Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to timely report a resident-to-resident incident to the New Jersey Department of Health and failures in medication administration and documentation.
Complaint Details
Complaint # NJ178109 involved failure to timely report a resident-to-resident incident. Complaint # NJ182273 involved medication administration errors and documentation failures.
Findings
The facility failed to submit an investigation of a resident-to-resident incident in a timely manner and did not follow its Abuse Policy. Additionally, the nursing staff failed to properly administer medications and document administration on the electronic Medication Administration Record (eMAR) for multiple residents, violating facility policy and state regulations.
Deficiencies (2)
Failure to timely report suspected abuse and submit investigation results to proper authorities.
Failure of nursing staff to sign on the electronic Medication Administration Record (eMAR) that medications were administered according to physician's orders and failure to administer medication according to orders.
Report Facts
BIMS score: 7
BIMS score: 3
BIMS score: 15
BIMS score: 8
BIMS score: 14
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to timely submit investigation and medication administration issues |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Present during interviews about investigation submission and medication administration |
| Regional Director of Nursing | Regional Director of Nursing (Regional DON) | Present during interviews about investigation submission and medication administration |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Observed administering medication incorrectly and signing medication records inaccurately |
| Unit Manager | Second Floor Unit Manager (UM) | Interviewed about medication orders and administration |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jun 26, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging deficiencies in medical records access, notification of change of condition, abuse monitoring, activities of daily living care, pain management, staffing, medication administration timing, and environmental safety.
Complaint Details
Multiple complaints including NJ Complaint #168809, #162168, #166562, #159451, #166769, #163249, #159539, #159783, and #162168 were investigated.
Findings
The facility was found deficient in multiple areas including failure to provide timely access to medical records, failure to notify family of change in condition, inadequate monitoring of a resident on 1:1 observation resulting in injury, failure to provide adequate incontinence and nail care, failure to administer pain medication as ordered and monitor pain, insufficient nursing staff to meet resident needs, medication administration outside prescribed timeframes, incomplete and inaccessible medical records, and failure to maintain a safe and sanitary environment.
Deficiencies (10)
Failure to provide a discharged resident with a copy of their medical records within a timely manner of the written request.
Failure to notify a resident's family after a change of condition.
Failure to ensure constant monitoring of a resident on 1:1 observation who sustained bruising and a fractured spine from an unwitnessed fall.
Failure to initiate and complete a thorough investigation of an injury of unknown origin for a resident on 1:1 monitoring.
Failure to provide incontinence care for residents during rounds and failure to provide nail care during activities of daily living.
Failure to ensure a resident received pain medications as ordered and to assess and monitor pain every shift.
Failure to provide sufficient nursing staff to meet resident care needs and maintain required staffing ratios.
Failure to administer medications according to physician's orders within prescribed timeframes.
Failure to maintain accurate, complete, and easily accessible medical records including missing discharge summaries and investigations.
Failure to maintain resident environment, equipment, and living areas in a safe, sanitary, and homelike manner.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 2
Residents affected: 4
Residents affected: 3
Residents affected: 2
Census: 91
Nurses: 4
Nurses: 2
Nurses: 0
Nurses: 2
Nurses: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in failure to provide incontinence care and 1:1 monitoring investigation |
| CNA #2 | Certified Nursing Assistant | Named in failure to provide incontinence care and nail care |
| CNA #3 | Certified Nursing Assistant | Named in nail care deficiency |
| CNA #4 | Certified Nursing Assistant | Named in 1:1 monitoring investigation |
| CNA #5 | Certified Nursing Assistant | Named in 1:1 monitoring investigation |
| CNA #6 | Certified Nursing Assistant | Named in 1:1 monitoring investigation |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including abuse investigation, pain management, staffing, and medication administration |
| Licensed Nursing Home Administrator | Administrator | Interviewed regarding multiple deficiencies including medical records, investigations, staffing, and environmental issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding abuse investigation and monitoring |
| Medical Records personnel | Medical Records personnel | Interviewed regarding medical records access and maintenance |
| Registered Nurse | Registered Nurse | Interviewed regarding nail care and abuse investigation |
| Unit Manager/Licensed Practical Nurse | Unit Manager/Licensed Practical Nurse | Interviewed regarding incontinence care and environmental conditions |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing schedules and shortages |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 15
Date: Jun 26, 2024
Visit Reason
The complaint investigation was conducted due to allegations of failure to maintain a safe, clean, and homelike environment, failure to treat justice involved residents with dignity and respect, and other related concerns.
Complaint Details
Complaint NJ #: 159451; 159783; 159539; 162168. The complaint involved issues related to resident environment, dignity and respect for justice involved residents, medication administration, infection control, staffing, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and odor-free environment, failure to ensure dignity and respect for justice involved residents including improper use of restraints and seclusion, inaccurate assessments, medication administration errors, inadequate staffing, failure to act on consultant pharmacist recommendations timely, failure to maintain infection control standards, and failure to implement a sustainable QAPI program.
Deficiencies (15)
Failure to maintain a clean and odor-free environment in resident rooms and common areas.
Failure to ensure justice involved residents were treated with dignity and respect, including improper seclusion and use of physical restraints.
Failure to accurately assess residents' status in Minimum Data Set (MDS) assessments.
Failure to issue required Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms prior to discharge from Medicare Part A services.
Failure to provide adequate incontinence care and nail care for residents.
Failure to develop and revise individualized comprehensive care plans consistent with residents' needs and conditions.
Failure to administer medications in a timely manner and failure to remove discontinued physician orders from active orders.
Failure to maintain accurate inventory and documentation of controlled medications including methadone.
Failure to properly store medications, maintain clean medication storage areas, and properly label opened multidose medications.
Failure to serve residents nourishing snacks when there was more than a fourteen-hour span between dinner and breakfast.
Failure to implement a facility-wide system to monitor antibiotic use and conduct surveillance.
Failure to maintain respiratory equipment and infection control standards during medication administration and staff nail length.
Failure to ensure sufficient nursing staff to meet residents' needs and maintain proper nurse staffing records.
Failure to ensure that registered sex offenders and inmates were included in the facility-wide assessment and QAPI program.
Failure to ensure that the facility's QAPI program was implemented to ensure sustainability with previously cited deficiencies.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 7
Residents affected: 2
Residents affected: 4
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration and methadone inventory findings |
| UM/LPN #1 | Unit Manager/Licensed Practical Nurse | Named in incontinence care and medication administration findings |
| LPN #1 | Licensed Practical Nurse | Named in wound care and medication cart narcotic log findings |
| LPN #2 | Licensed Practical Nurse | Named in wound care and medication cart narcotic log findings |
| DON | Director of Nursing | Named in multiple findings including infection control, medication administration, and QAPI |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings including facility oversight, QAPI, and infection control |
| ADON | Assistant Director of Nursing | Named in infection control and antibiotic stewardship findings |
| CNA #1 | Certified Nursing Assistant | Named in incontinence care findings |
| CNA #2 | Certified Nursing Assistant | Named in incontinence care findings |
| CP | Consultant Pharmacist | Named in medication management and antibiotic stewardship findings |
| DOR | Director of Rehab | Named in rehabilitation and orthotic care findings |
| DA | Director of Activities | Named in activities and resident choice findings |
Inspection Report
Routine
Deficiencies: 18
Date: Oct 20, 2022
Visit Reason
The inspection was a routine survey of Belle Care Nursing and Rehabilitation Center to assess compliance with regulatory requirements related to resident care, medication administration, infection control, facility operations, and quality assurance.
Findings
The survey identified multiple deficiencies including inaccurate documentation of residents' advanced directives, improper use of physical restraints, late and inaccurate completion and submission of Minimum Data Set (MDS) assessments, failure to complete significant change assessments, incomplete PASARR screening, failure to update care plans, medication administration errors, improper medication storage and dating, inadequate dialysis care, infection control lapses, incomplete antibiotic stewardship implementation, inadequate facility-wide assessment for special populations, and incomplete Quality Assurance and Performance Improvement (QAPI) activities.
Deficiencies (18)
Failed to accurately document and clarify a resident's life-sustaining treatment preferences on physician's orders.
Failed to ensure residents were free from physical restraints including use of full side rails without physician orders or assessments.
Failed to complete Comprehensive Minimum Data Set (MDS) assessments in a timely manner for multiple residents.
Failed to complete a significant change in status MDS for a resident recently placed on hospice.
Failed to complete Quarterly MDS assessments in a timely manner for multiple residents.
Failed to electronically submit MDS assessments within 14 days after completion for multiple residents.
Failed to ensure accurate completion of MDS assessments including coding of hospice status and restraint use.
Failed to provide and implement a care plan for a resident on hospice including goals and interventions.
Failed to follow professional standards by allowing staff to use personal blood pressure monitors and administering blood pressure medications without checking vital signs first.
Failed to ensure medications were appropriately dated when opened and lacked a comprehensive policy for dating medications after opening.
Failed to provide safe and appropriate dialysis care including monitoring access site, maintaining communication with dialysis center, following fluid restrictions, and updating care plan.
Failed to accurately complete PASARR screening to include psychiatric diagnoses for referral to appropriate state agencies.
Failed to provide and maintain a hand splint for a resident with decreased range of motion as ordered by therapy and physician.
Failed to maintain infection control standards including proper hand hygiene, safe wound treatment, proper storage of PPE and resident care equipment, and appropriate hand hygiene during medication administration.
Failed to ensure medication error rate was below 5%, with observed errors including administering blood pressure medications without checking vital signs first.
Failed to procure, store, and handle food in a manner to prevent foodborne illness and cross contamination including unlabeled meats, dirty equipment, and improper sanitizer concentrations.
Failed to ensure the Quality Assurance and Performance Improvement (QAPI) program was fully implemented with regular meetings, attendance of required members, and use of quantitative data to identify and address quality deficiencies.
Failed to ensure staff vaccination and mitigation measures were followed to prevent spread of COVID-19 including proper mask use and fit testing for unvaccinated staff.
Report Facts
Medication administration opportunities: 28
Medication administration errors: 2
Medication administration error rate: 7.14
Percentage of residents from correctional facilities or sex offenders: 31.7
Days late for MDS completion: 51
Days late for MDS completion: 67
Days late for MDS completion: 66
Days late for MDS completion: 44
Days late for MDS completion: 94
Days late for MDS completion: 89
Days late for MDS completion: 73
Days late for MDS completion: 68
Days late for MDS completion: 67
Days late for MDS completion: 68
Days late for MDS completion: 61
Days late for MDS completion: 60
Days late for MDS completion: 51
Days late for MDS completion: 24
Days late for MDS completion: 68
Days late for MDS completion: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed medication administration and use of personal blood pressure monitor |
| LPN #2 | Agency Licensed Practical Nurse | Observed medication administration and hand hygiene practices |
| RN/AUM | Registered Nurse/Acting Unit Manager | Observed wound care treatment and discussed care plan and infection control |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including MDS, medication administration, infection control, and QAPI |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding facility assessment, QAPI meetings, PPE storage, and other deficiencies |
| Regional LNHA | Regional Licensed Nursing Home Administrator | Interviewed regarding QAPI meetings, medication dating policy, and PPE storage |
| LPN/IP | Licensed Practical Nurse/Infection Preventionist | Interviewed regarding infection control, antibiotic stewardship, and hand hygiene |
| MD | Medical Director | Interviewed regarding antibiotic stewardship, QAPI meetings, and PPE storage |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed regarding dialysis care and fluid restriction |
| FSD | Food Service Director | Interviewed regarding dietary fluid restriction and COVID-19 vaccination status |
| HRSC | Human Resources Staffing Coordinator | Interviewed regarding COVID-19 vaccination and PPE usage |
| OT | Occupational Therapist | Interviewed regarding splint use and therapy recommendations |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding resident care and splint use |
| CDM | Certified Dietary Manager | Interviewed regarding kitchen food storage and sanitation |
| ALPN #1 | Agency Licensed Practical Nurse | Interviewed regarding dialysis care and communication |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 14, 2020
Visit Reason
The inspection was conducted to investigate complaints related to infection control practices, proper documentation of physician orders for transmission-based precautions, and adherence to PPE protocols in the facility.
Complaint Details
The investigation was complaint-driven focusing on infection control practices and physician order documentation related to transmission-based precautions for residents #223, #273, and #275. The complaint included concerns about PPE use, resident isolation, and staff education on COVID-19.
Findings
The facility failed to properly transcribe and document physician orders for transmission-based precautions for some residents and did not consistently implement appropriate infection prevention and control measures, including proper use of PPE and signage. Staff were observed wearing cloth masks instead of required PPE, reusing goggles without proper policy, and residents on quarantine were not always properly isolated or redirected. Ongoing staff education on COVID-19 was insufficient.
Deficiencies (2)
Failure to properly transcribe and document physician orders for transmission-based precautions for residents #273 and #275.
Failure to provide and implement an effective infection prevention and control program, including improper use of PPE and failure to isolate residents properly.
Report Facts
Residents on transmission-based precautions: 3
Staff education attendance: 63
Quarantine duration: 14
Staff in-service counts: 18
Staff in-service counts: 9
Staff in-service counts: 10
Staff in-service counts: 11
Staff in-service counts: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding PPE use and physician orders for Resident #273 and #275; confirmed lack of physician order for transmission-based precautions for Resident #275. |
| DON | Director of Nursing | Interviewed about physician orders, PPE policies, and staff education; confirmed orders should be telephone orders and acknowledged altered POS. |
| Regional Director/IP | Regional Director/Infection Preventionist | Interviewed about staff awareness of physician orders and PPE use; confirmed cloth masks are not PPE and discussed staff education needs. |
| QA Staff Member | Quality Assurance Staff | Observed wearing only N95 mask and showed surveyor PPE storage and isolation carts. |
| CNA #2 | Certified Nursing Assistant | Interviewed about PPE use and allergies to N95 mask; described PPE worn in isolation rooms. |
| LPN #3 | Licensed Practical Nurse | Interviewed and observed wearing cloth mask with surgical mask underneath; described PPE use for Resident #223. |
| DSS | Director of Social Services | Observed entering isolation rooms wearing only cloth mask; stated lack of education on PPE use. |
| LNHA | Licensed Nursing Home Administrator | Interviewed about PPE use and quarantine policies. |
| CNA #1 | Certified Nursing Assistant | Observed entering isolation room without gloves or face shield; forgot to wear full PPE. |
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