Belle Fountain Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff implemented safe repositioning techniques during incontinence care for one resident (R107) of two residents reviewed for accidents and supervision resulting in R107 falling from the bed and sustaining a dislocated shoulder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 4/26/2026 at 8:51 AM observed residue on the shelving surface of the food storage racks in walk in cooler. An interview with Dietary Manager (DM) H at this time found the shelves are cleaned. When asked how often, DM H indicated weekly or monthly. On 4/26/2026 at 8:53 AM observed the stand mixer with a plastic cover over it. When asked if the mixer is used, DM H indicated yes. Upon removal of the cover, brown buildup was observed accumulated on the upper portion of the mixer above the mixing bowl. DM H stated they would get someone to clean it. On 4/26/2026 at 9:15 AM observed red residue buildup on the inside nozzle of the juice gun. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/26/2026 at 8:32 AM observed an inoperable water fountain in the front entrance of the building lobby indicating possible stagnant water. The electric plug was observed unplugged and hanging. On 04/26/2026 at 10:36 AM observed an inoperable water fountain in the hearth room indicating a possible stagnant line. On 04/26/2026 at 11:06 AM observed a therapy tub in the spa room A hall. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement written comprehensive advance directives (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) for six (R4, R6, R7, R9, R64, and R70) of 14 residents reviewed for advance directives, resulting in the missed opportunity to grant life sustaining or life withholding decisions known by the resident or legal representative.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dignity was maintained for one resident (R38) of one resident reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide age-appropriate meaningful activities for one cognitively intact (R85) of four residents reviewed for activities, resulting in boredom, lack of interest in facility life, and loss of dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate monitoring of antibiotic use for one resident (R64) of five residents reviewed for antibiotic stewardship, resulting in the potential for the resident to experience unnecessary medication side effects or outcomes.

Inspectors wroteThis citation pertains to intake 2581458. Based on observation, interview and record review the facility failed to protect the resident's right to be free from verbal abuse from staff for one resident (R906) out of five residents reviewed for abuse, this failure resulted in the resident experiencing feelings of distress and emotional harm. Findings Include:Review of a Facility Reported Incident dated July 28,2025 revealed an allegation of a staff to resident verbal abuse incident. Record review of R906's electronic medical record revealed admission into the facility on 7/18/25 with a pertinent diagnosis of trochanteric fracture of left femur (thigh). Further review of revealed resident scored 15 out of 15 (intact cognition) on a Brief Interview of Mental Status (BIMS) on 8/4/25. Review of Kardex (Care Notes) dated 8/7/25, R906 required ADL (Activities of Daily Living) assist x1 staff. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure adequate supervision to prevent a fall for one resident (R904) out of three residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned and air dried before stacking; 2. Properly date-label food in the kitchen; 3. Ensure food items past the use-by-date were not stored with active food; 4. Store cartons of milk in a manner to avoid splash from mop water; and 6. Adequately clean the air gap basin. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan for a communication deficit was developed and implemented for one resident (R282) of nineteen residents reviewed for care plans.

Inspectors wroteThis citation pertains to intakes MI00150118 and MI00150053. Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLS) in a timely manner for one resident (R23) of three reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review the facility to ensure the foley catheter bag (bags used to collect urinary drainage from Foley catheters) was not resting on the floor for one (R37) of three residents reviewed for catheter/UTI (urinary tract infection) potentially resulting in the spread of infections and dislodgement.

Inspectors wroteThis citation pertains to intake MI00148212, MI00149641, and MI00149668. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that one (R506) of three residents reviewed for unnecessary medications had a specific diagnosis for use, clinical indications for use, or a valid informed consent for the use of psychotropic medications (drugs that affects brain activities with mental processes and behaviors).

Inspectors wroteThis citation pertains to intake MI00146645. Based on interview and record review, the facility failed to develop or implement a care plan for anticoagulant administration (warfarin, a blood thinner) for two (R801 and R802) of three residents reviewed for care plans resulting in R801 and R802 not having a care plan for monitoring anticoagulation therapy side effects and the potential for healthcare needs to go unmet.

Inspectors wroteThis citation pertains to intake MI00146645. Based on interview and record review, the facility failed to maintain complete and accurate medical records for one (R801) of three residents reviewed for medical records, resulting in R801's INR results not accurately documented or maintained in the resident's Electronic Health Record (EHR) resulting in the potential for an unclear picture of the resident's blood clotting times and health care needs.

Inspectors wroteThis citation pertains to intakes MI00144980 and MI00145055. Based on observation, interview, and record review, the facility failed to ensure expired food was not stored with active food stock resulting in the potential for food borne illness to affect all residents who consume food from the kitchen.

Inspectors wroteThis citation pertains to intakes: MI00144232, MI00144376, MI00144543, and MI00144585. Based on observation, interview, and record review, the facility failed to ensure call lights were answered promptly for four residents (R810, R811, R812, and R805) reviewed for accommodation of needs resulting in various unmet health care needs.

Inspectors wroteThis citation pertains to intake MI0014232. Based on interview and record review the facility failed to ensure information for transfer was communicated to the receiving hospital for one (R802) of two residents reviewed for discharges and transfers resulting in the receiving hospital being potentially unaware of the resident's reason for transfer, current medical treatments or allergies along with the resident's care needs to be unmet.

Inspectors wroteThis citation pertains to intakes: MI00144232, MI00144376, and MI00144868. Based on interview and record review the facility failed to implement fall interventions for three (R802, R807, and R809) of seven residents reviewed for falls resulting in all three residents not having initial fall risk assessments completed in a timely manner and all three residents sustaining falls without injury.

Inspectors wroteThis citation pertains to intake MI00142576. Based on observation, interview, and record review the facility failed to provide rationale, behavioral monitoring, or a physician evaluation for the extended use of a PRN (as needed) psychotropic medication for one (R502) of three residents reviewed for medications.

Inspectors wroteResident 340 (R340) Record review of Resident #340 (R340)'s face sheet revealed admitted to facility on 12/30/23 diagnoses included wedge compression fracture of first lumbar vertebrae, anemia, difficulty in walking. Review of the Minimum Data Set (MDS) dated [DATE] for R340 revealed a Brief Interview for Mental Status (BIMS) of 15/15 intact cognition and required moderate assistance for mobility. Record Review of physician orders dated 12/31/23 revealed Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 6 hours for Pain, Lidocaine 24 Hours External Patch 4 % (Lidocaine) Apply to Lower back topically two times a day for Pain. Record Review of R340's MAR revealed on 12/31/23 and 1/1/24 for Lidocaine 24 Hours External Patch 4 % (Lidocaine) Apply to Lower back topically two times a day for Pain no record of administration. [...]

Inspectors wroteThis citation pertains to intake MI00138960. Based on observation, interview, and record review the facility failed to notify the physician when a prescribed medication (pain patch) was not available for administration for 2 of 6 residents (R77 and R87) reviewed for medication administration, resulting in the physician being unaware of the missed medication and the potential for the resident's pain to go untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure floor stock items (laxative) were not expired and failed to refrigerate unopened Insulin (hormone used to control blood sugar) in one of four medication carts resulting in the potential for decreased effectiveness of the medications.