Belpre Landing Nursing And Rehabilitation

F 0684 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

multiple sclerosis. The DON confirmed the care plan said to monitor resident for elevated temperature despite the fact that her temperature drops once she has an infection due to multiple sclerosis. The DON confirmed their (electronic) system triggered multiple low temperatures for Resident #2 (as noted on the dates above) with no evidence of staff follow-up (comprehensive assessments) or notification to the physician documented. The DON stated there was increased monitoring of Resident #2's room temperature since she was re-admitted to the facility on [DATE REDACTED] but could not provide evidence of increased monitoring of Resident #2's body temperature. Per the DON, resident vital signs are typically obtained once per shift.

On 01/28/26 at 4:35 P.M. Resident #2 was observed in her room. The room felt cool, but not cold. During

the observation, the resident did not voice any current concerns related to her care by staff. The resident stated she was comfortable at this time and did not feel too cold. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Belpre Landing Nursing and Rehabilitation

1915 Hill Street Belpre, OH 45714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695

and site care revealed the following:

Level of Harm - Minimal harm or potential for actual harm

Respiratory Therapist (RT) #160 applied a protective gown, performed hand hygiene and donned non-sterile gloves. RT #160 was not observed to be wearing a mask. Observation of the bedside table revealed personal items were located on one-side of the table and treatment supplies were placed on the other side. There was no barrier or sterile field used for the tracheostomy supplies. RT #160 opened the tracheostomy care kit, split drain gauze, hydrogen peroxide and sterile saline. RT #160 removed the blue sterile gloves from the tracheostomy care kit and stated the sterile gloves were a medium size and did not fit his hands. RT #160 was observed throwing the sterile gloves in the trash. RT #160 removed the sterile items from the tracheostomy kit with non-sterile gloves, poured sterile water and hydrogen peroxide into the kit cleaning tray and inserted a split 4x4 gauze into the solution. RT #160 folded the gauze in half and cleaned around the lower aspect of Resident #2's tracheostomy stoma and disposed of the gauze. RT #160 grasped a second split 4x4 gauze with the same non-sterile gloves, inserted the gauze into the solution, cleaned around the upper aspect of Resident #2's tracheostomy stoma and disposed of the gauze. RT #160 removed his non-sterile gloves and disposed of them into the trash. RT #160 washed his hands at the sink, donned non-sterile gloves, returned to the bedside and placed a split gauze around the resident's tracheostomy stoma. RT #160 removed his gloves, washed his hands at the sink and donned non-sterile gloves. RT #160 grasped a sterile disposable tracheostomy inner cannula with his non-sterile gloved hand, disconnected the ventilator tubing, removed the used inner cannula from the resident's tracheostomy and inserted a new disposable inner cannula. RT #160 disposed of the used inner cannula, reattached the ventilator tubing to the tracheostomy, removed his gloves and isolation gown, and washed his hands at the sink. RT #160 stated the procedure was completed using a non-sterile procedure.

Residents Affected - Few

On 01/28/26 at 3:34 P.M., interview with the Director of Nursing verified tracheostomy care was to be completed using sterile technique including sterile gloves, use of a barrier for supplies and appropriate personal protective equipment including a mask should be used.

On 01/28/26 at 3:45 P.M., interview with RT #160 verified he did not use a barrier or wear a mask during tracheostomy care but stated he was arms length away from the resident during the procedure. RT #160 verified he wore non-sterile gloves because the sterile gloves in the tracheostomy kit were a medium size and he required a large sized glove. RT #160 verified the facility did have sterile gloves available to use but

the procedure did not require a sterile procedure. RT #160 verified the facility policy was to use sterile techniques at all times; however, RT #160 stated the policy was wrong.

Review of the undated policy: Tracheostomy and Tracheostomy Tube Care revealed a tracheostomy was a surgical opening in the trachea. Meticulous tracheostomy and trach tube care was mandatory to prevent complications. Since the tracheostomy was essentially an open wound and the normal protective mechanism in the upper airway are bypassed, the most hazardous complication was infection and prevention of infection was the primary goal of proper tracheostomy care techniques. To minimize the potential hazard of tracheostomy wound (stoma) infection the area was to be cleansed regularly using sterile technique at all times. To minimize the potential hazard of acute bronchopulmonary infection due to contamination of the artificial airway the inner cannula was to be cleaned regularly using sterile technique at all times.

This deficiency represents an incidental finding of non-compliance investigated under Complaint Number

1. 2702282. FORM CMS-2567 (02/99)

Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Belpre Landing Nursing and Rehabilitation

1915 Hill Street Belpre, OH 45714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

report any abnormalities to provider; nursing to monitor resident and assess for effectiveness of respiratory treatment: vitals, lung sounds, mental status, skin color, and report abnormalities to provider, nursing to assure set up of all required equipment and clean up after; provide oxygen as ordered; and provide respiratory treatment as ordered. Review of a care plan dated 04/02/25 revealed Resident #2 had an alteration in respiratory function and required a tracheostomy and ventilator. Goals included oxygen level to be kept at desired levels set per provider through the review date. Interventions included but were not limited to administer oxygen as ordered; aerosol treatments as ordered; change aerosol nebulizer set-up as ordered; change closed suction catheter system as ordered; change heated moisture exchange as ordered; change size six Shiley tracheostomy inner cannula as ordered; change trach ties as ordered; change ventilator circuit as ordered; cleanse tracheostomy site as ordered; ensure ventilator is on proper settings per orders: AC/VC via tracheostomy continuous, PC 22, RR 20, I time 1.2, PEEP 6, FIO2 32%, ventilator checks every four hours; medications as ordered; monitor lung sounds as ordered; monitor oxygen levels as ordered; and observe for signs and symptoms of dyspnea: labored respiration, low oxygen, use of accessory muscles, cyanosis, changes in mental status, and tachypnea; provide inhalers as ordered; respiratory therapist to change tracheostomy tube every 35 to 40 days and as needed; and suction trach per orders. Review of orders dated 12/24/25 revealed Resident #2's ventilator circuit needed changed monthly and as needed, HME needed changed daily and as needed, a respiratory therapist was to change tracheostomy tube every 30 to 45 days and as needed with a size six Shiley, change size six Shiley tracheostomy inner cannula every shift and as needed, and cleanse tracheostomy site with sterile water, pat dry, and apply a drain sponge every shift and as needed. Review of staffing schedules from 12/25/25 through 12/31/25 revealed on 12/26/25 for nightshift (6:00 P.M. to 6:00 A.M.) there were three licensed practical nurses (LPNs) working and no Respiratory Therapists (RTs) or Registered Nurses (RNs).

Interview on 01/28/26 at 3:34 P.M. with the Director of Nursing (DON) confirmed there was not an RN or RT working the nightshift of 12/26/25, but there were three LPNs. The DON stated 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 if an LPN was permitted to provide ventilator care without the supervision of an RN or RT, he stated since the LPNs received an education and watched ventilator care being performed, he felt the LPNs could work with ventilator residents without supervision despite lack of certification or return demonstration completed. The DON was not sure if ventilator care was in the scope of an LPN's practice. Review of the National Library of Medicine literature dated 08/08/23 revealed mechanical ventilators are sophisticated and require training to ensure positive outcomes and limit harm. Inappropriate setting changes, failure to change alarms, changing settings without appropriate orders, and failure to communicate changes to the medical team result in poor patient outcomes. The individual who is best equipped suited to manage, adjust and document the ventilator is the respiratory therapist and the number of healthcare professionals who are allowed to make adjustments to the ventilator should be limited. All ventilators have alarms when there is a change in ventilation and it is vital to know what to do. This deficiency represents non-compliance investigated under Complaint Number 2702282.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Belpre Landing Nursing and Rehabilitation

1915 Hill Street Belpre, OH 45714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of the facility assessment and interview, the facility failed to ensure the facility assessment was completed accurately. This had the potential to affect all residents in the facility. The facility census was 49.

Findings include:Review of the facility assessment dated [DATE REDACTED] revealed the facility treats a wide range of patients transitioning from hospital to home. Prior to the admission of any resident, the Director of Nursing (DON) along with the interdisciplinary team would assess the physical and psychosocial needs to determine if placement is appropriate. Prior to a new admission arriving at the facility, all care related items not currently in the facility are ordered. Special treatments that could be completed in the facility included, but were not limited to, respiratory treatments. Respiratory treatments that could be completed in the building included oxygen therapy (15), suctioning (5), tracheostomy care (0), and ventilator or respirator care (2). Further review of the facility assessment did not include information of staffing needs for residents receiving respiratory services. Interview on 01/22/26 at 4:32 A.M. with Respiratory Therapist (RT) #172 revealed there were two residents with a tracheostomy and two residents with ventilators. Interview on 01/28/26 at 1:14 P.M. with the Administrator revealed in the facility assessment, they entered the average number of residents they usually have with the care needs rather than the number of residents the facility is able to provide care for based on their needs. The Administrator stated they were able to admit ten residents with ventilators in the facility. The Administrator confirmed the facility assessment was not completed based on what services they were able to provide, but rather the average number of residents

they have needing those services, and there was no specific number of staffing requirements or types listed to address the needs of those residents on a ventilator or receiving trach services. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.

Event ID:

Facility ID:

If continuation sheet