Slate Belt Health & Rehabilitation Center
SLATE BELT HEALTH & REHABILITATION CENTER in BANGOR, PA — inspection on May 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on clinical record review, facility policy review, review of facility documentation, standards of
resident neglect that resulted in actual harm of a serious injury (fractured ribs and right patella - for Nursing Assistants, 11th edition dated January 2025, (comprehensive text used in nursing assistant training programs) revealed, when turning a person in bed you should turn the person toward you.
Review of facility documentation titled, Resident Handling Quiz, revealed staff should roll the resident towards them while performing care in bed and when rolling a patient on a bed, staff should stand on the side of the bed to which the patient would roll.
Review of the facility policy entitled, Safe Resident Handling and Body Mechanics Policy, dated November 18, 2024, revealed no specifics related to rolling a resident in bed.
Review of Nurse Aide (NA) 1's training record revealed she was educated on resident handling, including bed mobility during care, on April 1, 2026.
Review of Resident 10's clinical record revealed Resident 10 had diagnoses that included muscles weakness, Aphasia (difficulty speaking), and functional Quadriplegia (inability to use all four extremities due to an extreme physical limitation).
Review of Resident 10's Minimum Data Set assessment (periodic assessment of resident needs) dated February 11, 2026, revealed Resident 10 had cognitive impairment and was totally dependent on staff for toileting and bed mobility.
Review of Resident 10's clinical record revealed a nurse's note dated May 9, 2026 (6:10 a.m.), indicating Resident 10 rolled over the side of the bed away from the nurse aide and suffered a fall.
Review of Resident 10's nurse's' notes on May 9, 10, and 11, 2026, revealed Resident 10 was complaining of right knee pain.
Further review revealed on May 11, 2026, Resident 10 was sent to the emergency room where she was diagnosed with fractures (break or splinter of the bone into more than two fragments) of multiple right ribs and the right patella.
Review of facility documentation dated May 9, 2026, revealed Nurse Aide (NA) 1 rolled the resident away from her to change her brief and the resident rolled off the other side of the bed. In an interview on May 28, 2026, at 10:20 a.m., Resident 10 stated I hurt and my leg. In an interview on May 28, 2026, at 1:30 p.m., the Director of Nursing confirmed that NA 1 failed to roll Resident 10 towards her during care.
The Director of Nursing also confirmed that NA 1 was educated regarding this upon hire and that it would be expected that staff roll residents towards them during care as they are trained to do. 28 Pa.
Code 201.14(a) Responsibility of licensee.28 Pa.
Code 201.18(b)(1) Management.28 Pa.
Code 201.29(a) Resident rights.28 Pa.
Code 211.10(d) Resident care policies.28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.