Federal inspectors found that Belpre Landing Nursing and Rehabilitation violated staffing requirements for Resident #2, who required continuous ventilator support through a tracheostomy. The resident's care plan mandated round-the-clock monitoring of oxygen levels, lung sounds, mental status, and skin color, along with frequent equipment changes and respiratory treatments.
Director of Nursing told inspectors on January 28 that he "felt since there was an RN in the building eight hours earlier in the day as required, there did not need to be one at night." When asked whether LPNs could provide ventilator care without RN or respiratory therapist supervision, he said the LPNs had received education and watched ventilator care being performed.
He acknowledged the LPNs lacked certification and had not completed return demonstrations of ventilator care skills. The director was uncertain whether ventilator care fell within an LPN's scope of practice.
The resident's physician orders required extensive respiratory interventions. Equipment changes included monthly ventilator circuits, daily heated moisture exchangers, and tracheostomy tube replacements every 30 to 45 days. Staff were required to change the inner cannula every shift, cleanse the tracheostomy site with sterile water, and provide continuous monitoring for respiratory distress.
Ventilator settings included specific parameters: AC/VC mode via tracheostomy, pressure control at 22, respiratory rate of 20, inspiratory time of 1.2 seconds, positive end-expiratory pressure of 6, and oxygen concentration of 32 percent. Orders called for ventilator checks every four hours.
The care plan identified critical warning signs requiring immediate response: labored breathing, low oxygen levels, use of accessory muscles, cyanosis, changes in mental status, and rapid breathing. Staff were instructed to suction the tracheostomy as ordered and report any abnormalities to the provider immediately.
Federal health literature cited in the inspection emphasized the complexity of mechanical ventilators and the training required to ensure positive outcomes. Inappropriate setting changes, failure to change alarms, changing settings without proper orders, and failure to communicate changes to the medical team result in poor patient outcomes.
The literature specified that respiratory therapists are best equipped to manage, adjust and document ventilator care, and the number of healthcare professionals authorized to make ventilator adjustments should be limited. All ventilators have alarms when ventilation changes occur, and staff must know how to respond appropriately.
Resident #2's orders required respiratory therapist involvement for tracheostomy tube changes and other specialized interventions. The care plan dated April 2, 2025, established goals to maintain oxygen levels at provider-specified targets and included detailed protocols for aerosol treatments, suction procedures, and equipment maintenance.
The facility's staffing schedule showed that during the December 26 overnight shift from 6 p.m. to 6 a.m., only three LPNs were present to care for residents requiring complex medical interventions. No registered nurses or respiratory therapists were available to provide the supervision required for ventilator-dependent patients.
The director's assumption that daytime RN coverage satisfied regulatory requirements left the facility's most vulnerable resident without appropriate professional oversight for 12 hours. His admission that LPNs received informal training rather than formal certification highlighted gaps in staff preparation for life-sustaining respiratory care.
Inspectors documented the violation after investigating a complaint filed with state health officials. The deficiency represents a failure to provide adequate nursing services and ensure residents receive care from qualified professionals according to their individual needs and physician orders.
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.