Belle Maison Nursing & Rehabilitation Center, LLC

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were properly stored in 2 (Medication Cart 1 and Medication Storage room [ROOM NUMBER]) of 4 medication carts/storage rooms observed for medication storage.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store foods under sanitary conditions. The facility failed to ensure Food items were dated after opening. This deficient practice had the potential to affect 116 residents who were provided meals from the facility's kitchen.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure:1. Staff utilized proper Personal Protective Equipment (PPE) while providing care for 3 (#1, #56, and #70) of 4 sampled residents observed on Enhanced Barrier Precautions (EBP).2. Staff followed proper glove usage and perineal wipe supply management to prevent cross contamination for 1 (#2) of 3 residents observed during incontinence and perineal care. Review of the facility's policy titled Enhanced Barrier Precautions dated 08/2024 revealed the following, in part:Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevention of infection. The facility failed to timely complete pressure ulcer dressing change as needed for wound dressing soilage for 1 (#2) of 2 residents who were observed for wound care.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure free water flushes were administered per physician's orders for 2 (#1 and #75) of 2 residents reviewed for tube feedings. Review of the facility's undated policy titled Gastrostomy Tube revealed in part, the following:1. Flush tube as ordered by doctor. Resident #1Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status. Review of Resident #1's current physician orders revealed in part, the following:Every shift, flush tube with 40 mL of free water an hour. An observation was made on 06/08/2026 at 9:15 a.m. of Resident #1's tube feeding pump. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff completely and accurately documented resident tube feeding administration and monitoring per physician orders for 1 (#2) of 26 sampled residents' MARs reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop a comprehensive person centered care plan, which addressed the type of feeding assistance needed for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for comprehensive person centered care plans. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Sequelae of Cerebral Infarction, Dysphagia, Need for Assistance with Personal Care, Specified Forms of Tremor, Hereditary and Idiopathic Neuropathy, and Muscle Weakness. Review of Resident #1's most recent comprehensive person centered care plan revealed no documented evidence of feeding assistance interventions. An observation was made on 09/03/2025 at 8:32 a.m. of S3CNA providing feeding assistance to Resident #1. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate documentation for 2 (#66 and #122) of 22 (#1, #2, #3, #5, #7, #8, #10, #11, #32, #37, #44, #48, #50, #51, #58, #62, #68, #72, #75, #96, #97, and #113) sampled residents. The facility failed to ensure:1. Resident #66's oxygen use was accurately documented; and2. Resident #122's death note was accurately documented.1. Review of Resident #66’s clinical record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Dementia. Review of Resident #66’s Physician Orders revealed in part, the following: [DATE] Check Oxygen (O2) saturation routinely, every shift Notify Medical Doctor (MD) if less than 90%. Review of Resident #66’s [DATE]-[DATE] Medication Administration Record (MAR) revealed in part, the following: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable infection by failing to ensure staff performed appropriate infection control practices during and after incontinence care for 1 (#5) of 1 (#5) resident observed for catheter care.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, and #3) residents reviewed.

Inspectors wroteBased on observations and interview, the facility failed to store, prepare, and distribute foods in accordance with professional standards for food service safety. There were 108 residents who received meals prepared by the kitchen. On 07/08/2024 at 8:15 a.m., an observation was conducted of the kitchen meal prep area. Lemon pepper seasonings, 28 ounces, was found to be open and unlabeled. The following items were found to be open, unsealed and unlabeled: 25 lbs. bag of lima beans 25 lbs. bag of flour 25 lbs. bag of panko crumbs 5 lbs. bag of white rice 6 lbs. box tea bags On 07/08/2024 at 8:20 a.m., an observation was conducted of the walk in cooler with the following items opened and unlabeled: 1 gallon container of slaw dressing 1 gallon container of mayonnaise 1 gallon container of salad dressing On 07/08/2024 at 8:30 a.m., an interview was conducted with S5DM. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 4 (#38, #45, #62 and #119) residents out of a total of 24 sampled residents. The facility failed to ensure: 1. Resident #38 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #45 was coded correctly for anxiety; 3. Resident #62 was coded correctly for hospice; and 4. Resident #119 was correctly for discharge.

Inspectors wroteBased on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#9 and #27) of 6 (#9, #20, #27, #45, #69 and #71) residents reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#108) of 4 (#27, #65, #75, and #108) residents reviewed for falls.

Inspectors wroteBased on record review and interviews the facility failed to ensure the resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#108) out of 4 (#27, #65, #75, and #108) residents reviewed for falls.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice and the resident's preferences for 1 of 1 (#56) residents sampled for dialysis services. The facility failed to ensure staff maintained ongoing communication with the dialysis center to ensure Resident #56 received meals during dialysis treatments.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data, including resident census, total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 116 residents residing in the facility.

Inspectors wroteBased on record review, observations, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 114 residents who were served meals from the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a resident's privacy and dignity by staff failing to close privacy curtains while care was being performed for 1 (#2) of 2 (#2 and R1) residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced appropriate infection control practices, hand hygiene, and proper glove use for 2 (#2 and R1) of 2 (#2 and R1) residents observed for incontinence care.