Pennsylvania Department of Health
BELLE TERRACE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BELLE TERRACE
Inspection Results For:

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BELLE TERRACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on March 14, 2024, it was determined that Belle Terrace has a deficiency that has the potential for minimal harm to residents as related to the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.





 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:
Based on observation, it was determined that the facility failed to provide a clean, homelike, and comfortable environment on two of two nursing units. (A-wing and B-wing)

Findings include:

During tours of A-wing and B-wing nursing units on March 14, 2024, between 10:12 a.m. and 11:30 a.m., the following were observed:

In rooms 27, 32, 36, and 47, there were holes in the partition wall between the residents' sleeping area and the bathroom

On the right side of the B-wing hallway, between rooms 38 and 40, there was detached molding in the space where the floor met the wall, exposing a large hole in the wall.

In the shared bathroom located between rooms 38 and 40, two round holes in the sheetrock were observed.

In room 47-2, there was a hole in the wall under the window.

28 Pa. Code 201.18(b)(1)(e)(2.1) Management.


 Plan of Correction - To be completed: 04/26/2024

1. No residents were noted as being affected by the facility's alleged deficient practice.
2. A facility visual audit was conducted by the Director of Maintenance/NHA to identify any other areas of concerns related to the deficiency. Any additional areas identified will be corrected by April 26, 2024.
3. Maintenance Director educated on ensuring that identified structural repairs are completed in a timely manner. Facility staff will be educated on the process for reporting identified concerns to the Maintenance Staff, including the use of TELS, to ensure that identified repairs are completed in a timely manner.
4. Visual audits and reviews of the TELS system reporting will be completed by the Maintenance Director/Designee 2x a month x2 months then monthly x2 months to ensure that areas requiring repairs have been completed as required in a timely manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the NHA.


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