Belpre Landing: Staff Competency Violations - OH
Three licensed practical nurses covered the twelve-hour overnight shift. That was it.
The resident, identified in inspection records as Resident 2, depended on continuous ventilator support set to specific parameters: a respiratory rate of 20 breaths per minute, a pressure control of 22, an inspiratory time of 1.2 seconds, a PEEP of 6, and an oxygen concentration of 32 percent. Their care orders required ventilator checks every four hours, daily changes to the heated moisture exchange device, inner cannula changes every shift, and tracheostomy site cleaning with sterile water every shift. A respiratory therapist was supposed to change the tracheostomy tube itself every 30 to 45 days.
None of those tasks are routine nursing duties. Ventilator management requires training specific to the equipment, knowledge of alarm systems, and the clinical judgment to recognize when a setting change or equipment failure is becoming an emergency.
When inspectors interviewed the Director of Nursing on January 28, 2026, he confirmed there was no RN or respiratory therapist on the December 26 night shift. His explanation was that a registered nurse had been in the building eight hours earlier in the day, and he felt that satisfied the requirement. He did not believe another RN was needed at night.
He went further. When asked directly whether an LPN was permitted to provide ventilator care without supervision from an RN or respiratory therapist, the director said that because the LPNs had received some education and had watched ventilator care being performed, he felt they could manage ventilator residents on their own. He acknowledged they lacked certification. He acknowledged no return demonstration had been completed to verify their competency. And then he said he was not sure whether ventilator care even fell within an LPN's scope of practice.
The director of nursing for a facility housing a ventilator-dependent resident was uncertain whether his LPNs were legally or clinically qualified to manage that resident's care. He sent them in anyway.
A review of literature from the National Library of Medicine, cited in the inspection record, states plainly that mechanical ventilators are sophisticated devices requiring specific training to produce good outcomes and limit harm. Inappropriate setting changes, failure to respond correctly to alarms, and failure to communicate changes to the medical team all result in poor patient outcomes. The literature identifies the respiratory therapist as the professional best equipped to manage, adjust, and document ventilator function, and recommends limiting the number of healthcare workers authorized to make any adjustments at all.
Resident 2's care plan had been in place since April 2025. It listed more than a dozen specific respiratory interventions, from administering aerosol treatments to monitoring lung sounds to watching for signs of distress including cyanosis, labored breathing, changes in mental status, and dangerously low oxygen levels. Those are the warning signs of a patient in crisis. Recognizing them, and responding correctly, requires more than having once watched someone else do the job.
The staffing schedule confirmed the gap was not an accident or an emergency coverage failure. Three LPNs were scheduled. No RN. No respiratory therapist. The night shift was planned that way.
Inspectors cited the deficiency as causing minimal harm or the potential for actual harm, affecting a small number of residents. The complaint that triggered the inspection was filed under complaint number 2702282.
Resident 2 made it through the night. What the three LPNs did or didn't do between 6 p.m. and 6 a.m., and whether anyone checked the ventilator settings every four hours as ordered, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belpre Landing Nursing and Rehabilitation from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
BELPRE LANDING NURSING AND REHABILITATION in BELPRE, OH was cited for violations during a health inspection on January 30, 2026.
Three licensed practical nurses covered the twelve-hour overnight shift.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.