Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 3
Apr 24, 2025
Visit Reason
The inspection was conducted based on complaints NJ178109, NJ181841, and NJ182273 to investigate allegations of abuse, neglect, and failure to meet staffing and medication administration requirements at Belle Care Nursing and Rehabilitation Center.
Findings
The facility was found not in substantial compliance with federal and state regulations, including failure to timely report alleged abuse, inadequate medication administration documentation, and insufficient staffing levels. Deficiencies were identified in reporting alleged violations, pharmacy services, medication administration, and nurse staffing ratios.
Complaint Details
The complaint investigation was substantiated based on findings that the facility failed to timely report alleged abuse incidents, failed to accurately document medication administration for multiple residents, and failed to maintain adequate staffing levels for CNAs and nursing staff during the complaint survey period.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to submit the facility's investigation to the New Jersey Department of Health in a timely manner and failure to follow the facility's Abuse Policy. | Level D |
| Failure to provide routine and emergency pharmacy services including accurate medication administration documentation for multiple residents. | Level E |
| Failure to ensure staffing ratios met minimum requirements for Certified Nurse Aides (CNAs) and nursing staff for multiple shifts. | — |
Report Facts
Census: 104
Sample Size: 11
Deficiencies cited: 3
Staffing Deficiency Days: 12
Required Staffing Hours Week of 04/06/25: 273.25
Actual Staffing Hours Week of 04/06/25: 256
Staffing Hours Difference Week of 04/06/25: -17.25
Required Staffing Hours Week of 04/13/25: 278.25
Actual Staffing Hours Week of 04/13/25: 264
Staffing Hours Difference Week of 04/13/25: -14.75
Required Staffing Hours Week of 04/19/25: Not explicitly stated, but actual hours and difference provided
Actual Staffing Hours Week of 04/19/25: 272
Staffing Hours Difference Week of 04/19/25: -6.75
Inspection Report
Re-Inspection
Census: 94
Capacity: 106
Deficiencies: 21
Jun 26, 2024
Visit Reason
Recertification survey to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including follow-up on prior deficiencies.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident rights, staffing, medication management, infection control, and life safety code. Immediate Jeopardy was identified related to resident rights and self-determination for Resident #1. The facility submitted an acceptable removal plan and was verified in compliance on reinspection.
Complaint Details
Complaint investigations identified multiple deficiencies including resident rights violations, inadequate staffing, medication errors, infection control lapses, and life safety code violations. Immediate Jeopardy was declared related to resident rights and physical restraints for Resident #1.
Deficiencies (21)
| Description | Severity |
|---|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 44 out of 49 day shifts reviewed. | — |
| Failure to ensure all staff were trained and certified in LGBTQI+ training by an approved agency. | — |
| Failure to hire a designated Infection Preventionist with specialized training in infection control and prevention. | — |
| Failure to implement an effective antibiotic stewardship program including monitoring and documentation of antibiotic use. | — |
| Failure to maintain clean and sanitary medication storage areas and properly label opened multidose medications. | — |
| Failure to ensure medication administration without errors, including timely administration and proper documentation. | — |
| Failure to provide residents with nourishing snacks when there was more than a fourteen-hour span between dinner and breakfast. | — |
| Failure to maintain adequate illumination of means of egress including exit discharge lighting in stairwells and exit paths. | — |
| Failure to ensure hazardous area doors in the basement were self-closing or automatic closing as required. | — |
| Failure to ensure operational elevator emergency phone connections and firefighter emergency operation tests for 2 elevators. | — |
| Failure to maintain electrical panels locked and secure in resident accessible areas. | — |
| Failure to ensure resident rights and self-determination for Resident #1 including freedom from involuntary seclusion, freedom to participate in activities, community dining, communication with visitors, and freedom to leave room at will. | Immediate Jeopardy |
| Failure to ensure residents were free from physical and chemical restraints not required to treat medical symptoms, including Resident #1. | Immediate Jeopardy |
| Failure to maintain accurate, complete, and accessible medical records including investigations and discharge summaries. | — |
| Failure to develop and implement individualized comprehensive care plans consistent with residents' needs and diagnoses. | — |
| Failure to provide care consistent with professional standards including medication administration and monitoring. | — |
| Failure to maintain a safe, functional, sanitary, and comfortable environment including clean wheelchairs, resident rooms, and proper food handling. | — |
| Failure to maintain infection prevention and control program including adequate staffing and training. | — |
| Failure to ensure influenza and pneumococcal immunizations were offered, education provided, and refusals documented. | — |
| Failure to maintain fire safety code compliance including quarterly fire safety inspections and elevator safety features. | — |
| Failure to maintain electrical systems including guarding of live parts in electrical panels. | — |
Report Facts
Resident census: 94
Total licensed capacity: 106
Medication administration error rate: 10.3
Staffing deficiency days: 44
Number of residents reviewed: 35
Number of residents with deficiencies: 5
Number of residents with medication errors: 4
Number of residents with infection control issues: 1
Number of residents with immunization documentation issues: 2
Number of residents with self-determination violations: 1
Number of residents with restraint violations: 1
Number of residents with activity program deficiencies: 1
Number of residents with incomplete medical records: 3
Number of residents with medication monitoring deficiencies: 4
Number of residents with medication storage deficiencies: 2
Number of residents with medication administration documentation errors: 7
Number of residents with pain management deficiencies: 1
Number of residents with ADL care deficiencies: 4
Number of residents with tube feeding management deficiencies: 1
Number of residents with care plan deficiencies: 1
Number of residents with medication regimen irregularities: 4
Number of residents with medication errors: 4
Number of residents with insufficient nursing staff: 44
Number of residents with infection control deficiencies: 1
Number of residents with immunization deficiencies: 2
Number of residents with unsafe environment: 2
Number of hazardous area doors without self-closing devices: 2
Number of elevators with non-operational emergency phones: 2
Number of unlocked electrical panels: 1
Number of single station smoke alarms not tested: 46
Medication administration opportunities observed: 29
Medication administration errors observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication administration and electronic signing with shared login. |
| UM/LPN #1 | Unit Manager/Licensed Practical Nurse | Provided login to RN #1 and discussed medication administration procedures. |
| Resident #1 | Resident | Subject of resident rights and self-determination deficiencies. |
| LPN Supervisor #1 | Licensed Practical Nurse Supervisor | Interviewed regarding Resident #1's care and PPE requirements. |
| CNA #1 | Certified Nursing Aide | Interviewed regarding Resident #1's care and activities. |
| DON | Director of Nursing | Interviewed regarding infection control and antibiotic stewardship. |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding staffing and facility policies. |
| ADON | Assistant Director of Nursing | Interviewed regarding infection control and antibiotic stewardship. |
| Maintenance Director | Director of Maintenance | Interviewed regarding fire safety and facility maintenance. |
| Pharmacy Consultant | Consultant Pharmacist | Provided medication regimen recommendations. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Jun 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulatory requirements following allegations related to facility operations and staffing.
Findings
The facility was found to be in substantial compliance overall but had deficiencies including failure to report a prolonged freight elevator outage to the Department of Health and failure to maintain required minimum direct care staff to resident ratios on multiple shifts.
Complaint Details
The complaint visit found the facility in substantial compliance with 42 CFR Part 483, Subpart B, but identified deficiencies related to elevator outage reporting and staffing ratios.
Deficiencies (2)
| Description |
|---|
| Failure to report the loss of the freight elevator, which resulted in both elevators being out of service for more than 3 hours, to the Department of Health. |
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 7 out of 14 day shifts and 1 out of 14 overnight shifts reviewed. |
Report Facts
Census: 86
Sample Size: 4
Elevator outage duration: 15
Staffing deficiencies: 7
Staffing deficiencies: 1
Required CNAs: 11
Actual CNAs: 6
Required total staff overnight: 6
Actual total staff overnight: 5
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Sep 30, 2021
Visit Reason
The inspection was conducted as a complaint survey based on three complaint numbers NJ00142995, 00148689, and 00148738.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ00142995, 00148689, and 00148738 were investigated and the facility was found compliant.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 1
Apr 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations due to failure to utilize appropriate personal protective equipment (PPE) by staff, specifically a temporary nursing assistant who did not wear all required PPE while providing care to a resident on transmission-based precautions.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to utilize appropriate personal protective equipment (PPE) to prevent the potential spread of infection, specifically a temporary nursing assistant wearing only a surgical mask instead of full PPE while providing nail care to a resident on transmission-based precautions. | SS=D |
Report Facts
Census: 81
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided information on PPE requirements and conducted staff in-service training related to infection control deficiencies |
| Temporary Nursing Assistant | Temporary Nursing Assistant | Observed not wearing full PPE while providing care to a resident on transmission-based precautions |
| Administrator | Administrator | Provided information on PPE requirements during interviews |
Inspection Report
Routine
Census: 81
Deficiencies: 0
Dec 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
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