Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fountain Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an adequate emergency food supply, as observed during a survey. The Dietary Manager noted missing items such as chicken noodle soup, cheese sauce, and green beans from the designated emergency food area. The facility's policy requires maintaining sufficient food and supplies for emergencies, which was not adhered to.
The facility's kitchen had several food safety and sanitation deficiencies, including improper cleaning and drying of pans, failure to date-label food items, and storing milk cartons directly on the floor. Additionally, the air gap basin used for cleaning produce was inadequately cleaned, increasing the risk of foodborne illness.
A resident with hearing loss was not provided with a care plan to address their communication needs, despite being observed using writing materials to communicate. The Unit Manager was unaware of the need for communication aids, and the resident's medical record lacked interventions. The DON confirmed a care plan was created but resolved without reason, leaving staff without guidance. The MDS Nurse admitted to resolving the care plan without completion, impacting the resident's communication.
A resident with moderately impaired cognition and requiring assistance with ADLs was observed with unkempt personal hygiene, expressing a desire for grooming care that was not provided on scheduled shower days. The care plan indicated the need for assistance, which was confirmed by the Unit Manager and DON.
A resident with a Foley catheter was found with the catheter bag resting on the floor, contrary to the facility's care plan and policy. The resident, who required assistance with daily activities and had a neuromuscular dysfunction of the bladder, was observed in bed with the catheter bag improperly positioned. Staff interviews confirmed that a barrier should have been used to prevent the bag from touching the floor, highlighting a deficiency in catheter management.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours a day, seven days a week, potentially affecting all residents. The Master Schedule for Nurses showed no 8-hour RN coverage on specific days, confirmed by the Director of Nursing (DON), who acknowledged staffing issues. The facility's staffing policy did not address the required RN coverage.
A resident was prescribed Seroquel without a specific diagnosis or valid informed consent. Despite declining psychiatric treatment, the resident was given the medication, and consent was improperly obtained from a family member who was not the DPOA. The facility's policy for psychotropic medication use was not followed.
The facility failed to develop or implement care plans for two residents receiving warfarin, despite physician orders to monitor anticoagulation therapy. Both residents lacked documented care plans for monitoring side effects or bleeding risks. The DON acknowledged the absence of care plans and the lack of a specific policy for anticoagulant use.
A facility failed to maintain accurate medical records for a resident on warfarin, resulting in incomplete documentation of INR results in the EHR. Despite physician orders to review the Warfarin Flowsheet nightly, only one entry was documented, and additional INR results were not included in the EHR. The DON acknowledged the oversight, and the physician confirmed that INR tests were conducted but not properly documented.
The facility failed to prevent expired food from being stored with active stock, risking foodborne illness for residents. Moldy hamburger and hot dog buns, along with undated or expired refrigerated items, were found during a kitchen inspection. Staff confirmed a resident was served moldy bread, violating the facility's food storage policy.
The facility failed to promptly respond to call lights for four residents, resulting in unmet healthcare needs. One resident waited over 15 minutes for bathroom assistance, another was left in a wheelchair for hours, and a third needed a bedpan urgently. A fourth resident reported waiting over two hours for assistance, leading to severe discomfort. The facility's policy required prompt response to call lights, but staff were busy, and a nurse turned off call lights before meeting residents' needs.
A resident with dementia and a history of falls was transferred to a hospital without proper documentation or communication of their medical needs. The facility's policy required a transfer form with specific information, which was not completed, leading to a deficiency.
The facility failed to conduct timely fall risk assessments for three residents, leading to falls without injury. Despite having policies requiring assessments within 24 hours of admission, these were not completed for residents with cognitive impairments and histories of falls. The DON confirmed the oversight, highlighting a deficiency in adhering to the facility's Fall Risk/Injury Prevention policy.
A resident with multiple diagnoses was repeatedly prescribed Ativan 0.5 mg every 12 hours PRN without proper documentation, behavioral monitoring, or physician evaluation. The resident reported difficulty receiving the medication and concerns about withdrawal symptoms. The facility failed to follow its policy on psychotropic medication use, including gradual dose reductions and non-pharmacological approaches.
Inadequate Emergency Food Supply
Penalty
Summary
The facility failed to ensure an adequate supply of emergency food was available, as observed during a survey. On March 10, 2025, an observation and interview with the Dietary Manager (DM) revealed that the emergency food supply was insufficient. A designated section in the dry food storage room was marked for emergency food, but upon comparison with the facility's emergency food supply list, it was found that chicken noodle soup, cheese sauce, and green beans were missing. The facility's policy, titled 'Disaster and Emergency Planning for Food Service,' dated February 3, 2023, mandates that adequate food, water, and disposable supplies be maintained to ensure meals can be prepared and served during emergencies. The Nursing Home Administrator acknowledged that the kitchen should audit the emergency food supply to ensure compliance.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the kitchen, as observed during a survey. Several deficiencies were noted, including the improper cleaning and drying of pans before stacking them with clean ones, and the failure to properly date-label food items. Specifically, opened containers of chicken and vegetable base were not labeled with expiration dates, and expired apple juice containers were found in the cooler. Additionally, a bag of hot dogs was labeled with an opened date but lacked an expiration date. In the dry food storage room, opened packages of spaghetti and polenta were not labeled with expiration dates. Further observations revealed that milk cartons were stored directly on the cooler floor, contrary to the requirement that they be stored at least 12 inches off the floor to prevent contamination. The air gap basin used for cleaning produce and thawing meat was found to be inadequately cleaned, with a build-up of residue and food debris. The Maintenance Director admitted to using bleach but not cleaning the basin, and the Dietary Manager acknowledged its dirty appearance. These practices increased the potential for foodborne illness among residents consuming food from the kitchen.
Failure to Implement Communication Care Plan for Hearing-Impaired Resident
Penalty
Summary
The facility failed to develop and implement a care plan for a communication deficit for a resident with hearing loss. The resident, who was observed to be alert and using writing materials to communicate, expressed difficulty in hearing and interacting with others due to ineffective hearing aids. Despite the resident's clear communication needs, the Unit Manager was unaware of the necessity for communication aids, and the resident's medical record lacked any documented communication interventions. The Director of Nursing confirmed that a care plan for the resident's hearing deficit was created but was resolved without a reason, leaving no guidance for staff to provide appropriate care. The MDS Nurse admitted to resolving the care plan without completing it, acknowledging that this oversight negatively impacted the resident's ability to communicate. The absence of a care plan and corresponding Kardex for the CNAs hindered the resident's care and interaction with others.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADLs) care for a resident, identified as R23, who was observed on two occasions sitting in a wheelchair with facial hair, greasy unkempt hair, and long dirty untrimmed fingernails. During an interview, R23 expressed a desire to be shaved, have their hair washed and combed, and receive nail care, confirming that no assistance was offered for these tasks on scheduled shower days. R23, who has moderately impaired cognition and requires one-person assistance with all ADLs, was unable to recall the last time they received a shower or their scheduled shower days. The care plan, revised in February 2025, indicated that R23 required assistance with bathing, dressing, and personal hygiene due to muscle weakness. The Unit Manager confirmed that R23's scheduled shower days were Mondays and Thursdays, during which they should have received grooming care. The Director of Nursing stated that all residents should receive nail care and shaves if it is their preference.
Improper Catheter Bag Management
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, leading to a deficiency in catheter management. The resident, who was admitted with a neuromuscular dysfunction of the bladder and a history of repeated falls, was observed with a catheter bag resting on the floor. This observation was made while the resident was asleep in bed, which was positioned low to the ground. The facility's care plan for the resident included securing the catheter with a securement device and providing a barrier when the bed was in a low position. However, these interventions were not implemented, as evidenced by the catheter bag being wedged between the floor mat and the wheel of the bed. Interviews with the Unit Manager and the Director of Nursing revealed that the nurse aides were responsible for ensuring the catheter bags were properly hung and not on the floor. Both staff members acknowledged that a white basin should have been placed under the catheter bag to prevent it from touching the floor. The facility's policy on catheter care, dated August 2023, mandates appropriate care for residents with indwelling catheters, which was not adhered to in this instance. The failure to follow the care plan and facility policy potentially resulted in the risk of infection and dislodgement of the catheter.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which could potentially lead to inadequate coordination of emergency or routine care and unmet care needs for all residents. During the review of the Master Schedule for Nurses from January 1, 2025, to January 26, 2025, it was found that there was no consecutive 8-hour scheduled RN coverage on January 12, 19, and 25, 2025, with resident census numbers of 72, 77, and 71, respectively. The Director of Nursing (DON) confirmed the absence of RNs on these days and acknowledged the staffing issue, stating that RNs were recently hired to assist with coverage. Additionally, the facility's staffing policy, dated November 3, 2023, did not address the requirement for RN coverage for at least 8 consecutive hours a day, 7 days a week.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R506, had a specific diagnosis, clinical indications for use, or valid informed consent for the use of psychotropic medications. R506 was admitted with diagnoses including multiple falls, traumatic ischemia of muscle, and diabetes, and had a BIMS score indicating no cognitive impairment. Despite declining psychiatric treatment and services, R506 was prescribed Seroquel by Physician K without a corresponding diagnosis or clinical indication. The resident expressed a desire not to be on Seroquel, and the social worker informed the nurse and physician, but the medication was not discontinued. The facility's policy requires informed consent for psychotropic medications, which was not obtained from the appropriate authorized representative. A consent form was signed by a family member who was not the resident's DPOA, and the family member later clarified they had directed the social worker to contact another family member for consent. The resident was taken off Seroquel at the hospital, and the facility's policy for psychotropic medication use was acknowledged as not being followed by the Nursing Home Administrator.
Failure to Implement Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop or implement care plans for anticoagulant administration for two residents, R801 and R802, who were receiving warfarin. R801 was admitted with a history of pulmonary embolism and was prescribed warfarin 7.5 mg daily. Despite the physician's order to review the warfarin flowsheet every nightshift, there was no care plan or interventions documented for monitoring the side effects or risk of bleeding due to warfarin administration. The Director of Nursing (DON) acknowledged the absence of a care plan for R801 and confirmed that the facility lacked a specific policy for anticoagulant use. Similarly, R802, admitted with a history of Atrial Fibrillation, was prescribed warfarin 12.0 mg daily. The resident's care plan also lacked documentation for monitoring side effects or the risk of bleeding associated with anticoagulation therapy. The DON confirmed the absence of a care plan for R802 as well. The facility's Care Plan policy, last revised on 8/25/23, mandates a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, which was not adhered to in these cases.
Incomplete Documentation of INR Results for Resident on Warfarin
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as R801, who was receiving warfarin for anticoagulation therapy. The deficiency was identified when the State Agency received a complaint regarding the monitoring of the resident's side effects from warfarin. The resident's Electronic Health Record (EHR) was found to be incomplete, with only one Warfarin Flowsheet documented, despite the physician's order to review the Warfarin Flowsheet every night shift. The missing documentation resulted in an unclear picture of the resident's blood clotting times and healthcare needs. The Director of Nursing (DON) acknowledged the incomplete documentation and produced two additional INR lab results that were not part of the resident's EHR. These results were obtained from the lab and were not documented in the facility's records. The facility's policy required that laboratory results be uploaded into the resident's EHR, but this was not done for R801. The physician confirmed that the INR blood tests were being conducted and reviewed through the lab, but the Warfarin Flowsheets were not up-to-date in the EHR.
Expired Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that expired food was not stored with active food stock, which could potentially lead to foodborne illness for all residents consuming food from the kitchen. During a kitchen tour, it was observed that several packs of hamburger and hot dog buns were opened, undated, and showed signs of mold. Additionally, other food items in the refrigerator, such as pre-made breakfast biscuits and sausages, were either undated or past their use-by dates. This oversight in food storage and labeling was confirmed by kitchen staff, who acknowledged the presence of mold on a sandwich served to a resident. The facility's Food Storage policy mandates that all food items be labeled and used within recommended time guidelines to prevent foodborne illness. However, the policy was not adhered to, as evidenced by the undated and expired food items found during the inspection. The Nursing Home Administrator was aware of the incident involving a resident being served moldy bread, indicating a lapse in monitoring and enforcing food safety protocols. This deficiency highlights a failure in the facility's food storage and labeling practices, posing a risk to resident health.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for four residents, leading to unmet healthcare needs. Observations on a specific date revealed that call lights for three residents remained on for an extended period, with one resident waiting over 15 minutes for assistance to go to the bathroom. Another resident had been waiting for hours to be assisted back to bed, and a third resident needed a bedpan urgently but was left waiting. The call lights were turned off by a nurse before the residents' needs were met, indicating a delay in response. Resident 810, who had chronic obstructive pulmonary disease and a history of falls, was observed waiting for assistance to use the bathroom. Resident 811, with Down's syndrome and a fracture, was left in a wheelchair for hours without being assisted back to bed. Resident 812, who had a fracture and required extensive assistance, was left waiting for a bedpan, risking incontinence. These residents had intact cognition, as indicated by their BIMS scores, and required varying levels of assistance for mobility. Resident 805 reported waiting over two hours for assistance on two occasions, leading to severe discomfort and the need to call emergency services. The facility's policy stated that staff should respond to call lights promptly and leave them on until the resident's needs were met. However, the nurse unit manager confirmed that the CNAs were busy, and she had to answer most call lights herself, turning them off before addressing the residents' needs.
Failure to Communicate Transfer Information to Hospital
Penalty
Summary
The facility failed to ensure proper communication of transfer information for a resident, identified as R802, to the receiving hospital. The resident, who had multiple diagnoses including dementia and a history of a fall with a fractured tibia, was admitted to the facility with severe cognitive impairment and required substantial assistance for mobility. On a specific date, the resident was found on the floor with a skin tear, prompting a physician to order a transfer to the hospital. However, there were no progress notes or transfer forms documenting the transfer, leaving the receiving hospital potentially unaware of the resident's medical needs and history. The Director of Nursing (DON) confirmed the absence of documentation regarding the transfer, acknowledging that the nurse should have completed a transfer form. The facility's policy on transfers and discharges, last revised in November 2023, outlines the necessary information to be included in a transfer form, such as contact information, advance directives, resident status, diagnoses, allergies, and special care instructions. The lack of adherence to this policy resulted in a deficiency, as the required information was not communicated to the hospital, potentially impacting the resident's care.
Failure to Implement Fall Interventions and Assessments
Penalty
Summary
The facility failed to implement fall interventions for three residents, resulting in a deficiency related to fall risk assessments. Resident 802, who had severe cognitive impairment and a history of falls, was admitted without a fall risk assessment. This resident experienced two falls, one resulting in a skin tear and another in a laceration, before being sent to the hospital. Similarly, Resident 807, with intact cognition and a history of joint replacement surgery, and Resident 809, with moderately impaired cognition and a history of a lumbar fracture, were also admitted without fall risk assessments. Both residents experienced falls without injury. The Director of Nursing confirmed that no fall risk assessments were conducted within 24 hours of admission or prior to the falls for these residents. The facility's Fall Risk/Injury Prevention policy mandates that a fall risk assessment be completed within 24 hours of admission, quarterly, or when a significant change in condition occurs. The policy also states that a score of greater than 10 on the assessment indicates an increased risk of falls, and the interdisciplinary team may add interventions for residents deemed at risk. The lack of timely fall risk assessments for these residents represents a failure to adhere to the facility's policy, contributing to the deficiency.
Failure to Provide Rationale and Monitoring for Extended Use of PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide rationale, behavioral monitoring, or a physician evaluation for the extended use of a PRN psychotropic medication for a resident. The resident, who had multiple diagnoses including Sepsis, Depression, Anxiety, and Adjustment Disorder, was prescribed Ativan 0.5 mg every 12 hours PRN for 14 days, which was repeatedly re-ordered without proper documentation or evaluation. The resident reported difficulty in receiving the medication and expressed concerns about withdrawal symptoms due to her long-term use of Ativan at home. There was no evidence of psychiatric services being offered or accepted, and no documentation of discussions regarding the risks and benefits of the medication use was found in the resident's EHR. The care plan for the use of psychotropic medications was initiated 15 days after the initial prescription of Ativan, but it lacked proper follow-up and documentation. The interventions included consulting with pharmacy, considering dosage reduction, and reviewing behaviors and alternate therapies, but there were no records of these actions being taken. The resident's physician continued prescribing the medication based on the resident's requests without documented discussions about alternative treatments or non-pharmaceutical interventions. Additionally, there was no AIMS assessment or behavior monitoring documented in the resident's EHR. The Director of Nursing confirmed the lack of psychiatric services and the responsibility of social work and the resident's physician in managing the psychotropic medication. The social worker admitted to not following up with the resident due to the absence of reported concerns from nursing staff. The physician acknowledged the continued prescription of Ativan without considering alternative treatments or a gradual dose reduction. The facility's policy on psychotropic medication use emphasized the need for gradual dose reductions, non-pharmacological approaches, and proper documentation, which were not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 883 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — 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 Riverview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rivergate Health Care Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Rivergate Terrace | 0.8 mi | ★★★★★ | 13 | 0 |
| The Orchards At Southgate | 1.3 mi | ★★★★★ | 8 | 0 |
| Aerius Health Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Applewood Nursing Center, Inc | 4.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Belle Fountain Nursing & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.