Belle Grande Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Belle Grande Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 1, 2023

  Based on record reviews, observations, and interviews, the facility failed to ensure cognitively impaired residents who were wanderers, and at risk for elopement were adequately supervised and not allowed to exit the building without staff knowledge, for 3 (#1, #2, and #3) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility failed to: 1. Ensure Resident #1 who was severely impaired cognitively, and required supervision, was accurately assessed for a risk of elopement. Resident #1 exited the facility unsupervised on 01/07/2023 and eloped to a local pharmacy; 2. […]

• Immediate jeopardy, patternF835Feb 1, 2023

  Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 3 Residents (#1, #2 and #3) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility failed to: 1. Have an effective system in place to ensure Residents (#1, #2, and #3) who were known to require supervision, were wanderers, and were assessed as being at risk for elopement and/or wore a wander alert bracelet, were adequately supervised to prevent them from exiting the building without supervision; 2. Ensure staff were effectively trained and competent in supervising Residents (#1, #2, #3) who were identified as wanderers and were at risk for elopement; and 3. […]

• Immediate jeopardy, isolatedF689Apr 9, 2025

  Based on observations, interviews, and record review the facility failed to ensure a resident remained free from falls, by failing to ensure proper practices were followed while using a lift during a transfer for 1 (#1) of 2 (#1 and #2) sampled residents reviewed for incidents and accidents. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 03/27/2025 at 1:57 p.m., when Resident #1 fell from a mechanical lift onto the floor while being transferred by S3 CNA and S4 CNA. Resident #1 sustained a complete displacement fracture of the proximal left femur, and a subarachnoid hemorrhage as a result of the fall. […]

• Actual harm, isolatedF600Mar 14, 2023

  Based on interview and record review the facility failed to ensure residents' rights to be free from physical and psychosocial abuse. The facility failed to ensure 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents was not physically abused by S4 CNA. This deficient practice resulted in an Actual Harm for Resident #5 that began on 02/01/2023, when S4 CNA struck Resident #5, a severely cognitively impaired Resident, multiple times with an electronic bed remote and a white, plastic coat hanger. Resident #5 experienced psychosocial harm in that he reported not feeling safe, a worsening fear of being hurt again, and increased anxiety resulting in an increase in Ativan (an anti-anxiety medication). […]

• Actual harm, isolatedF689Apr 23, 2021

  Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 (#73) of 3 sampled residents (#18, #41, and #73) who required the use of a self-releasing seat belt while up in a wheelchair. This deficient practice resulted in an actual harm for resident #73, a cognitively impaired resident with a language barrier, on 03/24/2021 at approximately 3:00 p.m., when S3 PT returned the resident to her room from therapy without a self-releasing seat belt in place, and instructed the resident not to get out of her wheelchair. S3 PT left the resident alone in her wheelchair, and resident #73 fell to the floor while attempting to get out of her wheelchair. […]