Pennsylvania Department of Health
 BELLE TERRACE
Patient Care Inspection Results

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BELLE TERRACE
Inspection Results For:

There are  108 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 an Abbreviated survey in response to two complaints completed on March 20, 2026, it was determined that Belle Terrace, was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

















 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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, 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 February 22, 2026, through March 14, 2026, 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 February 22, 23, 24, 25, 26, 27, 28, 2026, and March 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14, 2026.

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 February 24, 2026, and March 9 and 13, 2026.

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 February 22, 23, 24, 25, 26, 27, 28, 2026, and March 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 , 11, 12, 13, and 14, 2026.

In an interview on March 20, 2026, at 12:30 p.m., the Administrator confirmed that the facility failed to meet the minimum NA to resident ratios on the dates listed.




 Plan of Correction - To be completed: 04/20/2026

NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct CNA ratios.
NHA/designee will audit the nursing schedules in advance daily x3 weeks to ensure CNAs are staffed at the proper ratio. If ratios are not met, agency will be implemented.
Results will be shared at QAPI until substantial compliance is met.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 20 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 22, 2026, through March 14, 2026, 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 February 27 and March 1, 2026.

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 February 22, 24, 25, 26, 27, 28, 2026, and March 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14, 2026.

In an interview on March 20, 2026, at 12:30 p.m., the Administrator confirmed that the facility failed to meet the minimum LPN to resident ratio on the dates listed.






 Plan of Correction - To be completed: 04/20/2026

NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct LPN ratios.
NHA/designee will audit the nursing schedules in advance daily x3 weeks a staffing meeting to ensure LPN Ratios is being met. If ratios are not met agency will be implemented,
Results will be shared at QAPI until substantial compliance is met

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct nursing care for each resident for seven of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 22, 2026, through March 14, 2026, revealed the following total nursing care hours below minimum requirements:

February 25, 2026 3.00 care hours per resident.
February 26, 2026, 3.19 care hours per resident.
February 27, 2026 3.15 care hours per resident.
February 28, 2026, 3.19 care hours per resident.
March 1, 2026, 3.13 care hours per resident.
March 9, 2026, 3.00 care hours per resident.
March 13, 2026, 3.04 care hours per resident.

In an interview on March 20, 2026, at 12:30 p.m., the Administrator confirmed that the facility failed to meet the minimum nursing care hours per resident on the dates listed.





 Plan of Correction - To be completed: 04/20/2026

NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct PPD.
NHA/designee will audit the nursing schedules in advance daily x3 weeks a staffing meeting to ensure PPD is being met. If PPD is not met agency will be implemented.
Results will be shared at QAPI until substantial compliance is met


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