Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belleville Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to maintain left hand ROM: A resident with intact cognition sustained fractures to the L wrist and fingers after a fall from her wheelchair, then had marked loss of flexion and functional use despite OT orders for gentle ROM and a later restorative ROM program. Documentation showed restorative ROM was inconsistent and then stopped, and the resident was later observed with a contracted hand, unable to self-propel with that hand, and reporting constant pain.
Incomplete Facility Assessment for Staffing and Emergency Needs: The facility failed to complete a thorough facility-wide assessment for resident care resources, staffing, and emergencies. The assessment identified daily nursing hours but did not specify weekend staffing by shift, did not address resident acuity, and lacked a detailed emergency staffing plan. During survey, staff provided a different assessment and confirmed the emergency staffing plan was not detailed.
Missing Qualified Dietary Manager: The facility failed to employ a full-time CDM for residents receiving meals from the kitchen. Dietary Staff BB was observed preparing the noon meal and confirmed she was not a CDM, though she had enrolled in dietary certification classes. Administrative Nurse D also confirmed the staff member lacked dietary manager certification. The facility policy listed CDM, CFPP, Certified Food Service Manager, national food service management and safety certification, or a relevant degree as acceptable qualifications for the dining services manager.
Insufficient dietary staffing delayed meal service and left residents waiting for their noon meal. The DM had the food ready, but staff were not available in the dining room to serve residents until later, and the DM said only one dietary aide was available to handle drinks, tray items, and dishwashing. Two residents also had not received their noon room meal trays, and an admin nurse stated the meal should be served in a timely manner and was unaware the dietary dept was short-staffed.
Uncovered clean linen and resident clothing were observed being transported through the facility on an uncovered laundry cart. Housekeeping staff and an Administrative Nurse confirmed that resident clothing should be covered when taken to rooms, and the facility policy stated clean linens should be delivered on covered carts with the covers down.
A CNA failed to treat a resident with dignity during a meal by saying, "Here is your bib," and placing a clothing protector on the resident while seated in the dining room. The DON stated staff should offer a clothing protector at meals and should not call it a bib. The facility policy requires residents to be treated with respect and dignity and recognized as individuals.
Failure to Accommodate Walker Use in Bathroom: A resident with cellulitis, OA, polyneuropathy, HTN, and frequent pain used a walker for locomotion and required supervision or set-up help for ADLs. Staff failed to ensure her walker could safely fit into the bathroom, and observations showed she had to leave the walker outside the door and use the sink and door frame to toilet and wash her hands. The EMR lacked nursing notes about accommodation of needs or pain, and staff verified that the bathrooms were not safe for her use.
A resident with sepsis, anxiety, seizures, and a history of sudden cardiac arrest had moderately impaired cognition and was dependent on staff for all ADLs. After two hospital transfers, the facility did not provide a bed hold notice to the resident or representative, and consultant verification confirmed the notices were missing. The facility policy required notice of the bed hold policy within 24 hours of transfer.
Failure to revise a resident’s fall care plan after repeated falls. A resident with dementia, anxiety disorder, and a prior CVA had severe cognitive impairment, was dependent on staff for mobility, and was identified as high fall risk. He experienced multiple falls from bed, wheelchair, and in common areas, yet the care plan was not updated with new effective interventions after each event; some entries only added measures such as a fall mat, wheelchair repositioning, non-slip material, or lab work, and one fall note documented no intervention to prevent further falls.
Failure to provide scheduled bathing and hygiene care. A resident with intact cognition, a walker, chronic pain, and ADL assistance needs was supposed to receive showers per preference, but the EMR showed only one shower in 12 days. During observation, the resident had unkempt hair and a urine odor, and she stated she felt dirty and had only had one shower since admission. Staff stated residents were expected to receive showers per preference and more often than once every 12 days.
Failure to provide adequate supervision and fall prevention led to repeated unsafe events for two residents. One resident with impaired mobility, a non-weight-bearing R foot, and a fall risk care plan fell in the shower when her foot slipped on a wet floor; she reported staff would not help her transfer or shower, and staff said she either only observed the shower or that she refused assistance. Another resident with dementia and severe cognitive impairment had multiple falls from bed and wheelchair, pulled out his call light, slid from his chair, and continued unsafe behaviors despite existing care plan interventions and monitoring.
A resident experienced significant unintended weight loss due to the facility's failure to consistently monitor weights, follow the RD's nutritional recommendations, and provide necessary assistance with eating and drinking. The resident, with multiple medical conditions, did not receive adequate protein intake for wound healing, and the care plan directives were not consistently followed, resulting in a 19.5% weight loss over ninety-five days.
A facility failed to implement Enhanced Barrier Precautions during the care of a resident with a wound infection. A Licensed Nurse and a CNA performed a dressing change without donning gowns, as required by the facility's policy for high-contact care. The resident was on EBP due to a wound infection, and the failure to adhere to the policy was confirmed by the staff and Administrative Nurse.
A resident with dementia had her wedding ring misappropriated in an LTC facility. Despite the resident's cognitive impairment and the ring's difficulty to remove, it went missing. The facility conducted a search and involved law enforcement, but the ring was not found. The facility's policies on safeguarding personal property were not effectively implemented, leading to the loss.
A resident with a history of diabetes and a foot infection did not receive proper infection control during wound care. A nurse failed to change gloves after cleansing the wound, contrary to the facility's infection control policy. Both the nurse and administrative staff acknowledged the oversight.
Failure to Maintain Left Hand ROM
Penalty
Summary
The facility failed to provide restorative nursing services to maintain or improve range of motion for a resident with limited mobility of the left hand. The resident had diagnoses including depression and traumatic subdural hematoma, and the quarterly MDS documented intact cognition with a BIMS score of 14. The MDS also documented no range of motion services during the look-back period and no functional limitation in ROM, while the care area assessment identified functional mobility as a care area to address. After the resident fell out of her wheelchair while outside smoking, she sustained fractures of the left wrist and left small finger and was transferred to the hospital. She returned with orders to wear a brace, later changed to a specialized brace that could be removed for ROM and hygiene. Orthopedic follow-up documented the need for gentle finger ROM for three weeks, then gentle wrist ROM. OT evaluation showed a major decline in left wrist, thumb, ring finger, and pinky flexion compared with prior function, and OT documented impairments in dexterity, fine motor coordination, mobility, and strength. OT later discharged the resident and recommended a restorative ROM program. The restorative ROM task was documented for May, June, and July 2025, but the record showed it was performed inconsistently, and no ROM documentation was found for August 2025 before the task was discontinued. When observed in September, the resident’s left hand was contracted, she stated her hand was frozen and she could not move her fingers, she could not self-propel her wheelchair with that hand, and she reported pain in the left hand at all times. The Director of Therapy stated she had placed the resident on a restorative ROM program, while an Administrative Nurse stated she did not know why restorative ROM activities were discontinued.
Incomplete Facility Assessment for Staffing and Emergency Needs
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. The facility identified a census of 48 residents, and the survey sample included 12 residents. On 09/15/25, Administrative Nurse D provided a Facility Assessment updated 04/28/25, which identified required staffing needs per day but did not identify specific staffing needs by shift for weekends, did not identify resident acuity for care needs, and did not provide a detailed emergency staffing plan for emergent situations. During the survey, Consultant HH stated at 03:00 PM that the facility assessment previously given to the survey team was not the correct assessment and provided a new one, stating it was the actual facility assessment. Consultant HH also stated Administrative Nurse D completed the assessment and that anything typed by her would appear in bold black print. At 03:15 PM, Administrative Nurse D stated she did not feel the facility had low weekend staffing and that the assessment included daily nursing hours with increased staff presence during weekdays. On 09/16/25 at 10:00 AM, Administrative Staff A verified the facility assessment did not have a detailed emergency staffing plan. The facility’s undated Facility Assessment and Procedure Policy stated it was the facility’s policy to conduct and document a facility-wide assessment for day-to-day operations, including nights and weekends, and during emergencies.
Missing Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for residents who received meals from the facility kitchen. The facility had a census of 48 residents, and the sample included 12 residents. On 09/15/25 at 11:00 AM, the noon meal was reviewed and consisted of chicken breast with seasoned tomatoes, squash, fortified mashed potatoes, buttered noodles, and cake. Later that morning, at 11:30 AM, Dietary Staff BB was observed in the kitchen preparing the noon meal, and at 10:50 AM she verified that she was not a Certified Dietary Manager and stated that she had enrolled in and started dietary certification classes. On 09/16/25 at 10:07 AM, Administrative Nurse D confirmed that Dietary Staff BB did not have dietary manager certification but had enrolled in and started the dietary certification classes. The facility's Dining Services Manager Roles and Responsibilities Policy stated that the dining services manager should be a Certified Dietary Manager, Certified Food Protection Professional, Certified Food Service Manager, have national certification for food service management and safety, or hold an associate's or higher degree in food service management or hospitality from an accredited institution.
Insufficient Dietary Staffing Delayed Meal Service
Penalty
Summary
The facility failed to provide an adequate number of dietary staff to safely and effectively carry out food and nutrition services for a census of 48 residents. On 09/15/25 at 11:45 AM, the Dietary Manager had tempered the food on the steam table and was ready to serve the noon meal, but several residents were still waiting in the dining room. Staff did not come to the serving window until 12:15 PM, and the Dietary Manager completed serving at 1:00 PM, even though the scheduled noon meal time was 11:30 AM. The Dietary Manager stated she could not begin serving residents in the dining room until staff were available there to serve food, and that only one dietary aide was available to place drinks and other items on trays and also handle dishwashing. On 09/16/25 at 12:55 PM, two residents had not received their noon room meal trays. An Administrative Nurse stated the noon meal should be served in a timely manner and was unaware the dietary department was short-staffed. The facility did not provide a policy regarding dietary staff serving time upon request.
Uncovered Transport of Clean Linen and Clothing
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when clean linen and resident clothing were transported through the facility without being covered. On 09/14/25 at 12:30 PM, Housekeeping Staff U was observed taking an uncovered laundry cart through the facility to the southeast hall with clean resident clothing hanging up and linens on the shelf. On 09/15/25 at 11:55 AM, Housekeeping Staff V verified that staff were to cover residents' personal clothing when transporting it to their room. On 09/15/25 at 01:00 PM, Administrative Nurse D stated staff should cover residents' clothing when taking it through the hall to their room. The facility's Handling Clean Linen policy, dated 06/2025, stated linen could become contaminated from environmental contaminants and that clean linens should be delivered to resident care units on covered carts with the covers down.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to treat Resident 16 with dignity at the dining table when a CNA stated, "Here is your bib," and placed a clothing protector on the resident during the noon meal. The resident was seated in the dining room at the time of the interaction. During interview, the Administrative Nurse stated that staff should offer a resident a clothing protector at meals and should not call it a bib. The facility's Promoting/Maintaining Resident Dignity Policy states that residents are to be treated with respect and dignity and cared for in a manner that maintains or enhances quality of life by recognizing each resident's individuality.
Failure to Accommodate Walker Use in Bathroom
Penalty
Summary
The facility failed to accommodate Resident 31’s needs when her walker would not safely fit into the bathroom after admission. Resident 31’s record documented diagnoses of cellulitis of the lower extremities, osteoarthritis, polyneuropathy, and hypertension. Her admission MDS showed a BIMS score of 14, indicating intact cognition, and that she required supervision or touching/set-up help for all ADLs and used a walker for locomotion. The MDS also documented scheduled and PRN pain medication use, frequent pain that occasionally affected sleep and day-to-day activities, and a pain rating of 7 out of 10. The care area assessments documented that Resident 31 used a walker, had weakness and polyneuropathy that could impair sensation and balance, had chronic daily pain, and took medications that could lead to dizziness and increase fall risk. Her care plan directed staff to assess pain each shift, treat reported pain in a timely manner, anticipate and meet her needs, keep her call light within reach, and respond promptly to requests. However, the EMR lacked nursing notes regarding accommodation of needs or pain. During interview and observation, Resident 31 stated she had been unable to safely use the bathroom because her walker would not fit, so she left it outside the door and used the sink and door frame to get to the toilet and wash her hands. Staff observed the walker not fitting into the bathroom in more than one room, and an administrative staff member verified that neither bathroom was safe for her to use.
Failure to Provide Bed Hold Notice After Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to Resident 4 or her representative upon discharge from the facility. Resident 4’s record documented diagnoses of sepsis, anxiety, seizures, and a history of sudden cardiac arrest, and her Quarterly MDS dated [DATE] showed a BIMS score of 10, indicating moderately impaired cognition, with dependence on staff for all activities of daily living. Her medical record showed she was discharged to a hospital on 03/22/25 and again on 04/02/25, with readmissions to the facility after each hospitalization. The record lacked evidence that a bed hold notice was provided at the time of either discharge. On 09/15/25, Resident 4 was observed in bed with the head of the bed elevated and a gastric tube feeding running at 35 milliliters per hour. On 09/16/25, Consultant HH verified that the facility had not provided bed hold notices for two of Resident 4’s hospital stays. The facility’s Transfer and Discharge policy dated 02/01/20 stated staff were to provide notice of the resident’s bed hold policy to the resident and their representative within 24 hours of transfer.
Failure to Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to review or revise Resident 5’s care plan with new effective interventions after each fall. Resident 5 had diagnoses of anxiety disorder, dementia, and cerebral infarction, and his admission MDS documented a BIMS score of 7, indicating severely impaired cognition. He was dependent on staff for activities of daily living, including mobility, and his fall risk assessment documented that he was at high risk for falling, had a history of falls, and was forgetful of his own safety limits. Resident 5’s fall-related documentation showed repeated incidents over several months, including falls from bed, from his wheelchair, and while in the dining room or lounge. The care plan contained interventions such as educating him on the call light, offering him to lie down after meals, repositioning his bed against the wall, increasing monitoring during confusion, placing his water cup within reach, adding Dycem to his chair, and obtaining labs to evaluate for acute infection. However, after multiple falls, the record did not show new effective interventions being added in response to each event, and one fall note specifically documented no intervention to prevent further falls after the resident slid under the dining room table. The facility’s records also showed that after later falls, interventions were limited to actions such as placing a fall mat by the bed, turning the wheelchair to face staff, adding non-slip material to the wheelchair seat, and obtaining lab work. Administrative Nurse D verified that obtaining lab work was not an immediate fall prevention intervention and that interventions should be directed toward preventing further falls. The facility’s policy stated the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change.
Failure to Provide Scheduled Bathing and Hygiene Care
Penalty
Summary
The facility failed to ensure Resident 31 was showered and bathed according to her preference, twice a week. Resident 31 had diagnoses of cellulitis of the lower extremities, osteoarthritis, polyneuropathy, and hypertension. Her admission MDS documented a BIMS score of 14, indicating intact cognition, and that she required supervision or touching/set-up help for all ADLs and used a walker for locomotion. The MDS also documented scheduled and as-needed pain medication, frequent pain that occasionally affected sleep and day-to-day activities, and a pain rating of 7 out of 10. The Functional Abilities CAA documented that Resident 31 required supervision or light touch for ADLs, used a walker, had weakness and polyneuropathy, and had chronic daily pain. Her care plan, dated 09/04/25, documented moderate/partial assistance with toileting hygiene and bathing, while all other ADLs were listed as supervision or independent; it also directed staff to assess pain each shift and respond promptly to requests. The EMR documented only one shower in the twelve days she had been in the facility. During observation, Resident 31 had unclean, unkempt hair and a distinct odor of urine, and she stated she had only had one shower since admission and felt dirty, unclean, and like she smelled. Staff stated they expected residents to receive showers per preference and more often than once every twelve days.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide a safe environment with adequate supervision to prevent accidents for two residents who were identified as being at risk for falls. One resident had diagnoses including anxiety, arthritis, depression, abnormal gait and mobility, and a chronic non-pressure wound to the right foot. Her MDS documented intact cognition, need for assistance with dressing, bathing, toileting, and shower transfer, and one fall during the lookback period. Her care plan identified her as a fall risk, noted she was non-weight-bearing to the right foot, and directed staff to assist with bathing and transfers, but it did not include interventions for her refusal of help with transfers or showering. That resident fell in the shower area when her left foot slid on the wet floor as she moved herself to her wheelchair. The incident note documented she fell forward to her knees and caught herself on the wheelchair, with bruising to both inner elbows and abrasions to both knees. The fall investigation stated the exhaust fan was off and humidity was seen on the floor, possibly causing a slick surface. During interview, the resident stated staff would not help her transfer, that she was non-weight-bearing on her right foot because of an ulcer, and that she never received help from staff in the shower area. A CNA stated she only observed the resident showering and did not help her with anything in the shower, while an administrative nurse stated the resident refused all staff assistance with transferring or bathing. The second resident had diagnoses including anxiety disorder, dementia, and cerebral infarction, with severely impaired cognition on the MDS and dependence on staff for activities of daily living and mobility. His fall CAA identified him as at risk for falls and directed staff to anticipate and meet his care needs so he would not attempt ADLs without staff assistance. His care plan included interventions such as call light education, lying down after meals, bed positioning, increased monitoring during confusion, placing his water cup within reach, Dycem in his chair, and lab work for acute infection, but the record showed repeated falls and unsafe behaviors continued. The resident had multiple falls and unsafe episodes, including being found on the floor by his bed, leaning forward and falling face first from his wheelchair, sliding out of his chair in the dining room, and being found on the floor beside or in front of his wheelchair on several occasions. He also pulled the call light cord out of the wall, stated he was trying to get up to get something to eat, and at another time said he was trying to pick up his water cup after it fell. Therapy later documented decreased participation, refusals, decreased safety awareness, and noncompliance with interventions. An administrative nurse verified that obtaining lab work was not an immediate fall prevention intervention and that interventions should be directed toward preventing further falls.
Failure to Provide Adequate Nutritional Support Leads to Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional support for a resident, leading to significant unintended weight loss. The resident, who had multiple medical conditions including diabetes mellitus, congestive heart failure, and major depressive disorder, was admitted with a weight of 191 pounds. The facility did not consistently obtain weights to establish a baseline, and the resident's weight was not monitored weekly as required. This lack of monitoring resulted in a failure to identify and respond to the resident's progressive weight loss. The facility also did not follow the Registered Dietician's (RD) recommendations to provide nutritional support. The RD had recommended additional protein intake to aid in wound healing, but this was not ordered or administered until much later. The resident's meal intake records were incomplete, and there was a lack of documentation regarding the resident's food and fluid intake. Observations revealed that the resident often did not receive assistance with eating and drinking, which contributed to the resident's inadequate nutritional intake. Furthermore, the facility's staff did not adhere to the care plan directives, which included ensuring adequate protein intake and providing supplements as needed. The resident's care plan also required regular repositioning to prevent skin breakdown, but this was not consistently documented or followed. The facility's failure to implement these interventions resulted in a 19.5% weight loss over ninety-five days, placing the resident at risk for decreased nourishment and delayed wound healing.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that staff implemented Enhanced Barrier Precautions (EBP) during the high-contact care of a resident with a wound infection. Specifically, on December 17, 2024, a Licensed Nurse (LN) and a Certified Nurse's Aide (CNA) entered the room of a resident with a wound infection to perform a dressing change. Both staff members donned gloves but failed to wear gowns, which are required under EBP for high-contact care activities. The resident, identified as R1, was on EBP due to a wound infection on the buttocks, and the failure to don gowns during the dressing change was acknowledged by both LN G and CNA M after the procedure. The facility's Enhanced Barrier Precautions Policy, dated April 1, 2024, mandates that staff must wear gowns and gloves during high-contact care to prevent the transmission of multi-drug resistant organisms. The policy also requires that personal protective equipment (PPE) be readily available near or outside the resident's room. Despite these guidelines, the staff did not adhere to the policy, as confirmed by Administrative Nurse D, who verified that R1 was on EBP and that the staff should have donned gowns. This oversight placed the resident at risk for infectious diseases.
Resident's Wedding Ring Misappropriated
Penalty
Summary
The facility failed to protect a resident, identified as R2, from the misappropriation of her personal property, specifically her wedding ring. R2, who had diagnoses including dementia and moderately impaired cognition, valued her personal belongings and required supervision for various activities. Despite these needs, the facility did not adequately safeguard her wedding ring, which was reported missing. The ring was known to be difficult to remove due to the size of R2's knuckle, suggesting it could not have fallen off accidentally. The incident was reported when staff noticed the ring was missing from R2's finger. R2 mentioned that someone had sprayed something on her finger and taken the ring, but she could not recall who or when this occurred. The facility conducted a search of R2's room, her roommate's belongings, and common areas, but the ring was not found. Staff interviews and witness statements were collected, and local law enforcement was notified. Despite these efforts, the ring remained missing, and the facility's investigation did not identify the perpetrator. The facility's policies on personal property and residents' rights to freedom from abuse, neglect, and exploitation were not effectively implemented to prevent the misappropriation. The facility's failure to ensure the security of R2's wedding ring, despite previous suggestions to the family to remove or secure valuable items, resulted in the loss of the ring and placed R2 at risk for further property loss and psychosocial decline.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to ensure adequate infection control measures during wound care for a resident with a recent infection in her right foot wound. The resident had a medical history that included diabetes mellitus, anxiety, depression, hypertension, an open lesion, and cellulitis of the foot. The care plan directed staff to observe and assess the resident's skin weekly and follow facility protocols for treatment of injury. The physician's order specified cleansing the open lesion with Hibiclens and water, applying Triple Antibiotic Ointment, and dressing the wound daily. During an observation, a licensed nurse sanitized her hands, donned a clean gown and gloves, and removed the soiled dressing from the resident's foot. After taking pictures of the wound, the nurse cleansed the wound but failed to change her gloves before applying the antibiotic ointment and dressing the wound. Both the licensed nurse and the administrative nurse acknowledged that the gloves should have been changed after cleansing the wound. The facility's infection control policy required hand hygiene before and after changing a dressing, which was not adhered to in this instance.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Home Inc | 17 mi | ★★★★★ | 0 | 0 |
| Park Villa | 19.7 mi | ★★★★★ | 14 | 0 |
| Parkview Haven Nursing Home | 22.7 mi | ★★★★★ | 0 | 0 |
| Blue Valley Lutheran Nursing Home | 23.9 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Superior | 27.4 mi | ★★★★★ | 0 | 0 |
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