Belpre Landing: Staffing Assessment Failures - OH
Three licensed practical nurses covered the facility that night, from 6 p.m. to 6 a.m. That was it.
The resident, identified in inspection records as Resident #2, depended on continuous ventilator support. The care plan was detailed and demanding: ventilator checks every four hours, daily changes to the heated moisture exchange device, inner cannula replacement every shift, tracheostomy site cleaning with sterile water every shift, and a respiratory therapist responsible for changing the tracheostomy tube itself every 30 to 45 days. The ventilator ran on a specific set of parameters, AC/VC mode through the tracheostomy, with pressure control, respiratory rate, inspiratory time, and oxygen concentration all set to precise values by order.
None of the three LPNs working that night held certification in ventilator care. None had completed a return demonstration.
When a federal inspector interviewed the Director of Nursing on January 28, 2026, he confirmed the staffing gap without dispute. He said he believed it was acceptable because a registered nurse had been in the building eight hours earlier in the day. He said he felt the LPNs could manage ventilator care because they had received some education on it and had watched it being performed.
He also said he was not sure whether ventilator care fell within an LPN's scope of practice.
Inspectors cited literature from the National Library of Medicine, published in August 2023, finding that mechanical ventilators are sophisticated equipment requiring specific training to produce good outcomes. The literature identified the respiratory therapist as the professional best suited to manage, adjust, and document ventilator function, and recommended limiting the number of healthcare workers permitted to make any adjustments at all. It noted that inappropriate setting changes, missed alarms, and failures to communicate with the medical team all lead to poor patient outcomes.
Every ventilator has alarms. Knowing what to do when one sounds is not a skill absorbed by watching.
The inspection was triggered by a complaint, filed under Complaint Number 2702282, and completed January 30, 2026. CMS rated the harm level as minimal harm or potential for actual harm, with few residents affected. The deficiency was cited under the tag governing the facility's responsibility to provide necessary care and services.
What the Director of Nursing described was not an isolated staffing miscalculation. It was a settled belief: that an RN's presence earlier in the day satisfied whatever obligation the night shift carried, and that observation of a skill was preparation enough to perform it alone, in the middle of the night, on a patient who could not breathe without a machine.
The tracheostomy inner cannula for Resident #2 was supposed to be changed every shift. The tracheostomy site was supposed to be cleaned every shift. The ventilator settings were supposed to be checked every four hours. Whether any of that happened on the night of December 26, and whether it was done correctly, the inspection record does not say.
What it does say is that no one qualified to make that judgment was there to know.
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 facility that night, from 6 p.m.
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.