Pennsylvania Department of Health
BELLE TERRACE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BELLE TERRACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on a Revisit to an Emergency Preparedness Survey completed on December 8, 2025, it was determined that Belle Terrace, was in substantial compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 (ORIGINAL & PERSONAL CARE) - Component: 01 - Tag: 0000
Facility ID# 024302

Component 01

Original Building &;; Personal Care

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 8, 2025, it was determined that Belle Terrace - Original Building &;; Personal Care Building was not in substantial compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two story, Type V (000), unprotected, wood-frame building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 (ORIGINAL & PERSONAL CARE) - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Findings Include: 1. Document review on December 8, 2025, at 9:30 a.m., revealed the facility had the following sprinkler documentation deficiencies: a. Missing fourth quarter sprinkler report. b. Quarterly sprinkler report dated July 22, 2025, had a deficiency that stated, "Break Room by sectional valve-4x1 &;;1/4 mechanical tee, 1 &;; &;frac14; tee screw piping corroded" and "Women's bathroom same area-4" groove piping has pinhole and corroded." Evidence of corrective action was unavailable at the time of survey. c. 5-year internal pipe and valve report dated May 5, 2021, showed a failed internal inspection due to clogged line. Evidence of corrective action was not available at time of survey. Exit Interview with the Administrator and Maintenance Director on December 8, 2025, at 1:15 p.m., confirmed the missing documentation. 2. Observation on December 8, 2025, at 12:00 p.m., revealed by the main double doors there were numerous sprinkler heads positioned incorrectly in an upright position below the suspended ceiling. Exit interview with the Administrator and Maintenance Director on December 8, 2025, at 1:15 p.m., confirmed the current position of the sprinkler heads. ********************************************************** Based on an onsite Revisit conducted on February 10, 2026, the following was determined: Item 1b - Not Completed. The Quarterly sprinkler report dated July 22, 2025, had a deficiency that stated, "Break Room by sectional valve-4x1 &;;1/4 mechanical tee, 1 &;; &;frac14; tee screw piping corroded" and "Women's bathroom same area-4" groove piping has pinhole and corroded." Evidence of corrective action was unavailable at the time of this revisit. All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 03/15/2026

Item 1b: This repair was completed on 2/19/2026. We will have the documentation available by 3/15/2026.

Initial comments:Name: BUILDING 02 (A WING) - Component: 02 - Tag: 0000
Facility ID# 024302

Component 02

A Wing

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 8, 2025, it was determined that Belle Terrace - A Wing was in substantial compliance with the requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected, non-combustible building, with a partial lower level and crawl space, that is fully sprinklered.

Plan of Correction:

Initial comments:Name: BUILDING 03 (B WING) - Component: 03 - Tag: 0000
Facility ID# 024302

Component 03

B Wing

Based on a Medicare/Medicaid Recertification Survey completed on December 8, 2025, at Belle Terrace - B Wing, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

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