6/17/24, revealed the electronic signature of the ADON.
On 6/18/24 at 9:18 AM, the surveyor interviewed the ADON who stated that she was the nurse on the medication cart on 6/17/24. The ADON was unsure about administering methadone to Resident #51. The surveyor with the ADON, reviewed the Methadone Chain of Custody Record for Resident #51. The ADON then stated that she had not realized she was supposed to sign the record and should have signed the
record for the removal of the methadone.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of107 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 0755 On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the resident's individual controlled drug sheet was to be signed when the controlled drug was removed from inventory so that there were no Level of Harm - Minimal harm or discrepancies. In addition, if there were any discrepancies then a supervisor was to be notified and the potential for actual harm discrepancy was to be corrected immediately.
Residents Affected - Some A review of the facility's undated Schedule II Controlled Substance Medication policy included .When a CDS (controlled substance medication) is administered, in addition to following procedures for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials .
4. On 6/18/24 at 8:45 AM, the surveyor observed RN #1 preparing to administer medications to Resident #51 which included 50 ML of methadone liquid with a concentration of 10 milligrams/10 ML. RN #1 stated that the methadone was obtained by the nursing supervisors from the methadone clinic on a weekly basis. RN #1 explained that the methadone was a controlled drug and had an inventory sheet (Methadone Chain of Custody Record) that was provided by the methadone clinic and had to be signed by the nurse and the resident for the appropriate date and all empty bottles were returned back to the clinic.
At that time, the surveyor, with RN #1, reviewed the resident's Methadone Chain of Custody Record and the Methadone bottles. The RN #1 stated that there were seven bottles in a bag for Resident #51. The RN #1 added that four were empty and three contained 50 ML of methadone. RN #1 stated that she was removing one bottle and signing the record for 6/18/24. The Methadone Chain of Custody Record revealed that on 6/17/24, there was no signature by a nurse for the removal of the methadone.
At that time, RN #1 stated that she thought the Assistant Director of Nursing (ADON) was supposed to sign
the form on 6/17/24. Resident #51 stated that they thought they had taken their methadone on 6/17/24, and had not remembered signing.
At that time, the surveyor with RN #1 reviewed the Narcotic Count Sheet (a monthly sheet for daily nurses' signatures to verify the inventory count of the controlled drugs at the change of shift) that corresponded to
the First Floor nursing unit high side medication cart, which revealed that the sheet was not signed for 6/18/24 for the Nurse In. RN #1 stated that she had done an inventory count at the beginning of her shift with
the outgoing nurse, but had forgotten to sign the Narcotic Count Sheet and proceeded to sign the sheet in front of the surveyor. RN #1 then stated that she had not told the ADON or any other supervisor about the missing signature for the methadone inventory because there was no discrepancy.
Further review of the Narcotic Shift Count revealed that the following nurse signatures were missing:
-6/4/24 11 PM Nurse Out
-6/7/24 11 PM Nurse Out
-6/10/24 11 PM Nurse In
-6/11/24 7 AM Nurse Out
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of107 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 0755 -6/14/24 11 PM Nurse In
Level of Harm - Minimal harm or -6/15/24 7 AM Nurse Out potential for actual harm
On 6/18/24 at 9:18 AM, the surveyor interviewed the ADON who stated that she was unaware of any Residents Affected - Some discrepancies regarding the Narcotic Count shift to shift sheets.
On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the inventory count of the controlled drugs in the medication carts were completed before each shift and there were three shifts; 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM. The DON explained that the inventory count was completed when the incoming nurse came in for their shift and the outgoing nurse was leaving their shift. The DON further explained that the Narcotic Count Sheet should be signed when the inventory was completed. The DON stated that the Narcotic Count Sheets should be thoroughly completed meaning there were no blanks.
In addition, the DON stated that if there were any discrepancies, then that should be reported to a supervisor immediately. The DON explained that this system prevented any discrepancies from occurring with the controlled drug inventories.
A review of the current facility's undated Schedule II Controlled Substance Medication policy included .when dispensing controlled substances An inventory count of all CDS (controlled drug substance) medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form .
44833
5. On 6/18/24 at 11:45 AM, the surveyor, in the presence of RN #1, reviewed the First Floor nursing unit high side medication cart's narcotic logs. The following was observed:
The June 2024 shift-to-shift Narcotic Count Sheet, RN #1 pre-signed for the 6/18 3 PM outgoing nurse.
The Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #51's pregabalin 150 MG capsules (a controlled medication used to treat nerve and muscle pain) was missing Nurse Administering signatures for 6/14/24 9 AM and 9 PM doses.
At that time, the surveyor interviewed RN #1, who confirmed she had pre-signed the outgoing nurse portion of the shift-to-shift stating I shouldn't have pre-signed informing the surveyor that this sheet was to be signed by the incoming and outgoing nurses together at shift change after a complete count of narcotics had been performed together. RN #1 further stated that there should be no missing signatures or documentation on the individual patient-controlled substance logs.
On 6/18/24 at 12:25 PM, the surveyor, in the presence of the LPN, reviewed the Second Floor nursing unit high side medication cart's narcotic logs. The following was observed:
Resident #9's tramadol HCl 50 MG tablet (controlled pain medication) declining inventory log was missing
the administration time documentation for 5/30/24.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of107 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 0755 At that time, the LPN stated that declining inventory logs should not have any missing documentation for doses that have been dispensed. Level of Harm - Minimal harm or potential for actual harm On 6/18/24 at 12:53 PM, the surveyor interviewed UM/LPN #2 who stated there should be no missing documentation on narcotic declining inventory logs. Residents Affected - Some
On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the inventory count of the controlled drugs in the medication carts were completed before each shift and there were three shifts; 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. The DON explained that the inventory count was completed when the incoming nurse comes in for their shift and the outgoing nurse was leaving their shift and the Narcotic Count Sheet should be signed when the inventory completed. In addition, if there are any discrepancies then that should be reported to a supervisor immediately. The DON added that the individual resident controlled drug sheets were to be signed when the controlled drug was removed from inventory so that there were no discrepancies.
Review of the facility's undated Schedule II Controlled Substance Medication included .a declining inventory sheet will be provided with each dispensed prescription for controlled dangerous medications .when CDS medication is administered, in addition to proper procedure for charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining, and his/her initials. An inventory count of all CDs medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form .
NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(k), 29.7(c)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of107 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33106
Residents Affected - Many Based on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 4 of 5 residents reviewed for medication management (Resident #34, Resident #80, Resident #60, and Resident #61) and was previously cited during the facility's last standard survey on 10/20/22. The evidence was as follows:
Refer
F-Tag F725
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 43 of107 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 44 of107 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 45 of107 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 46 of107 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 47 of107 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 0679 Provide activities to meet all resident's needs.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38080 potential for actual harm Based on observation, interview, and review of pertinent facility documents, it was determined that the facility Residents Affected - Some failed to ensure a Justice Involved Resident (JIR) was provided since admission activities of their choice designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This deficient practice was identified for 1 of 1 JIR (Resident #1) reviewed.
The findings were as follows:
Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents.
A review of the facility's Resident Rights dated revised 1/3/24, included 10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience [ .] the right to retain and use personal possessions [ .] the right to receive services
in the facility with reasonable accommodation of resident needs and preferences [ .]the right to share a room with a roommate of his/her choice [ .] 6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment .
A review of the facility's Activities policy dated reviewed 5/1/24, included the facility's activity programs are designed to meet the needs of each resident and are available on a daily basis .the facility's activity programs are designed to encourage participation and are individualized to meet each resident's needs .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of107 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 0679 On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Level of Harm - Minimal harm or Supervisor #1), who stated Resident #1 had a stage 4 pressure wound (full-thickness skin loss extends potential for actual harm through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when the resident was Residents Affected - Some out of the room, and LPN Supervisor #1 stated that Resident #1 was a Justice Involved Resident (JIR) who remained in their room unless to go to the rehabilitation (rehab) gym. LPN Supervisor #1 continued that the resident did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and the resident always remained in the room alone with two armed Correctional Officers (COs).
On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were on their cell phones stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed the resident, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the Correctional Facility (CF); they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. The resident stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to
the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. The surveyor asked if the resident saw the facility's SW, and the resident stated, no, but they thought they were supposed to.
At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and
the CO confirmed yes, the resident was incarcerated.
On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1.
A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock.
A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE REDACTED] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had
a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of107 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 0679 A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected
the resident had a brief interview for mental status score of 15 out of 15, which indicated a fully intact Level of Harm - Minimal harm or cognition. potential for actual harm
A review of the individual comprehensive care plan (ICCP) included the following focus areas: Residents Affected - Some
A focus area dated 7/3/24, that the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by
the CF. The intervention was that the resident would be closely monitored by the CF.
A focus area dated 7/3/24, inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration.
The ICCP did not include a focus area for activities.
On 8/29/24 at 11:24 AM, the surveyor interviewed the facility's SW, who stated she had just started at the facility last week and had not gotten to speak to all the residents yet. The surveyor asked if the SW spoke with Resident #1, and she stated no, but the resident was on her list.
On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see them that often. The DA continued that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated the resident requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide.
On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down
the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and the resident stated to see the wound doctor, that they did not want to see the doctor here. The resident reported their appointment was at the hospital, and that their wound was improving. The surveyor asked the resident if they ever received the playing card they requested, and the resident confirmed no.
On 8/29/24 at 12:56 PM, the surveyor interviewed the LNHA in the presence of the DON, who stated that
she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA continued that Resident #1 stayed
in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for the resident to make a phone call, but
she did not believe there was a set schedule.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of107 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 0679 At that time, the DON stated that the resident informed the facility that the CF had to approve all visits, and
the resident could not have a visitor unless the CF approved it. The DON stated there were no private visits, Level of Harm - Minimal harm or that there were always COs; the resident could not be without them. The DON stated it was the CF's potential for actual harm policies; the resident could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only the resident and the COs could be in the elevator during Residents Affected - Some transportation, and the resident saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated that Resident #1 received the same level of care as all the other residents in the facility,
they just did not have the freedoms. The DON stated that the facility was in control of the resident's nursing care, and everything else was controlled by the CF. The surveyor requested a copy of the resident's activity assessments.
On 8/29/24 at 3:05 PM, the DON informed the survey team that she had spoken to the CF to have the CF inform the facility who was permitted to visit the resident and when.
No additional information was provided.
NJAC 8:39-7.3(a)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of107 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or 44833 potential for actual harm Based on observation, interviews, and review of pertinent facility documents, it was determined that the Residents Affected - Few facility failed to a.) obtain a physician's order for pressure reducing devices and b.) implement the individualized comprehensive care plan (ICCP) intervention to use a pressure reducing device on a resident's bed. This deficient practice was identified for 1 of 1 resident reviewed for pressure ulcer/injury(Resident #9), and was evidenced by the following:
On 6/17/24 at 10:54 AM, during initial tour of the facility, the surveyor observed Resident #9 lying in bed. The resident was on a regular mattress which was placed atop a deflated low air loss mattress/pressure reducing mattress, which was connected to an air pump that was not plugged into the power outlet or turned on.
On 6/19/24 at 11:01 AM, the surveyor observed Resident #9's bed which contained a regular mattress covered with bed linens placed on top of a a deflated low air loss mattress. The resident was not present at
the time of observation.
On 6/19/24 at 11:05 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated, Resident #9 was being followed by wound care consultations (consults) for a pressure ulcer, which was now resolved. The UM/LPN reviewed the resident's ICCP with the surveyor, and identified that the resident was care planned for being at risk for skin breakdown, having been treated for a pressure ulcer with interventions that included to use a pressure reducing device when in bed. The UM/LPN further stated that
the resident did not have physician's order for pressure reducing devices.
At that time, the surveyor and the UM/LPN went to the resident's room to observe the mattress setup. The UM/LPN confirmed that there was a regular mattress on top of deflated air loss/pressure reducing mattress.
The UM/LPN acknowledged there was no pressure reducing device in bed for the resident; that the air mattress underneath the regular mattress was used incorrectly.
The surveyor reviewed the medical record for Resident #9.
A review of the Admission Record face sheet (an admission summary) indicated the resident was admitted to
the facility with diagnosis which included rash and other nonspecific skin eruption and erythematous condition (skin redness can have causes that are not due to underlying disease. Examples include too much pressure on the area, blushing, or exercise).
A review of the current Physician Order Summary Report did not include a physician's order for use of pressure reducing devices.
A review of the ICCP included a focus for risk for skin breakdown with interventions which included the use of pressure reducing device for bed and chair.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of107 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 0686 A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/9/24, indicated under section M: Skin Conditions that the resident had one stage two pressure ulcer (partial thickness loss of Level of Harm - Minimal harm or dermis skin layer presenting as a shallow open ulcer with a red or pink wound bed) with treatments including potential for actual harm pressure reducing device for chair and for bed.
Residents Affected - Few On 6/20/24 at 10:34 AM, in the presence of the survey team, the surveyor interviewed the Director of Nursing (DON) confirmed that Resident #9 had history of pressure ulcers and that the resident should be on a pressure reducing air mattress set to the resident's weight. The DON was presented with a photograph of how the resident's bed was arranged with a regular mattress atop a deflated air mattress, to which the DON stated that was unacceptable and that she had never seen that done this way, we don't use it this way. She further stated we should not have a regular mattress on top, it defeats the purpose [of the air mattress].
On 6/26/24 at 10:46 AM, the surveyor, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), and Assistant Director of Nursing (ADON), asked the DON if Resident #9 had an order for use of a pressure reducing device on the bed, to which the LNHA shook her head No and the DON stated, there should have been one.
Review of the facility's Wound Prevention and Treatment policy dated reviewed March 2024, included Pressure Ulcer Prevention .Provide a pressure reduction surface for bed and/ or wheelchair per the facility's Support Surface Selection Algorithm. (Refer to Algorithm of this Wound Prevention and Management Protocol) .Stage II Treatment .Notify physician and obtain orders for the most appropriate treatment protocol .
NJAC 8:39-27.1(e)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of107 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm 49094
Residents Affected - Few Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to monitor an enteral tube feeding administration pump to ensure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents reviewed for tube feeding (Resident #32), and was evidenced by the following:
On 6/17/24 at 10:54 AM, the surveyor observed Resident #32 lying in bed awake with a tube feeding pump (TF; a tube feeding surgically inserted into the stomach) was located on a pole near their bed. There was no nutritional formula being administered at this time. When asked by the surveyor if they received tube feedings daily, Resident #32 shook their head indicating yes.
On 6/19/24 at 10:35 AM, the surveyor observed Resident #32 lying in bed awake with the TF pump administering Jevity 1.5 (nutritional formula) at a rate of 70 milliliters (mL) an hour with a total volume infused thus far of 464 mL. The Jevity 1.5 bottle was labeled as hung on 6/18/24 at 7:30 PM.
On 6/19/24 at 12:30 PM, the surveyor observed Resident #32 lying in bed with the TF pump administering Jevity 1.5 at a rate of 70 mL an hour with a total volume infused thus far of 600 mL.
The surveyor reviewed the medical record for Resident #32.
According to the Admission Record face sheet (admission summary), the resident was admitted to facility with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to
the area), gastro-esophageal reflux disease (stomach acid repeatedly flows back up into the tube connecting
the mouth and stomach), dysphagia (difficulty swallowing), aphasia (affects how you communicate), and vitamin deficiency (do not have enough vitamins in the body).
According to the most recent Minimum Data Set (MDS), an assessment tool dated 3/22/24, revealed Resident #32 did not have a Brief Interview for Mental Status (BIMS) score due to the resident was rarely or never being understood with short term and long-term memory problems with moderately impaired cognition.
A review of the MDS Section K. Swallowing/Nutritional Status, revealed that Resident #32 had a feeding tube (TF) while a resident, and received more than 51% of their total calories through the tube feeding.
A review of the individualized comprehensive care plan (ICCP) dated effective 7/13/22 to present, included that the resident required a TF for nutritional support related to need for nothing by mouth (NPO) status with dysphagia. Interventions included to monitor labs as ordered; tolerate tube feeding; maintain fairly stable weight without significant change; provide Jevity 1.5 as ordered; and monitor weight monthly.
A review of the June 2024 Physician Order Sheet (POS) included a physician's order (PO) dated 6/10/24, to administer Jevity 1.5 via pump at the rate of 70 mL an hour; start at 4:00 PM (4 PM) until completion of total volume to equal 1260 mL.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of107 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 0693 A review of the corresponding June 2024 electronic Medication Administration Record (eMAR) indicated the following: Level of Harm - Minimal harm or potential for actual harm The TF order for Jevity 1.5 was signed by the nurse indicating it was administered at 4 PM on 6/18/24.
Residents Affected - Few A review of the corresponding June 2024 Administration History Report indicated that on 6/18/24, the enteral tube feeding Jevity 1.5 was hung at 4:50 PM.
During an interview with the surveyor on 6/19/24 at 12:15 PM, the Unit Manager/Licensed Practical Nurse (UM/LPN) was asked how the facility monitored the amount of formula infused by the TF pump. The UM/LPN responded, if the resident's tube feeding order was for a total volume amount of 1270 mL, then the pump was set to administer the total volume of 1270 mL, and the pump stopped when the total volume was infused. The UM/LPN also stated that the nurse signed on the eMAR when they started the tube feeding, but
the nurses did not document the total volume infused at the end of each shift.
On 6/19/24 at 12:30 PM, the UM/LPN accompanied the surveyor to Resident #32's room, and they observed
the resident in bed with the TF running at a rate of 70 mL per hour with a total volume of 600 mL infused.
The UM/LPN stated that Resident #32's TF was usually completed around 10:00 AM, and that possibly the nurse who changed the Jevity 1.5 bottle, cleared the total volume infused on the pump which the UM/LPN confirmed they should not do. The surveyor asked can you determine the total amount of the Jevity 1.5 that
the resident received since the feeding was started on 6/18/24 at 4 PM, and the UM/LPN responded, they could not say for certain if the total volume was cleared. The UM/LPN also acknowledged that the TF would continue to administer the formula until it reached a total volume of 1270 mL which would take approximately nine hours to reach that volume, and it would overlap the resident's next feeding that started at 4 PM. The UM/LPN also acknowledged it was possible that the resident could have received more than 1270 mL, since
the feeding usually ended at 10:00 AM, and overfeeding could have led to the resident vomiting. At that time,
the UM/LPN instructed a nearby nurse to stop the feeding.
On 6/20/24 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that a resident's TF was hung according to the physician's orders; that the TF should be administered at the time ordered, and continue to infuse until the resident received the total volume. When asked how do the facility monitored
the total volume administered each shift, the DON responded, the total volume the resident received was displayed on the pump. The DON also stated the nurse documented on the eMAR when the TF was started, but the nurses did not document the total volume administered each shift. The surveyor then asked, how do you know if Resident #32 received the ordered amount of Jevity 1.5 6/19/24, if at 12:30 PM, the TF pump indicated 600 mL as the total volume. The DON stated that she could not confirm if the resident received the ordered amount, and the nurse should have documented in the Progress Notes if they held the feeding and why, and it should have been communicated to the next shift.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of107 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 0693 On 6/26/24 at 10:35 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and survey team stated that through interviews with staff, they were Level of Harm - Minimal harm or assuming the tube feeding was hung late, and the nurse should be have been checking and making rounds potential for actual harm on the units. The DON acknowledged the facility needed to be more diligent in tracking when the tube feeding was hung and how much was infused each shift, and the nurse should have documented if the TF Residents Affected - Few was hung late or the feeding was held for a length of time. When asked if the facility conducted an investigation, the DON stated that she verbally spoke to staff but did not document anything. The DON also acknowledged there was no documentation that the physician was made aware. The DON could not speak to why the nurse signed the TF was started on 4/18/24 at 4:50 PM, but acknowledged it was not appropriate to start the next TF directly after the previous TF ended.
A review of the facility's Enteral Feeding policy dated revised 5/1/11, included Procedure: [ .] 16. Document administration of feeding on Medication Administration Record (MAR) including: Date, Formula, Rate and Continuous bolus. 17. Document total intake separated into formula and water flush on MAR or Intake & Output Record if applicable. 18. Document the following, including, but not limited to: Tube placement verification, Time tube feeding initiated, Resident/patient tolerance, and Amount of gastric residual, as applicable .
NJAC 8:39-27.1(a)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of107 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
F-Tag F865
F-F865
According to the U.S. CDC Core Elements of Antibiotic Stewardship for Nursing Home, page last reviewed June 11, 2020, included, Tracking and Reporting Antibiotic Use and Outcomes Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Process measures: Tracking how and why antibiotics are prescribed Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.
A review of the facility's Antibiotic Stewardship policy dated reviewed January 2022, included the [Infection Preventionist (IP)] or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics .All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: resident name and medical record number; unit and room number; date and symptoms appeared; name of antibiotic; start date of antibiotic; pathogen identified; site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events.
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) who the facility's Infection Preventionist (IP) was, and
the DON stated the facility's previous IP left about two or three months ago and the position was vacant. The DON stated herself, the Assistant Director of Nursing (ADON), and the two unit managers reviewed immunizations, antibiotic stewardship, and infection control issues. At that time the surveyor requested a copy of the infection control certifications as well as the date the IP stopped working.
On 6/18/24 at 11:42 AM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked.
On 6/19/24 at 12:55 PM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked as well as the antibiotic stewardship tracking and surveillance.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of107 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 0881 On 6/19/24 at 1:36 PM, the surveyor interviewed the DON who stated she did not have a certification in infection control; but she reviewed infection control with the ADON who also was not certified. The DON Level of Harm - Minimal harm or stated only the Unit Manager/Licensed Practical Nurse (UM/LPN) had an infection control certification. The potential for actual harm DON stated the unit managers provided the antibiotic stewardship information to the ADON who reviewed, summarized, and completed the monthly report, and the ADON in-services staff on infection control. Residents Affected - Many
On 6/20/24 at 12:36 PM, the ADON provided the surveyor with a copy of the facility's Monthly Antibiotic Summary since January 2024. A review of the summary revealed the following:
In January 2024, four residents received antibiotics, and three residents had a blank for the diagnostic section (X-ray and laboratory).
In February 2024, six residents received antibiotics, and all six had a blank for the diagnostic section. Resident #40 had no documented symptoms.
In March 2024, six residents received antibiotics, and all six had a blank for the diagnostic section. Resident #44 and Resident #98 both were not indicated if they met the criteria for an antibiotic.
For April 2024, four residents received antibiotics with no residents having documented symptoms; two had diagnostic test documented; none had the origin documented; and no one had documented if the criteria was met.
For May 2024, eleven residents received antibiotics with only two residents had documented symptoms; no one had diagnostic tests documented; none had the origin documented; and no one had documented if the criteria was met.
For June 2024, eight residents received antibiotics with Resident #197 with no documented symptoms; and no one had documented diagnostic testing, origin, or criteria met.
On 6/20/24 at 12:36 PM, the surveyor interviewed the ADON who stated the facility had no IP since April of 2024, everyone was pitching in with infection control. When asked why the summaries were not completed,
the ADON stated she had just completed May's antibiotic stewardship review yesterday.
On 6/20/24 at 12:57 PM, the surveyor informed the LNHA and DON about the missing documentation for the antibiotic stewardship. The DON stated there was a log on the medication cart with the antibiotic that was being tracked.
No additional information was provided.
NJAC 8:39-19.1
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of107 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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in
the nursing home. Level of Harm - Minimal harm or potential for actual harm 38080
Residents Affected - Some Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to hire a designated Infection Preventionist (IP) who worked at least part-time and had completed specialized training in infection control and prevention. The deficient practice was identified and evidenced by the following:
Refer
F-Tag F881
F-F881
During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) a copy of the facility's QAPI program plan and
the last three quarterly sign-in sheets.
On 6/18/24 at 11:52 AM, the surveyor requested from the LNHA a copy of the facility's QAPI program plan and last three quarterly sign-in sheets.
On 6/19/24 at 9:00 AM, the surveyor received a copy of the last three quarterly sign-in sheets for the facility's QAPI program, but no policy was provided.
On 6/20/24 at 12:57 PM, the survey team met with the LNHA and DON to discuss their concerns which included accuracy of the Minimum Data Set (MDS) assessments; medication storage; acting on Consultant Pharmacy (CP) reports; and antibiotic stewardship program.
On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail.
A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the QAPI committee on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population.
On 6/25/24 at 1:22 PM, the survey team met with the LNHA, DON, and Regional Nurse to discuss additional concerns which included the facility's assessment did not include registered sex offenders or inmates in their special population.
A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies from the facility's last standard survey included the facility was cited for the following concerns: MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment to include registered sex offenders and inmates, and the facility's QAPI program.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of107 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 0865 On 6/26/24 at 11:52 AM, the survey team met with the LNHA, DON, and Assistant Director of Nursing (ADON) to discuss the facility's QAPI program which all three staff members were part of. When asked Level of Harm - Minimal harm or where the facility obtained their concerns for their QAPI program, the LNHA stated the facility utilized the potential for actual harm CMS 2567 statement of deficiencies from previous surveys. The survey team informed the facility that there were repeated concerns from the last standard survey which included MDS assessments, medication Residents Affected - Many storage, acting on CP reports, antibiotic stewardship program, facility assessment, and QAPI, and asked what the facility implemented to ensure sustainability. The LNHA acknowledged that even though she started at the facility in April 2024, she was present for the April quarterly QAPI meeting as well as reviewed and signed the facility assessment and reviewed the CMS 2567 from last standard survey. At that time the DON stated she was aware of the facility's previous deficiencies and that facility educated staff and completed reports.
No additional information was provided.
A review of the facility provided Administrator job descriptions included the Administrator is responsible for planning and is accountable for all activities and departments at [name redacted] subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of care is constantly provided to the residents .
A review of the facility provided Senior Director of Nursing Services job descriptions included in addition to
the standard responsibilities of Director of Nursing, Senior Director of Nursing is responsible for providing leadership, training and expert guidance. Individuals selected for this position and must be knowledgeable in all aspects of long term care nursing and have demonstrated ability in managing a nursing department . Performs Related Duties: 1. in the absence of the Administrator and/or licensed Assistant Administrator, the DON is responsible carrying out the administrative duties of the nursing facility .
NJAC 8:39-33.1(a)(e); 33.2 (a)(b)(c)(d)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of107 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 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or 49094 potential for actual harm Based on observation, interview, review of pertinent facility documents, it was determined that the facility Residents Affected - Some failed to: a) change respiratory equipment tubing in a manner to prevent the spread of infection for 1 of 1 resident reviewed for respiratory care (Resident #80); b.) ensure that infection control standards were followed during medication pass for 1 of 2 nurses observed during medication administration; and c.) ensure staff maintained appropriate nail length to prevent the spread of infection for 1 of 2 unit managers. This deficient practice was identified on 2 of 2 nursing units, and was evidenced by the following:
1. During the initial tour of the Second Floor nursing unit on 6/17/24 at 10:52 AM, the surveyor observed Resident #80 lying in bed. Resident #80 was receiving humidified oxygen at 3 liters per minute (lpm) via nasal cannula (tubing that delivered oxygen through the nose). The surveyor observed the nasal cannula tubing with a piece of clear tape attached to the tubing dated 6/5/24.
The surveyor reviewed the medical record for Resident #80.
A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to facility with diagnoses which included chronic obstructive pulmonary disease (COPD) (refers to a group of diseases that cause airflow blockage and breathing-related problems), morbid obesity (having too much body fat, which increases the risk of health problems), and anemia (low levels of healthy red blood cells to carry oxygen throughout your body).
A review of the most recent Minimum Data Set (MDS), an assessment tool dated 4/25/24, revealed the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition.
A review of the June 2024 Treatment Administration Record (TAR) included a physician's order (PO) dated 6/12/24, to change oxygen cannula/tubing once weekly on Wednesday during the night shift and as needed.
On 6/19/24 at 10:18 AM, the surveyor observed Resident #80 lying in bed awake and alert. Resident #80 was receiving humidified oxygen at 3 lpm via nasal cannula. The surveyor observed the nasal cannula tubing with a piece of clear tape attached to the tubing dated 6/5/24. Resident #80 said that they change my oxygen tubing when I ask the nurse, and the last time it was done was about two weeks ago.
On 6/20/24 at 11:48 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) regarding how often oxygen tubing was changed, and LPN #1 responded it was changed weekly by the overnight nurse. LPN #1 confirmed the resident should not be using nasal tubing that was more than seven days old.
On 6/20/24 at 12:20 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed oxygen tubing was changed weekly on the 11:00 PM to 7:00 AM shift by the nurse. The DON stated the nurse dated when they changed the tubing. The DON acknowledged nasal tubing should not be used past seven days because it was an infection control issue.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of107 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 0880 The facility had no Infection Preventionist.
Level of Harm - Minimal harm or A review of the facility's Cleaning Respiratory Equipment policy dated revised May 2022, included potential for actual harm Procedure: 1. Supplies: Replace masks and/or cannula used by an individual resident within seven (7) days and as needed (PRN) when obviously contaminated . Residents Affected - Some 34033
2. On 6/18/24 at 8:59 AM, during the morning medication administration pass, the surveyor, observed the Registered Nurse (RN) preparing eight (8) medications for Resident #5 which included Cosopt (an eye drop medication used for glaucoma) eye drops. The RN stated that she did not have any tissues on the medication cart to use when administering the Cosopt eye drops. The surveyor observed the RN, with gloved hands, go into the resident's bathroom and removed toilet paper from the roll that was hanging in the bathroom. The RN then folded the toilet paper into a small wad, and used the toilet paper to dab the right eye
after administering one drop of the Cosopt and then turned the toilet paper wad over and used the other side to dab the left eye after administering one drop of Cosopt into the left eye.
On 6/18/24 at 9:13 AM, the surveyor interviewed the RN who stated that she felt the toilet tissue was clean.
The RN also stated that she was an agency nurse, and this was not her usual medication cart and that it was difficult to know what was stocked in the cart.
On 6/19/24 at 1:13 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The DON confirmed that toilet paper from the bathroom should not have been used while administering eye drops, it was not sanitary. The DON stated that there were boxes of tissues provided for
the medication carts.
The facility had no Infection Preventionist.
A review of the facility's Medication Administration policy dated 12/23/23, included .Prior to preparing and administering medications, follow the facility's infection control policies (for example, handwashing) .
38080
3. On 6/17/24 at 9:56 AM, the surveyor observed the Unit Manager/Licensed Practical Nurse (UM/LPN) at a medication cart. The UM/LPN stated she was administering medication to residents. The surveyor observed her nails to be manicured and long in length.
On 6/25/24 at 11:30 AM, the surveyor observed The UM/LPN at the nurse's station with long manicured acrylic nails that were over an inch in length and curled. The surveyor commented to the UM/LPN that their nails were long, and the UM/LPN hid their nails and replied not to look at them. The surveyor asked the UM/LPN if they provided resident care, and the UM/LPN replied no.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of107 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 0880 On 6/25/24 at 1:30 PM, the surveyor interviewed the DON and LNHA, and the DON stated if there was a staffing issue, the unit manager should assist with resident care. The DON acknowledged administering Level of Harm - Minimal harm or residents' medications was considered resident care. When asked if they were aware of the UM/LPN's nail potential for actual harm length, both the LNHA and DON acknowledged that the UM/LPN's nail length was not appropriate. The DON stated they were too long which could result in bacterial growth underneath as well as resident care issues. Residents Affected - Some
The facility had no Infection Preventionist.
A review of the facility provided Dress Code which required an employee signature and date, included the length of nails should be reasonable so as not to interfere with resident care or time clock .
NJAC 8:39-19.4(a)(k)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of107 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 0881 Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm or 38080 potential for actual harm Based on observation, interview, and review of pertinent facility documents, it was determined that the facility Residents Affected - Many failed to a.) implement a facility-wide system to monitor antibiotic use specifically according to the facility's antibiotic stewardship program and b.) monitor antibiotic use and conduct surveillance from January 2024 through June 2024. This deficient practice was cited during the facility's last standard survey on 10/20/22, and was evidenced by the following:
Refer
F-Tag F882
F-F882
A review of the Administrator's job description provided by the facility revealed the following:
Administrator is responsible for planning and is accountable for all activities and departments at [name redacted] subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of care is constantly provided to the residents .
Responsibilities/Accountabilities included but not limited to: implements [name redacted] objectives as determined and directed by the governing body; interprets practices within guidelines and recommends changes as necessary; superintends physical operations of the facility; concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents; oversees and guides department managers in the development and use of departmental policies and procedures; and ensure that residents and families receive the highest level of service in a caring and compassionate atmosphere which recognizes the individuals needs and rights .
1. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the LNHA and Director of Nursing (DON) who the facility's Infection Preventionist (IP) was, and the facility did not have an IP for two or three months, that the Assistant Director of Nursing (ADON), two unit managers, and herself reviewed antibiotic stewardship and inserviced staff on infection control. The surveyor requested a copy of their infection control certifications.
On 6/19/24 at 1:36 PM, the surveyor interviewed the DON who stated she did not have a certification in infection control; but she reviewed infection control with the ADON who also was not certified. The DON stated only the Unit Manager/Licensed Practical Nurse (UM/LPN #1) had an infection control certification.
The DON stated the unit managers provided the antibiotic stewardship information to the ADON who reviewed, summarized, and completed the monthly report, and the ADON in-serviced staff on infection control.
On 6/20/24 at 12:36 PM, the surveyor interviewed the ADON who stated the facility had no IP since April of 2024, everyone was pitching in with infection control. The ADON stated she had just completed May's antibiotic stewardship review yesterday.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of107 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 0835 On 6/25/24 at 10:58 AM, the surveyor re-interviewed the ADON who confirmed she had no infection control certification, and she was responsible for providing staff with infection control training. Level of Harm - Immediate jeopardy to resident health or On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked safety the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were Residents Affected - Few met.
2. On 6/18/24 at 7:57 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN #1) entering electronic signatures for the medications that she had administered to Resident #89 in the electronic Medication Administration Record (eMAR).
On 6/18/24 at 8:13 AM, RN #1 stated I had to borrow a password, explaining that she was using the login password for the UM/LPN #2 because she was an agency nurse, and she had a problem with her login.
On 6/18/24 at 8:21 AM, the surveyor observed RN #1 entering electronic signatures for the 8:00 AM (8 AM) and 9:00 AM (9 AM) medications for four sampled residents, (Resident #32, #61, #79, and #84), and six unsampled residents, (unsampled Resident #1, #2, #3, #4, #5, #6). RN #1 stated that she had already administered the morning medications to those residents and needed to sign the eMAR. RN #1 explained that she administered morning medications to the residents earlier because they were a priority since the residents were either diabetic, on dialysis or had a feeding tube (surgical tube inserted into the stomach), and she had not had a chance to sign the eMAR.
On 6/18/24 at 8:45 AM, the surveyor observed RN #1 administer and electronically sign for medications that were administered to Resident #51.
A review of the eMARs for Resident #89, #51, #32, #61, #79, #84 and the six unsampled residents revealed that the initials for the 8 AM and 9 AM medications on 6/18/24 had the electronic signature initials for UM/LPN #2.
On 6/18/24 at 11:27 AM, the surveyor interviewed UM/LPN #2 at the nurse's station, who stated that she had given RN #1 her login because there was a problem this morning. In addition, UM/LPN #1 stated that medications should be signed for immediately after administering them to the resident.
At that time, the Assistant Director of Nursing (ADON) was at the nurse's station and confirmed UM/LPN #2 should not have given RN #1 her login password. The ADON stated that when the computer system changed on 6/11/24, the staff were trained on how to use the system, but that agency nurses were already familiar with the system.
On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked
the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met.
3. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the LNHA and DON how the facility's staff was, and the LNHA stated that the facility relied heavily on Agency staffing.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of107 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 0835 On 6/18/24 at 8:02 AM, the surveyor conducted an incontinence tour on the Second Floor nursing unit accompanied by the Um/LPN #1 and observed the following: Level of Harm - Immediate jeopardy to resident health or The surveyor and UM/LPN #1 entered Resident #147's room who was observed lying in bed. UM/LPN #1 safety 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 Residents Affected - Few 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.
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:
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 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 6/25/24 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 regulation which required one CNA to every eight residents for the morning shift; one CNA for every ten 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of107 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 0835 On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked
the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all Level of Harm - Immediate departments and department heads to ensure residents received the services, were safe, and needs were jeopardy to resident health or met. safety 4. On 6/19/24 at 1:27 PM, the surveyor requested from the LNHA and DON the Consultant Pharmacist's Residents Affected - Few (CP) recommendations for Resident #34, #60, #61, and #80) from March 2024 until present.
A review of the CP's recommendations revealed that recommendations made in March 2024, were acted on
after surveyor inquiry.
On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated that the CP reports were sent to the facility through email by the CP, and the CP's recommendations were to be completed by the unit managers.
The DON stated that an appropriate time for the CP's recommendations to be completed was within seven days of receiving. The DON could not explain why the recommendations provided from the CP from March 2024, April 2024 and May 2024 were not completed until 6/19/24 after surveyor inquiry.
On 6/20/24 at 10:16 AM, the surveyor interviewed UM/LPN #1 who stated that the CP report recommendations were usually completed by the unit manager, but could be assigned to the nurse on the unit or divided amongst the nursing staff to complete. UM/LPN #1 stated that an appropriate time to complete
the CP's recommendation report was within one week. She continued to add that the unit managers usually received an email of the recommendations, but since switching over to the new electronic medical records (EMR), which was switched on 6/11/24, the DON received the recommendations. UM/LPN #1 revealed that
the CP recommendations from March 2024, April 2024 and May 2024 were not given to the unit managers to complete until yesterday (6/19/24).
On 6/20/24 at 12:24 PM, the surveyor interviewed the facility's CP who stated that she had been at the facility since March 2024, and it was important that the facility acted upon the pharmacy recommendations as soon as possible (ASAP) so that if there was a medication safety concern, it could be taking care of immediately. The CP stated that the facility needed more education because the new pharmacy consultant company was new to the facility and the staff was on a learning curve.
On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked
the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met.
5. On 6/17/24 at 1:00 PM, the surveyor requested from the LNHA a copy of investigations for reportable events to the New Jersey Department of Health (NJDOH) or any investigations that included injury of unknown origin or allegation of abuse and neglect for July and August 2023.
The surveyor reviewed an investigation for the closed medical record for Resident #254.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of107 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 0835 A review of the Incident Report dated 8/14/23 at 8:30 AM, revealed that the ADON was called to Resident #254's room to assess the resident who had blue discoloration on both ears, a three centimeter by three Level of Harm - Immediate centimeter (3 cm x 3 cm) abrasion to right knee; discoloration on right side of face and mid arm. When staff jeopardy to resident health or attempted to turn the resident over, the resident screamed in pain; the physician was made aware and a new safety order was put in place to send to the emergency room (ER) for evaluation. The ER report indicated the resident sustained a lower back fracture. The resident's medical record revealed prior to the injury of Residents Affected - Few unknown origin, they were on one to one (1:1) monitoring every shift. The incident report did not include how
a resident on 1:1 monitoring sustained bruising to both ears and a lower back fracture through an unwitnessed fall.
On 6/20/24 at 1:24 PM, the survey team met with the LNHA and the DON, and the surveyor requested additional information on how a resident who was on 1:1 monitoring had an unwitnessed fall that resulted in two bruised ears and a fractured back. At that time, the LNHA acknowledged that the investigation should include how the resident on a 1:1 had an unwitnessed fall.
On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked
the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met.
On 6/26/24 at 10:36 AM, the survey team met with the LNHA, DON, and ADON to discuss their concerns.
The LNHA stated an investigation should have included an assessment of the resident, interviews of possible witnesses and resident, psychology if needed, psychosocial if needed with a social worker, summary, conclusion and interventions put in place so will not happen again, and individualized comprehensive care plan (ICCP) was updated.
6. During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the LNHA and the DON
a copy of the facility's assessment.
During initial tour on 6/17/24 at 10:29 AM, the surveyor observed Resident #26 observed in bed asleep. The surveyor observed that both the resident and their unsampled roommate were both incarcerated with four Corrections Officers (CO) present in the room.
On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail.
A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the Quality Assurance and Performance Improvement (QAPI) committee and signed by the LNHA on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population.
On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked
the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of107 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 0835 On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, ADON, and survey team acknowledged the registered sex offenders and inmates were not included in the facility assessment. Level of Harm - Immediate jeopardy to resident health or 7. On 6/20/24 at 12:57 PM, the survey team met with the LNHA and DON to discuss their concerns which safety included accuracy of the Minimum Data Set (MDS) assessments; medication storage; acting on Consultant Pharmacy (CP) reports; and antibiotic stewardship program. Residents Affected - Few
On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail.
A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the QAPI committee on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population.
On 6/25/24 at 1:22 PM, the survey team met with the LNHA, DON, and Regional Nurse to discuss additional concerns which included the facility's assessment did not include registered sex offenders or inmates in their special population.
On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked
the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met.
A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies from the facility's last standard survey included the facility was cited for the following concerns: MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment to include registered sex offenders and inmates, and the facility's QAPI program.
On 6/26/24 at 11:52 AM, the survey team met with the LNHA, DON, and ADON to discuss the facility's QAPI program which all three staff members were part of. When asked where the facility obtained their concerns for their QAPI program, the LNHA stated the facility utilized the CMS 2567 statement of deficiencies from previous surveys. The survey team informed the facility that there were repeated concerns from the last standard survey which included MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment, and QAPI, and asked what the facility implemented to ensure sustainability. The LNHA acknowledged that even though she started at the facility in April 2024, she was present for the April quarterly QAPI meeting as well as reviewed and signed the facility assessment and reviewed the CMS 2567 from last standard survey. At that time the DON stated she was aware of the facility's previous deficiencies and that facility educated staff and completed reports.
NJAC 8:39-9.2(a); 9.3(a); 27.1(a)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of107 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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 38080
Residents Affected - Many Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary to protect the health, safety, and welfare of all residents prior to admission of registered sex offenders and residents admitted from the correctional facility. This deficient practice was previously identified and cited during the facility's last standard survey on 10/20/22, and was evidenced by the following:
Refer
F-Tag F883
F-F883
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) who the facility's Infection Preventionist (IP) was, and
the DON stated the facility's previous IP left about two or three months ago and the position was vacant. The DON stated herself, the Assistant Director of Nursing (ADON), and the two unit managers reviewed immunizations, antibiotic stewardship, and infection control issues. At that time the surveyor requested a copy of the infection control certifications as well as the date the IP stopped working.
On 6/18/24 at 11:42 AM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked.
On 6/19/24 at 12:55 PM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked.
On 6/19/24 at 1:36 PM, the surveyor interviewed the DON who stated she did not have a certification in infection control; but she reviewed infection control with the Assistant Director of Nursing (ADON) who also was not certified. The DON stated only the Unit Manager/Licensed Practical Nurse (UM/LPN) had an infection control certification. The DON stated the unit managers provided the antibiotic stewardship information to the ADON who reviewed, summarized, and completed the monthly report, and the ADON in-serviced staff on infection control.
On 6/20/24 at 12:36 PM, the surveyor interviewed the ADON who stated the facility had no IP since April of 2024, everyone was pitching in with infection control. The ADON stated she had just completed May's antibiotic stewardship review yesterday.
On 6/25/24 at 10:58 AM, the surveyor re-interviewed the ADON who confirmed she had no infection control certification, and she was responsible for providing staff with infection control training.
On 6/25/24 at 1:30 PM, the surveyor informed the LNHA and DON of the concern with infection control. The LNHA stated the previous IP's last day of work was 5/3/24.
No additional information was provided.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of107 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 0882 A review of the facility's undated Infection Prevention and Control Program policy included the infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection Level of Harm - Minimal harm or preventionist). The qualifications and job responsibilities of the Infection Preventionist are outlined in the potential for actual harm Infection Preventionist Job Description .
Residents Affected - Some NJAC 8:39-19.1(b)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of107 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49094 potential for actual harm Based on interview, record review, and review of other pertinent facility documents, it was determined that Residents Affected - Few the facility failed to implement their policy to a.) ensure all eligible residents were educated on the benefits and potential side effects of the pneumococcal immunization and b.) document in the medical record the residents' education and refusal of the pneumococcal immunization. The deficient practice was identified for 2 of 8 residents reviewed for immunizations (Resident #76 and Resident #87), and was evidenced by the following:
1. According to the Admission Record, Resident #87 was admitted to the facility with diagnoses including but not limited to diabetes mellitus (a disease of inadequate control of blood levels of glucose), hypertension (high blood pressure), heart failure (heart muscle does not pump blood as well as it should), and stroke (damage to the brain from interruption of its blood supply).
A review of the most recent Minimum Data Set (MDS), an assessment tool dated 3/18/24, reflected the resident had a brief interview for mental status score of 15 of out of 15, indicating a fully intact cognition. A
review of Section O0300 indicated Resident #87's pneumococcal vaccine (immunization) was not up to date; that the resident was offered and declined.
A review of Resident #87's Immunization Record revealed no pneumococcal vaccine was administered, but
the resident was administered influenza vaccine on 3/11/24.
A review of Resident #87's Progress Notes did not include documentation that the resident was educated, offered, and declined the vaccination.
On 6/20/24, the surveyor requested the Pneumococcal Immunization Informed Consent declination form from the Director of Nursing (DON).
On 6/24/24, a review of a Pneumococcal Immunization Informed Consent, revealed that Resident #87 was offered the pneumonia vaccine on 6/18/24 and declined. There was no documentation that the resident was offered or that the resident was offered the pneumococcal vaccine prior to survey.
On 6/24/24 at 10:02 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated upon admission, the nurse reviewed the resident's vaccination status. The ADON stated if there was no documented immunizations received, the nurse offered the immunization and had the resident signed the consent form or declined the immunization on the same form. The ADON stated the resident was offered the pneumococcal vaccine on 6/18/24, but declined. The ADON confirmed the facility did not have the resident's declination form from admission.
On 6/26/24 at 10:35 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), ADON, and survey team stated, the resident was offered on admissions, but the facility could not provide documentation.
2. According to the Admission Record, Resident #76 was admitted to the facility with diagnoses included hypertension (high blood pressure), stroke (damage to the brain from interruption of its blood supply), and end stage renal disease (kidneys can no longer function on their own).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of107 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 0883 A review of the most recent MDS dated [DATE REDACTED], reflected the resident had a BIMS score of 13 out of 15, which indicated a fully intact cognition. A review of Section O0300 indicated Resident #76's pneumococcal Level of Harm - Minimal harm or vaccine was not up to date; that the resident was offered and declined. potential for actual harm
A review of Resident #76's Immunization Record, revealed no pneumococcal vaccine administered, but the Residents Affected - Few resident was administered influenza vaccine on 9/22/23.
A review of Resident #76's Progress Notes did not include documentation that the resident was educated, offered, and declined the pneumococcal vaccine.
On 6/20/24, the surveyor requested the Pneumococcal Immunization Informed Consent declination form from the DON.
On 6/24/24, a review of a Pneumococcal Immunization Informed Consent, revealed that Resident #76 was offered the pneumonia vaccine on 6/23/24, and declined. There was no documentation that the resident was educated or that the resident was offered the pneumococcal vaccine prior to surveyor inquiry.
On 6/24/24 at 10:02 AM, the surveyor interviewed the ADON who stated upon admission, the nurse reviewed the resident's vaccination status. The ADON stated if there was no documented immunizations received, the nurse offered the immunization and had the resident signed the consent form or declined the immunization on the same form. The ADON stated the resident was offered the pneumococcal vaccine on 6/23/24, but declined. The ADON confirmed the facility did not have the resident's declination form from admission.
On 6/26/24 at 10:35 AM, the DON in the presence of the LNHA, ADON, and survey team stated, the resident was offered on admissions, but the facility could not provide documentation.
A review of the facility's undated Pneumococcal Vaccine policy included all residents will be offered pneumococcal vaccines to aide in preventing pneumonia/pneumococcal infections. Prior to admissions residents will be assessed for eligibility to receive pneumococcal series, and when indicated, will be offered
the vaccine series within thirty days of admission .before receiving the pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccines[ .]provisions of such education shall be documented in the resident's medical record .residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the pneumococcal vaccination .
NJAC 8:39-19.4(i)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page106of107 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 Page107of107 315124