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 Belle Grande Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident mail was not being delivered on Saturdays. Residents reported they were told to wait until Monday for mail that arrived over the weekend, and staff confirmed Saturday mail was stored until Monday instead of being distributed. The ADM stated she expected residents to receive their personal mail on Saturdays and was unaware it was being held.
Excessive hot water temperatures were found in multiple resident bathroom sinks and one shower room, with readings above 120 degrees F in several areas and one sink reaching 129.3 degrees F. The Maintenance Supervisor stated the water heaters were set at 130 degrees F to prevent legionella and confirmed the temperatures were above the allowed limit, while the ADM denied any scalding, burns, or complaints.
Dialysis Communication Binder Not Completed for Scheduled Treatments: A resident with ESRD and an order for dialysis 3 times weekly did not have dialysis communication sheets completed for most of the month. The binder was usually sent with the resident to dialysis, but sometimes was not, and an LPN stated vital signs were taken before and after dialysis but not documented on the sheet. The DON confirmed only 2 communication sheets were in the binder despite the resident's regular dialysis schedule.
Improper Food Storage and Labeling: Surveyors observed undated lettuce, open garlic bread, and open, undated pitchers of lemonade and Gatorade in the walk-in freezer/cooler. The facility policy required prepared and ready-to-eat foods to be labeled with the food name and date and stored in sealable, leak proof containers, and the Dietary Manager confirmed the items were not dated and should not have been open to air.
Failure to Provide Needed Oral and Nail Care: A resident with CVA-related hemiplegia, dysphagia, impaired cognition, and dependence for oral hygiene and personal hygiene was observed with dirty fingernails and foul-smelling breath on multiple occasions. The resident denied refusing care and stated staff had not brushed his teeth or cleaned his nails, while records showed oral care was documented only intermittently. Staff, including a CNA, LPN, and the DON, confirmed the resident should have received oral care and nail care and that it had not been completed or documented appropriately.
Incompetent Dialysis Access Assessment: A resident receiving dialysis had a physician order for the access site to be monitored for bruit and thrill every shift, but an LPN did not correctly assess the shunt. The facility policy required checking for a bruit or thrill, yet the LPN stated she felt for a pulse and checked the wrist pulse instead of using a stethoscope for bruit, and the DON acknowledged the assessment was not done correctly.
A resident was not given the Influenza vaccine after admission, despite a consent form signed by the responsible party during admission paperwork. The resident had diagnoses including OA, MDD, Alzheimer's disease, dementia, and lung cancer, and the DON confirmed the vaccine had not been administered since admission.
A resident with multiple comorbidities who required a two-person assist and a specific sling size for transfers fell from a mechanical lift when staff used the wrong size sling and failed to attach the sling loops correctly. This resulted in the resident sustaining a femur fracture and subarachnoid hemorrhage.
A resident with multiple medical conditions and total dependence for toileting did not receive incontinence care for approximately eight hours, despite physician orders and a care plan requiring checks and care at least every two hours. Facility records and interviews confirmed that two CNAs failed to provide the necessary care during their shifts, and the DON verified the lapse in required services.
The facility was found to have improperly stored food items in the walk-in freezer/cooler, including corn dogs, biscuits, squash, and breadsticks, which were open to air and undated. This was against the facility's policy requiring all frozen foods to be tightly wrapped or packaged. S4 DM confirmed that staff should label, date, and store opened food items properly, which was not done in this instance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds, as there was no signage or PPE outside their rooms. Additionally, an LPN did not follow proper hand hygiene protocols during wound care, using the same gloves for different wounds. These deficiencies indicate a lack of adherence to infection control policies.
A facility failed to transmit a resident's MDS Assessment within the required 14 days. The resident, with conditions including Cerebral Infarction and Hemiplegia, had a completed Quarterly MDS Assessment that was not transmitted until over a month later. An LPN/MDS Nurse acknowledged forgetting to notify the ADON to close and transmit the assessment, resulting in the delay.
A resident with dementia and an above-the-knee amputation did not receive necessary grooming assistance, specifically shaving, despite requiring substantial help with ADLs. The resident was observed with long facial hair, and staff interviews confirmed the oversight, with CNAs responsible for ADL care and nurses for monitoring.
Resident Mail Not Delivered on Saturdays
Penalty
Summary
The facility failed to ensure a resident's right to receive mail by not delivering mail to residents on Saturdays. Review of the facility's Resident Rights policy stated that residents have the right to privacy in written communications, including the right to send and promptly receive mail. During the Resident Council Meeting, residents stated they did not receive mail on Saturdays and were told to wait until Monday to receive mail delivered on Saturday. The residents in attendance agreed they wanted their mail delivered on Saturdays rather than delayed until Monday. Interviews confirmed the facility's weekend mail process. The [NAME] Clerk/CNA stated the mailman delivers mail to the front desk on Saturday, where it is placed in a basket behind the desk and stored until Monday. The HR staff member stated the mail delivered on Saturday is stored safely until Monday and then reviewed and distributed by her and the Business Office Manager, and she was not aware of any Saturday distribution process. The Administrator stated she expected resident mail received on Saturday to be delivered to residents and was unaware the [NAME] Clerk was not distributing it on Saturdays.
Excessive Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure resident bathroom and shower room water temperatures remained free from accident hazards. Review of the facility’s water temperature logs showed no temperatures greater than 120 degrees for the 06/2025, 07/2025, 08/2025, and 09/2025 logs, but direct observations on 09/22/2025 found multiple resident bathroom sinks and one shower room with hot water temperatures above 120 degrees. Observed temperatures included Bathroom A at 125.2 degrees F, Bathroom B at 121.2 degrees F, Bathroom C at 124.4 degrees F, Bathroom D at 125.3 degrees F, Bathroom E at 122.4 degrees F, Bathroom F at 122.6 degrees F, Bathroom G at 124.0 degrees F, Bathroom H at 124.4 degrees F, Bathroom I at 129.3 degrees F, Bathroom J at 123.6 degrees F, Bathroom K at 122.0 degrees F, Bathroom L at 126.0 degrees F, Bathroom M at 124.3 degrees F, Bathroom N at 124.7 degrees F, Bathroom O at 124.8 degrees F, Bathroom P at 122.5 degrees F, and Shower Room Z at 125.3 degrees F. The Maintenance Supervisor stated the three hot water heaters were set at 130 degrees to prevent legionella and confirmed the temperatures were above 120 degrees and should not have been. The Administrator denied any scalding, burns, or complaints and stated the water temperatures would be lowered that day.
Dialysis Communication Binder Not Completed for Scheduled Treatments
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident who required dialysis by not communicating and collaborating with the dialysis facility. Resident #13 was admitted on 07/01/2025 with diagnoses including dependent on renal dialysis, hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease/end stage renal disease. The resident had an order to attend dialysis on Monday, Wednesday, and Friday, and the MDS showed a BIMS score of 15, indicating intact cognition. Review of the medical chart showed the most recent dialysis communication sheets in the chart were dated 09/22/2025 and 09/23/2025. Observation of the dialysis daily communication binder on 09/23/2025 revealed one incomplete dialysis communication sheet for 09/22/2025 and one completed sheet for 09/23/2025, with no other dialysis communication sheets completed for the month of September 2025. An LPN stated the binder is usually sent with the resident to dialysis but sometimes does not get sent, and that she took the resident's vital signs before and after dialysis but did not document them on the dialysis communication sheet. The DON confirmed there were only 2 communication sheets in the binder for September and acknowledged the resident went to dialysis three times weekly, with no sheets for the rest of the month's dialysis visits.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to maintain a clean, sanitary environment and to ensure food was served in accordance with professional standards for food service safety. During observation of the walk-in freezer/cooler, surveyors found 1 bag of lettuce that was undated, 1 box of garlic bread open to air, 2 plastic pitchers of lemonade open and undated, and 1 plastic pitcher of Gatorade open and undated. The facility policy titled Food storage and Labeling stated that temperature controlled foods and ready-to-eat foods prepared in the facility must be labeled with the food name and date, and that food must be stored in sealable, leak proof, durable, and undamaged containers. The Dietary Manager stated that staff who open a food item should label and date it and store it properly, and confirmed that the observed items were not dated and should have been, and that the items open to air should not have been.
Failure to Provide Needed Oral and Nail Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform ADLs received the necessary assistance to maintain grooming and personal hygiene. Resident #54 had diagnoses including dysphagia following cerebral infarction, neurogenic bowel, generalized muscle weakness and wasting, right-sided hemiplegia and hemiparesis following cerebral infarction, and major depressive disorder. The resident’s MDS showed moderately impaired cognition, dependence for oral hygiene, substantial to maximal assistance with personal hygiene, and a PEG tube. The care plan directed staff to provide person-centered care for bathing, hygiene, dressing, and grooming, including cleaning and trimming fingernails weekly and assisting with bathing on schedule. Observation and interview showed Resident #54 with dirty brown substance on both fingernails and a foul odor from the mouth on multiple occasions. The resident stated he did not refuse care, denied that anyone had cleaned his fingernails or brushed his teeth, and said he would like them cleaned. Facility task records showed oral care was documented only on a few dates during the review period. Staff interviews confirmed that bathing included nail care, that the resident’s nails should have been cleaned after the shower, and that oral care should have been provided daily and documented appropriately. The DON also confirmed that the resident’s fingernails should have been cleaned after the shower and oral care should have been performed and documented, but had not been.
Incompetent Dialysis Access Assessment
Penalty
Summary
Nursing staff were not competent to provide care for a resident receiving dialysis, as the facility failed to ensure the resident's dialysis access site was assessed for bruit and thrill as ordered. The facility had only one resident receiving dialysis. The resident was admitted with diagnoses including dependence on renal dialysis, hypertensive heart and chronic kidney disease with heart failure, and end stage renal disease. The resident's MDS showed a BIMS score of 15, indicating intact cognition. A physician's order dated 07/01/2025 directed staff to monitor the dialysis access site for bruit and thrill every shift. The facility policy titled Fistula Maintenance: Post Dialysis Care stated that the access site should be checked daily for a bruit or thrill and that if neither is felt or heard, the dialysis unit should be called immediately because the access may be clotted. During interview, an LPN stated she checked the shunt by feeling for a pulse and checking the wrist for a pulse, and said she did not usually use a stethoscope to check bruit. The DON acknowledged the LPN did not correctly check the thrill and bruit on the resident's dialysis shunt, but should have.
Failure to Administer Influenza Vaccine After Admission Consent
Penalty
Summary
The facility failed to administer the Influenza vaccine on admission for Resident #24, one of five residents sampled for Influenza, Pneumococcal, and COVID-19 immunizations. Resident #24 was admitted on 10/30/2024 with diagnoses including Primary Generalized Osteoarthritis, Major Depressive Disorder, Alzheimer's Disease, Dementia, and Malignant Neoplasm of the Lower Lobe Left Bronchus or Lung. Review of the resident's medical record showed no evidence that the Influenza vaccine was received in 2024 or 2025. The admission record included a consent form dated 10/30/2024 indicating the responsible party consented to the Influenza vaccine, and the DON confirmed in interview that the resident had not been administered the vaccine since admission.
Failure to Follow Lift Transfer Protocols Results in Resident Fall and Serious Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure proper practices were followed during a mechanical lift transfer, resulting in a resident falling from the lift. The resident, who had multiple diagnoses including schizoaffective disorder, bipolar disorder, diabetes mellitus, muscle wasting with atrophy, and Parkinson's disease, was dependent on staff for transfers and required a two-person assist with a specific size and color of sling as indicated on her care plan and wall care sheet. Despite these clear instructions, staff used a sling that was the wrong size and did not attach the sling loops correctly to the lift, with one strap being hooked in a different loop position than the others. On the day of the incident, two CNAs were responsible for transferring the resident using the mechanical lift. The sling used was a large, blue-trimmed pad instead of the required medium, red-trimmed pad. The top right strap of the sling was attached to a higher notch, while the other three straps were attached to the lowest level, closest to the pad. Staff involved in the transfer admitted to not checking the care sheet for the correct sling size and instead used the sling that was already in the room. Both CNAs had previously received training and check-offs on proper lift use, sling size selection, and correct attachment procedures, but failed to follow these protocols during the transfer. As a result of these failures, the resident fell from the lift, sustaining a complete displacement fracture of the proximal left femur and a subarachnoid hemorrhage. The incident was witnessed by other staff, and immediate first aid was provided before the resident was sent to the hospital. The facility's investigation confirmed that the wrong sling size was used and the sling was not properly attached, directly leading to the resident's fall and injuries.
Removal Plan
- The administrative team in-serviced all CNAs and nurses on proper lift technique and correct sling use.
- The administrative nursing team checked-off all CNAs and nurses on the lift and slings, using return demonstration technique.
- All lifts were inspected by the assistant administrators to ensure they were in safe working order.
- S3 CNA and S4 CNA received individual counseling and in-service. Skills check-off was completed, with follow-up questions, to ensure complete understanding.
- S3 CNA and S4 CNA were to ensure a nurse was present during any transfer of a resident with a lift. The nurse completed a check-off sheet, documenting use of the correct sling size and correct connection of the sling to the lift.
- S2 ADON ensured all residents requiring use of the Vander-Lift had the correct sling size indicated on the care sheet in their room. The size/color of sling to be used was added to each order for the Vander-Lift.
- The housekeeping supervisor checked all the slings in the building, ensuring they were not frayed or torn, and were in good working condition.
- The medical equipment company inspected all lifts in the facility to ensure they were in safe use.
- S1 ADM provided an in-service to all Laundry staff regarding proper laundering of lift slings.
- The Assistant Administrator ensured all resident rooms provided enough space for safe transfer with a lift.
- The DON or designee will monitor a random sample of residents being transferred with a lift to ensure the correct procedure was followed. This monitor will be completed 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed.
- The DON or designee will monitor, ensuring any lift sling in a resident's room was the correct size for the resident. This monitor will be completed on a random sample of residents with lift orders 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed.
- Administration was responsible for oversight of all the implemented actions, which would be reviewed during the weekly Quality Meeting for 6 weeks.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including traumatic subdural hemorrhage, muscle wasting, overactive bladder, and lack of coordination, did not receive required incontinence care. The resident was fully dependent on staff for toileting hygiene and was always incontinent of urine, as documented in the Minimum Data Set (MDS) and care plan. Physician orders and the care plan specified that incontinence care was to be provided at least every two hours and as needed, with a two-person assist, to maintain skin cleanliness and dryness. On the date in question, the resident did not receive incontinence care from 10:40 a.m. until 6:44 p.m., a period of approximately eight hours. Facility records and interviews confirmed that two CNAs failed to provide the required care during their respective shifts. The Director of Nursing verified that the resident should have received incontinence care at least every two hours, but this did not occur during the specified timeframe.
Improper Food Storage in Freezer
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in its food service operations, as observed during a survey. Specifically, the walk-in freezer/cooler contained several food items that were improperly stored. These items included a box of corn dogs, a bag of biscuits, a bag of squash, and a bag of breadsticks, all of which were open to the air and undated. According to the facility's policy on freezer storage, all frozen foods should be tightly wrapped or packaged to prevent freezer burn. During an interview, S4 DM confirmed that staff are expected to label, date, and properly store opened food items, acknowledging that the observed items did not meet these standards.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of communication and implementation of Enhanced Barrier Precautions (EBP) for residents with specific wound care needs. Observations revealed that there was no EBP signage or personal protective equipment (PPE) available outside the rooms of four residents who required such precautions due to their chronic wounds. The Infection Preventionist admitted to being unaware of the necessity for EBP in cases involving pressure ulcers, venous stasis ulcers, or diabetic foot ulcers, indicating a gap in the facility's adherence to its own policies. Additionally, the facility did not ensure proper hand hygiene during wound care procedures, as observed in the care of a resident with multiple wounds. The LPN responsible for the resident's wound care failed to change gloves or sanitize hands between handling different wounds, despite the facility's policy requiring such actions. This lapse in protocol was confirmed by the LPN, who acknowledged the mistake during an interview. The deficiencies highlight a significant oversight in both the communication of necessary precautions and the execution of proper infection control practices during wound care. These failures were observed during a survey, which included interviews and record reviews, and were directly linked to the facility's inability to provide a safe and sanitary environment for its residents.
Delayed Transmission of MDS Assessment
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) Assessment within the required 14 days of completion for a resident. The resident, who was admitted with diagnoses including Cerebral Infarction, Essential Hypertension, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side, had a Quarterly MDS Assessment with an Assessment Reference Date (ARD) of June 26, 2024. Although the assessment was completed, it was not transmitted until July 31, 2024, exceeding the 14-day requirement. During an interview, the LPN/MDS Nurse admitted to forgetting to notify the Assistant Director of Nursing (ADON) to close and transmit the assessment, confirming the delay in transmission.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide necessary grooming services to a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had a history of dementia and an above-the-knee amputation, required substantial assistance with personal hygiene, including shaving. Despite the resident's request for a shave and the facility's policy to assist with grooming, the resident was observed multiple times with facial hair approximately half an inch long, indicating that the grooming assistance was not provided. Interviews with staff revealed that the responsibility for providing and documenting ADL care, including grooming, fell to the CNAs, while nurses were responsible for monitoring these tasks. However, the resident did not receive the necessary grooming care, as confirmed by both the resident and the Director of Nursing (DON). The resident expressed a desire to be shaved, and the DON acknowledged the oversight, confirming the resident's facial hair had not been attended to as required.
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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.
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Nursing homes near Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency House Of Alexandria | 1.5 mi | ★★★★★ | 16 | 0 |
| Lexington House | 1.7 mi | ★★★★★ | 3 | 0 |
| The Summit | 2.2 mi | ★★★★★ | 10 | 0 |
| Matthews Memorial Health Care Center | 3.9 mi | ★★★★★ | 10 | 0 |
| Legacy Nursing At St. Christina | 5.4 mi | ★★★★★ | 23 | 0 |
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