Belle Grande Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure a resident's right to receive mail by not delivering mail to residents on Saturdays. This has the potential to affect all 96 residents residing in the facility. Findings:Review of an undated facility policy on 09/23/2025 at 4:23 p.m. titled, Resident Rights revealed the following in part .Resident Rights: The resident has a right to a dignified existences, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident including: (i) Mail: The resident has the right to privacy in written communications, including the right to 1. Send and promptly received mail.On 09/22/2025 at 1:30 p.m., the Resident Council Meeting was conducted and revealed that the residents did not receive mail on Saturdays. All residents in attendance agreed they were told they should wait until Monday to receive the mail delivered on a Saturday. The Resident Council agreed they would like their mail delivered on Saturdays and not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews the facility failed to ensure each resident's environment remained free of accident hazards. The facility failed to ensure hot water temperatures did not exceed 120 degrees for 15 (Bathroom A, Bathroom B, Bathroom C, Bathroom D, Bathroom E, Bathroom F, Bathroom G, Bathroom H, Bathroom I, Bathroom J, Bathroom K, Bathroom L, Bathroom M, Bathroom N, and Shower Room Z) resident bathroom/shower rooms. Findings: Review of the facility's undated policy titled General Policies read in part.Maintenance Services: 1. Maintaining the building in compliance with current federal, state and local laws, regulations and guidelines. Review of the facility's water temperature log by S3 Maintenance Supervisor revealed no water temperature greater than 120 degrees for the 06/2025, 07/2025, 08/2025 and 09/2025 water temperature logs. Observation on 09/22/2025 at 10:25 a.m. revealed Bathroom I's hot water temperature in the bathroom sink felt hot to touch. Observation on 09/22/2025 at 10:29 a.m., S10 Maintenance Supervisor checked Bathroom I's sink hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#13) of 1 (#13) resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility. The facility reported 1 resident currently received dialysis.Findings: Review of Resident #13's medical record revealed an admit date of 07/01/2025 with diagnoses that included, but were not limited to, Dependent on Renal Dialysis, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease. Review of Resident #13's physician's orders revealed an order for resident to attend dialysis on Monday, Wednesday, and Friday. Review of Resident #13's Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. Review of Resident #13's medical chart revealed the most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the Facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 96 Residents who received food prepared by the kitchen.Findings: Review of a policy titled Food storage and Labeling, with a revision date of 05/2023 read in part ,Policy: The facility will store and label all foods to ensure safety and quality.Procedures:1. All temperature controlled foods and ready-to-eat foods that are prepared in the facility shall be labeled with the food name and date.7. Food will be stored in containers that are sealable, leak proof, durable and undamaged. Observation on 09/22/2025 at 8:40 a.m. of the walk in freezer/cooler revealed:1. 1 bag of lettuce, undated.2. 1 box of garlic bread open to air. 3. 2 plastic pitchers of lemonade open and undated.4. 1 plastic pitcher of Gatorade open and undated.Interview at the time of observation with S3 Dietary Manager revealed the staff who opens a food item should label and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care and oral care for 1 (Resident #54) of 1 residents reviewed for ADLs. Total sample size was 29.Findings: Review of the undated facility policy titled: Nail Management revealed in part: Policy: Nail management is the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Essential points: When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident. Review of Resident #54's clinical record revealed an admit date of 05/02/2023 with diagnoses that included in part: Dysphagia following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure nursing staff were competent to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 (Resident #13) of 1 resident reviewed for dialysis. The facility failed to ensure nursing staff were competent in assessing Resident #13's dialysis access site, as ordered. The facility only had one resident receiving dialysis.Findings:Review of an undated facility policy titled Fistula Maintenance: Post Dialysis Care on 09/23/2025 at 11:23 a.m. revealed in part.Policy: to provide appropriate assessment, care and treatment of the vascular access post dialysis. Procedure: A. General Care for Fistulas: 1. Check for a pulse (bruit or thrill) at lease every day. Put your finger over the access site to feel the pulse. If you do not feel or hear a thrill, call the dialysis unit immediately because it may be clotted. Review of Resident #13's medical record revealed an admit date of 07/01/2025 with diagnoses that included in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to administer the Influenza Vaccine on admit to the facility for 1 (#24) of 5 (#1 #3 # 4 # 8 #24) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations.Findings: Review of the facility's undated policy titled Vaccine: Influenza read in part.Policy: All residents of the facility will be offered the influenza vaccine annually to encourage and promote the benefits associated with immunizations against influenza. Review of Resident #24's clinical record revealed an admission date of 10/30/2024 with diagnoses that included: Primary Generalized Osteoarthritis, Major Depressive Disorder, Alzheimer's Disease, Dementia, and Malignant Neoplasm of Lower Lobe Left Bronchus or Lung. Review of Resident #24's medical record revealed no evidence that she had received the Influenza vaccine in 2024 or 2025. Review of Resident #24's admission records revealed a consent form dated 10/30/2024 consenting to the Influenza vaccine. Interview on 09/24/2025 at 10:55 a.m. with S2 DON confirmed that Resident #24's responsible party had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to provide incontinence care for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Record review revealed Resident #2 was admitted on [DATE] with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Muscle Wasting and Atrophy, Overactive Bladder, and Lack of Coordination. Review of Resident #2's Significant Change Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 02/21/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score was not conducted as resident was rarely or never understood. The resident was dependent for toileting hygiene. Toilet transfer was not attempted due to the resident's medical condition or safety concerns. Resident #2 was always incontinent of urine. Review of Resident #2's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the Facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Findings: Review of the facility policy titled: Storage: Freezer with no review date revealed in part .Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. Observation on 07/29/2024 at 8:30 a.m. of the walk in freezer/cooler revealed: 1. 1 box of corn dogs open to air and undated. 2. 1 bag of biscuits open to air. 3. 1 bag of squash open to air and undated. 4. 1 bag of breadsticks open to air. Interview at the time of observation with S4 DM revealed the staff who opens a food item should label and date it and store it properly. S4 DM confirmed: The above listed items were not dated and were opened to air.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development of communicable diseases and infections by failing to: 1. Ensure the use of Enhanced Barrier Precautions (EBP) was communicated to staff for 4 (#6, #28, #80, and #283) of 4 (#6, #28, #80, and #283) Residents reviewed for Enhanced Barrier Precautions; and 2. Perform proper hand hygiene during wound care for 1 (#283) of 2 (#6 and #283) residents reviewed Findings: 1. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) Information And Plan with no date, revealed the following, in part: 1. Residents who will be affected by Enhanced Barrier Precautions (EBP) guidelines include residents who have the following: .chronic wound requiring a dressing regardless of the MDRO status .7. CMS has published an Enhanced barrier Precautions (EBP) sign for providers and staff to be aware of who should be on these precautions. Please place this sign on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#56) of 1 sampled Resident with MDS record over 120 days old. Findings: Review of the clinical record for Resident #56 revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Essential Hypertension, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #56's Quarterly MDS Assessment with ARD of 06/26/2024 revealed the assessment had been completed. Review of the facility's MDS transmission reports revealed Resident #56's Quarterly Assessment with ARD of 06/26/2024 had been transmitted on 07/31/2024. Interview on 07/31/2024 at 8:51 a.m. with S6 LPN/MDS Nurse revealed she forgot to notify the ADON to close and transmit the 06/26/2024 Quarterly MDS. S6 LPN/MDS Nurse confirmed the Quarterly MDS assessment had not been transmitted timely and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADL's (Activities of Daily Living) received the necessary services to maintain good grooming for 1(Resident #62) of 2 (Resident #38 and Resident #62) Residents reviewed for ADL's. The facility failed to ensure Resident #62 received a shave. The total Sample Size was 38. Findings: Review of the facility policy titled: Hygiene and Grooming with no review date read in part . Policy: Staff will provide resident with whatever assistance is necessary to keep their facial hair properly groomed. Review of Resident #62's Electronic Health Record revealed Resident #62 was admitted to the facility on [DATE]. Resident #62 had diagnoses that included in part .Acquired Absence of Left Leg, Cognitive Communication Deficit, Phantom Limb Pain and Dementia. Review of Resident #62's Quarterly MDS with ARD of 05/21/2024 revealed Resident #62 had a BIMS score of 8 (moderately impaired cognition). Resident #62…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure resident care equipment was kept clean for 1 (#61) of 3 residents (#17, #61 and #77) reviewed for tube feeding. There was a total of 12 residents in the facility who received tube feedings. The total sample was 25 residents. Findings: Review of Resident #61's Physician Orders dated 06/2023 revealed an order for Glucerna 1.5 at 50 ml/hour continuous feeding via pump. Observation on 06/12/2023 at 9:15 a.m. revealed Resident #61's feeding pump was in use and noted to be dirty with sticky tan colored substance. Observation on 06/12/2023 at 11:57 a.m. revealed Resident #61's feeding pump was in use and noted to remain soiled with sticky tan substance. Observation on 06/13/2023 at 8:37 a.m. revealed Resident #61's feeding pump was in use and remained soiled with yellow/tan sticky substances. Observation on 06/13/2023 at 11:45 a.m. revealed Resident #61's feeding pump was in use and remained soiled with yellow/tan sticky substance. Interview with S2 RN on 06/13/2023 at 3:48 p.m. revealed that nurses and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to implement the plan of care to meet the needs of 1 (#33) out of a total of 25 sampled residents by failing to assist resident with meals and provide Ensure with meals as ordered by the physician. Findings: Review of Resident #33's Electronic Health Record revealed an admit date of 05/05/2017 with diagnoses that included in part .Moderate Protein-Calorie Malnutrition, Abnormal Weight Loss, Personal History of Traumatic Brain Injury and Flaccid Hemiplegia affecting Left Non-dominant Side. Review of Resident #33's Quarterly MDS with ARD of 01/27/2023 revealed Resident had a BIMS score of 3 (severely impaired cognition). Resident required extensive assistance, by two person physical assist with bed mobility, transfers, toileting, and 1 person physical assist with dressing, eating, and personal hygiene. Resident had upper and lower extremity range of motion impairment on left side. Resident required a mechanically altered, therapeutic diet. Review of Resident #33's Care Plan Review revealed in part . Potential for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.