Pennsylvania Department of Health
BELLE TERRACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BELLE TERRACE
Inspection Results For:

There are 106 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey, completed December 5, 2025, it was determined that Belle Terrace was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. 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. This deficiency was 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 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based on observation, it was determined that the facility failed to maintain the environment in a clean, comfortable, and homelike manner on two of two nursing units. (A and B wings)

Findings include:

Observations on December 3, 2025, from 10:45 a.m. through 2:00 p.m., and on December 4, 2025, from 10:45 a.m. through 2:00 p.m., revealed the following environmental issues:

In the shower room on A wing, the first room to the right of the door had a sink with brown stains and the faucet had white stains on it. The toilet had a black ring inside. In the shower room's central shower area, there were open holes in the wall around the shower valve system where the water flow and temperature were controlled. The bathtub room to the left of the central hallway had a marred wall on the left back side of the room, the bathtub had blue and brown stains inside, around the drain, and on the side wall by the faucet. The bathtub faucet had white stains. The shower stall in the back of the shower room had a brown ring around the floor where the floor met the wall and a large gray stain on the floor.

In the bathroom shared by resident rooms 30 and 32, there were stains on the mirror, a brown ring on the toilet base, a marred wall behind the toilet, a used brief opened and laying across the top of the bathroom garbage can, and pieces of paper garbage on the floor.

In resident room 36 (bed 1), there were four plastic wrappers and a large syringe (no needle) on the floor. The clock was displaying the wrong time.

In the hallway between resident rooms 43 and 45, there was a hole in the wall.

In resident room 46 (bed 1), there was a plastic lid, tissue, and paper debris on the floor.

In resident room 50 (bed 1), there was a full can of garbage and paper and food debris on the floor around the bed.

In the bathrooms of resident rooms 46 and 50, there were marred walls along the length of the wall adjacent to the toilet.

28 Pa. Code 201.14(a) Responsibility of licensee.

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

Plan of Correction - To be completed: 01/12/2026

1. Shower Room in A hall was immediately cleaned by on call housekeeping staff to remove stains found on sink, faucet and toilet. The Shower room was deep cleaned on 12/4 to remove all stains that were removable. This will also follow the audit schedule listed below.
Shared bathroom for room 30 and 32 was immediately cleaned on 12/4. Room 36, 46 and 50 was immediately cleaned on 12/4. Cleanliness in rooms was addressed to all staff and will be on an audit schedule. This is an area of focus at staffing meetings, and daily shift change meetings.
The Hole and Marred wall repair in A Hall Shower room will be completed by compliance date.
Room 36 clock repair will be completed by compliance date.
The Hole in wall by room 43 and 45 repaired will be completed by compliance date.
Marred wall in bathroom shared by room 46 and 50 repair will be completed by compliance date.
2. A building-wide environmental sweep was conducted to identify any other rooms or common areas that might lack a safe, clean, or homelike atmosphere. This included checking for clutter, odors, damaged furniture, peeling paint, inadequate lighting, institutional signage, and environmental issues that could detract from resident comfort. Any concerns identified during this audit will be corrected, including repairs, enhanced cleaning, and replacement of worn furnishings.
3. Staff will be educated on the components of this regulation with an emphasis on maintaining a safe, clean, comfortable, and homelike environment, and who to report concerns immediately.
4. Visual audits of the facility's environment will be done by the NHA/Designee 1x a week x4 weeks, 2x a month x1 month, then monthly x2 months, to ensure that residents are provided with a safe, clean, homelike environment.
5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. 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.

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:
Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 14 sampled residents. (Resident 19)

Findings include:

Review of the facility policy entitled, "Self-Administration of Medications," last reviewed on November 20, 2025, revealed that residents had the right to self-administer medications if the staff and practitioner determined it was clinically appropriate for residents to do so.

Clinical record review revealed that Resident 19 had diagnoses that included chronic obstructive pulmonary disease (COPD) and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated October 10, 2025, revealed that the resident's cognitive ability was intact and that he used oxygen. On October 31, 2025, a consulting specialist physician recommended that Resident 19 start taking an inhaler medication to treat COPD daily and that the patient must have this inhaler in his room to be taken immediately upon awakening. The attending physician noted that he agreed with this recommendation. A review of Resident 19's medication administration record revealed a physician's order dated October 31, 2025, and updated November 14, 2025, directing staff to administer one puff of the inhaler in the morning at 7:00 a.m. There was no indication that Resident 19 was evaluated to self-administer his inhaler medication prior to December 4, 2025.

On, December 4, 2025, at 12:05 p.m., Resident 19 was observed sitting in a wheelchair in his room. In an interview at that time, Resident 19 stated that the inhaler medication was not readily available and was locked in the medicine cart. The resident stated that the specialist told him to self-administer it when he awakened. Resident 19 stated that he was very frustrated with the nursing staff for not following the physician's recommendation.

In an interview on December 5, 2025, at 12:30 p.m., the Director of Nursing confirmed that the resident was not assessed to self-administer the medication as per the facility policy and the physician's orders prior to December 4, 2025.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/12/2026

1. Resident 19 was assessed to be able to self-administer the prescribed medication the same day and was deemed appropriate and medication placed at bedside.
2. A facility-wide audit was completed by the DON/Designee to identify additional residents who may have been affected by the deficient practice. This audit included a review of residents' records to verify that appropriate physician orders for self-administration were in place, that self-administration assessments had been completed, and that medications were being stored according to policy. Any resident found with missing or outdated assessments was immediately reassessed, and any inconsistencies between current practice and physician orders were corrected.
3. The facility's Medication Self-Administration Policy was reviewed with licensed nursing staff. The admission and quarterly review processes were amended to include automatic triggers for reassessment whenever there is a change in condition, medication adjustments, or observed safety concerns.
4. Audits will be done by the DON/Designee 1x a week x4 weeks, 2x a month x1 month, then monthly x2 months, of 5 residents to ensure that those who can qualify for a request self- administration of medications/treatments has an assessment and order for self-administration.
5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of two of 14 sampled residents. (Residents 1 and 4)

Findings include:

Clinical record review revealed that Section C (Brief Interview for Mental Status) of Resident 1's MDS assessment dated October 16, 2025, was incomplete.

In an interview on December 3, 2025, at 9:00 a.m., the Administrator confirmed that Resident 1's MDS assessment was incomplete.

Clinical record review revealed that Resident 4 received hospice services starting on November 13, 2025. The MDS assessment dated November 18, 2025, incorrectly indicated in Section O (Special treatments, Procedures, Programs) that the resident was not receiving hospice services during the previous seven days.

In an interview on December 3, 2025, at 9:59 a.m., the Director of Nursing confirmed that Resident 4's MDS assessment was inaccurate.

Plan of Correction - To be completed: 01/12/2026

1. The modification in section O was corrected to reflect hospice services the same day. An audit to ensure all of Section C in MDS was completed.
2. A facility-wide audit of current MDS assessments due or recently completed within the last 30 days was conducted to identify any additional inaccuracies. Any discrepancies found were immediately corrected, and assessments were modified as necessary to ensure accuracy.
3. Education on Comprehensive assessments, Resident exam Assessment and Assisting Nurse exam policies were given to appropriate staff members. The MDS Coordinator and contributing departments (nursing, therapy, dietary, social services, activities) received targeted education on MDS accuracy requirements, documentation standards, and regulatory expectations.
4. Audits will be done by the DON/Designee 1x a week x4 weeks, 2x a month x1 month, then monthly x2 months, to ensure accuracy of assessments.
5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 14 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on January 30, 2024, and had diagnoses that included depression. According to the Minimum Data Set Care Area Assessment summary dated January 22, 2025, the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration record from January through December 2025, revealed the resident received an antidepressant (trazodone) during the review period. There was no documented evidence that interventions to address Resident 1's psychotropic drug use were included in the current care plan. In an interview on December 5, 2025, at 10:00 a.m., the Director of Nursing confirmed there was no documented evidence that the care area was addressed Resident 15's current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/12/2026

1. The anti-depressant care plan was re-initiated the same day on Resident 1.
2. Facility-wide audit of residents was completed by the DON/Designee for antidepressant use and audit of care plan was completed for accuracy of residents.
3. Education on care plans and comprehensive assessment were given to the appropriate staff.
4. Audits will be done by the DON/Designee 1x a week x4 weeks, 2x a month x1 month, then monthly x2 months, to ensure that anti-depressant care plans are in place.
5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:
Based on clinical record review, review of facility documentation, observation, and staff and resident interviews, it was determined that the facility failed to accommodate food preferences for one of 14 sampled residents. (Resident 54)

Findings include:

Review of the facility's weekly menu revealed that the lunch meal for December 3, 2025, was spaghetti noodles with meat, breadstick, tossed salad, and fruit cocktail.

Clinical record review revealed that Resident 54 had diagnoses that included anxiety, gastroesophageal reflux disease, and major depressive disorder. The Minimum Data Set (MDS) assessment dated October 23, 2025, indicated that the resident was alert and able to make her needs known. During an interview on December 3, 2025, at 12:25 p.m., Resident 54 stated that her meals did not match what was on her ticket and she received foods she did not like. On December 3, 2025, at 12:30 p.m., her lunch tray was observed on her bedside table and had spaghetti noodles and meat sauce. Resident 54 stated that she did not like pasta, did not want spaghetti noodles, and would not eat them. The resident's tray card indicated that the resident was on a regular diet and did not like pasta.

In an interview on December 5, 2025, at 9:00 a.m., the Administrator stated that the dietary department did not follow Resident 54's food preferences identified on the meal ticket.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b) Management.

Plan of Correction - To be completed: 01/12/2026

1. The dietary manager immediately met with Resident 54 to update the resident's preferences. Staff were re-educated on the resident's individualized preferences, dietary restrictions, and required substitutes to ensure all meals align with the resident's choices and nutritional needs.
2. A facility-wide audit of residents' dietary preference sheets and meal service records was performed by the Dietary Manager. Any missing or outdated preferences were updated through direct interviews with residents and/or representatives. Corrections were made for any inconsistencies.
3. Dietary, nursing, and meal service staff were re-educated on accurately recording resident preferences, offering substitutes when needed, communicating preference changes promptly, and using the most current preference sheets during meal preparation and service.
4. Audits will be done by the Dietary Manager/Designee 1x a week x4 weeks, 2x a month x1 month, then monthly x2 months, to ensure that resident preferences are being followed. Audits to include full service and meal tickets/tray audits to ensure compliance.
5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:
Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and the use of personal protective equipment (PPE) to prevent the spread of infection for one of four sampled residents observed during medication administration. (Resident 4)

Findings include:

Review of the facility policy entitled, "Enhanced Barrier Precautions," last reviewed on November 20, 2025, revealed that staff was to wear a gown and gloves during high contact resident care activities, such as using the resident's feeding tube and for residents with indwelling medical devices to minimize the spread of multidrug resistant organisms.

Clinical record review revealed that Resident 4 had diagnoses that included dysphagia (difficulty swallowing) and lung cancer. Review of the Minimum Data Set (MDS) assessment, dated November 18, 2025, revealed that Resident 4 had an enteral feeding tube (a soft plastic tube inserted into the digestive system used to provide nutrition directly through the stomach.) On November 3, 2025, a physician's order directed staff to implement enhanced barrier precautions every shift for infection control. Review of the care plan revealed that Resident 4 received his nutrition and medications through the feeding tube and staff was to follow enhanced barrier precautions when providing care. Observations on December 4, 2025, from 9:15 a.m. to 9:30 a.m., revealed licensed practical nurse (LPN) 1 gave Resident 4 medications and food through Resident 4's feeding tube. LPN 1 did not wear a gown while providing care related to the feeding tube in accordance with the facility policy.

In an interview on December 5, 2025, at 8:37 a.m., the Administrator confirmed that LPN 1 should have worn a gown when providing care related to Resident 4's feeding tube.

CFR: 483.80 Infection Control

Previously cited 12/28/23, 8/1/24, 1/16/25

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/12/2026

1. Staff involved were immediately re-educated on the specific infection control concern observed.
2. A facility-wide observation audit was conducted in resident rooms, common areas, and clinical care spaces to identify any additional concerns related to infection control practices.
3. Education on infection control protocol with an emphasis on enhanced barrier precautions will be conducted with facility staff responsible for direct resident contact will be conducted by the DON/Designee.
4. Visual audits will be conduct randomly by the DON/Designee of staff providing care 1x a week x4 weeks, 2x a month x1 month, then monthly x2 months, to ensure staff are following infection control protocols include PPE and enhanced barrier precautions.
5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 21 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 21 through September 27, 2025, and from November 21, 2025, through December 4, 2025, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on September 21, 23 through 27, 2025, November 21, 23, and 25 through 30, 2025, and December 1 and 2, 2025.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on September 21 and 22, 2025, and November 21, 23, 25, 26, and 28, 2025.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on September 21 through September 27, 2025, and from November 21, 2025, through December 4, 2025

In an interview on December 5, 2025, at 8:35 a.m., the Administrator confirmed that the NA ratios were not met on the dates listed above.

Plan of Correction - To be completed: 01/12/2026

1. Nursing schedules were reviewed to ensure the proper nursing assistant ratio on the day and evening and overnights shifts.
2. The past 30 day of staffing schedules were reviewed to verify compliance with CNA ratio requirements.
3. NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct Nursing Assistant ratio.
4. NHA/designee will audit the nursing schedules in advance daily x3 week and hold staffing meetings to ensure nursing assistants are staffed at the proper ratio.
5. Results will be shared at QAPI until substantial compliance is met.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 21 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 21 through September 27, 2025, and from November 21, 2025, through December 4, 2025, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on September 21 and 24 through 27, 2025, November 22, 23, 27, 29, and 30, 2025, and December 1, 2025.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on September 21 through September 27, 2025, and from November 21, 2025, through December 4, 2025.

In an interview on December 5, 2025, at 8:35 a.m., the Administrator confirmed that the facility did not meet the minimum LPN to resident ratios for the above dates

Plan of Correction - To be completed: 01/12/2026

1. Nursing schedules were reviewed to ensure the proper LPN ratio on the day and overnight shifts.
2. 2. The past 30 day of staffing schedules were reviewed to verify compliance with LPN ratio requirements.
3. NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct LPN ratios.
4. NHA/designee will audit the nursing schedules in advance daily x3 weeks to ensure LPN's are staffed at the proper ratio.
5. Results will be shared at QAPI until substantial compliance is met.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed registered nurse (RN) to resident ratio for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 21 through September 27, 2025, and from November 21, 2025, through December 4, 2025, revealed the following:

The facility failed to meet the minimum RN to resident ratio of one RN for 250 residents on September 22, 23, and 24 2025.

In an interview on December 5, 2025, at 8:35 a.m.,the Administrator confirmed that the facility did not meet the minimum RN to resident ratio for the above mentioned dates.

Plan of Correction - To be completed: 01/12/2026

1. Nursing schedules were reviewed to ensure the proper RN ratio on the day and overnight shifts.
2. 2. The past 30 day of staffing schedules were reviewed to verify compliance with RN ratio requirements.
3. NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct RN ratios.
4. NHA/designee will audit the nursing schedules in advance daily x3 weeks to ensure RNs are staffed at the proper ratio.
5. Results will be shared at QAPI until substantial compliance is met

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 01/12/2026

1. Nursing schedules were reviewed to ensure the proper PPD on the day and overnight shifts.
2. 2. The past 30 day of staffing schedules were reviewed to verify compliance with proper PPD requirements.
3. NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct RN ratios.
4. NHA/designee will audit the nursing schedules in advance daily x3 weeks a staffing meeting to ensure PPD is being met.
5. Results will be shared at QAPI until substantial compliance is met

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