Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belle Terrace during CMS and state inspections, most recent first.
Unclean and Damaged Resident Areas: Surveyors observed multiple environmental issues across A wing and B wing, including stained sinks, toilets, faucets, tubs, mirrors, and shower areas, open holes in walls, marred walls, and debris on bathroom and resident room floors. In one resident room, surveyors also found four plastic wrappers, a large syringe without a needle, and a clock displaying the wrong time; other rooms had paper, tissue, food debris, and a used brief on top of a garbage can.
Failure to assess a resident for self-administration of an inhaler. A resident with COPD, muscle weakness, intact cognition, and oxygen use had a specialist and attending MD recommend daily inhaler use with the inhaler kept in his room for immediate use upon awakening. Instead, the MAR directed staff to give the inhaler in the morning, the inhaler was locked in the med cart, and the DON confirmed the resident was not assessed for self-administration per facility policy and the MD orders.
The facility failed to ensure accurate MDS assessments for two residents. One resident’s Section C was incomplete, and another resident’s MDS incorrectly stated that hospice services were not received during the prior 7 days even though the resident had started hospice services. The Administrator and DON confirmed the assessment errors.
A resident with depression received trazodone during the review period, and the MDS CAA summary indicated psychotropic drug use should be addressed in the care plan. However, there was no documented evidence that interventions for the resident’s psychotropic drug use were included in the current care plan, and the DON confirmed this during interview.
Failure to honor a resident’s food preferences. A resident with anxiety, GERD, and MDD was alert and able to make needs known, but her lunch tray contained spaghetti even though she stated she did not like pasta and would not eat it. Her tray card also indicated she did not like pasta, and the Administrator stated dietary did not follow the resident’s food preferences on the meal ticket.
Failure to use enhanced barrier precautions during feeding tube care. A resident with dysphagia, lung cancer, and an enteral feeding tube had a physician order and care plan directing enhanced barrier precautions for infection control. During observed med and nutrition administration through the feeding tube, an LPN did not wear a gown as required by facility policy, and the Administrator confirmed the gown should have been worn.
A resident with complex medical conditions did not receive a chest X-ray or a stool specimen collection as ordered by the physician. Documentation confirming completion of these diagnostic tests was missing, and the DON verified that the orders were not carried out.
Three residents at risk for pressure ulcers did not receive prescribed interventions, including heel boots and heel elevation, as ordered by physicians and outlined in their care plans. Observations confirmed that two residents were in bed without the required protective devices, and a third had heels resting directly on the bed instead of being floated. The DON confirmed these interventions were not provided as ordered.
The facility failed to conduct necessary background checks, verify licenses, and ensure abuse prevention training for six newly hired staff, including RNs and NAs, as per its policy. This oversight was confirmed by the administrator and identified through employee file reviews.
A resident with dysphagia and dementia was observed during lunch with most of her meal uneaten and food on her sweater. She was biting and licking the food on her sweater instead of using utensils, and staff did not redirect her, failing to promote dignified dining.
The facility did not report an abuse incident involving two residents to the Administrator and the State Survey Agency as required. A resident with cognitive decline and Alzheimer's disease threatened and physically assaulted another resident. The staff delayed notifying the Administrator and failed to report the incident to the State Survey Agency, as confirmed by the DON.
A facility failed to follow a physician's order to float a resident's heels, who was at risk for pressure ulcers due to limited mobility and heart failure. Despite the order given in March 2024, observations in January 2025 showed the resident's heels were directly on the bed, and the resident confirmed the staff's non-compliance.
A facility failed to provide and document ostomy care for a resident with an ileostomy, as required by the care plan. The resident, diagnosed with dementia, did not have their ostomy supplies changed from admission until six days later, when physician orders were finally put in place. The Director of Nursing confirmed the lack of documentation, and a family member reported that the supplies had not been changed since admission.
A resident with anxiety and Alzheimer's was prescribed melatonin and trazodone at bedtime. A pharmacist recommended reviewing the necessity of both medications and possibly discontinuing melatonin. The physician did not address this recommendation for two months, contrary to the facility's policy of addressing such recommendations within five to seven days.
The facility did not conduct QAA meetings with all required members for two quarters in 2024, as the Medical Director was absent. This was confirmed by reviewing QAPI sign-in sheets and an interview with the Administrator.
The facility did not follow its infection control policies for two residents. A physician failed to wear a protective gown while examining a resident with a Stage 3 pressure sore, and an LPN did not wear a gown while flushing a feeding tube for a resident with a history of stroke. These actions were against the facility's Enhanced Barrier Precautions policy.
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers, including reasons for the transfers and Ombudsman information. This deficiency was identified for three residents who were transferred due to changes in their conditions. The Administrator confirmed that the required written notices were not provided.
The facility did not meet the required nurse aide (NA) to resident ratios on multiple occasions. During the reviewed period, the day shift was understaffed on several days, failing to provide one NA per ten residents. The evening shift on one day did not meet the required one NA per eleven residents, and the night shift was below the required one NA per fifteen residents on multiple days. These deficiencies were identified through a review of nursing time schedules.
The facility did not meet the required LPN to resident ratios, failing to provide one LPN per 25 residents during the day shift on nine out of fourteen days reviewed. This deficiency was identified through nursing schedule reviews and staff interviews.
The facility failed to implement physician's orders for two residents, resulting in deficiencies in care. One resident did not receive prescribed treatment for a surgical incision, while another did not receive ordered medications and treatments for metabolic encephalopathy and cellulitis. The lack of documentation was confirmed by the Manager on Duty.
The facility was found deficient for not having a qualified Infection Preventionist (IP) as required by its policy. The IP is responsible for overseeing the infection prevention and control program, conducting infection surveillance, and serving as a resource for staff. The Administrator confirmed the absence of a qualified IP, violating specific state codes related to resident care policies and nursing services.
The facility did not follow its infection control policies by failing to post required signs for transmission-based precautions for residents who tested positive for COVID-19. This oversight involved 13 residents across two nursing unit wings, where no signs were posted outside their rooms to inform staff and visitors of necessary precautions, as confirmed by the Administrator.
The facility failed to provide a clean, homelike, and comfortable environment on A-wing and B-wing. Observations included holes in partition walls in several rooms, detached molding exposing a large hole in the hallway, and holes in the sheetrock in a shared bathroom and under a window in a resident's room.
Unclean and Damaged Resident Areas
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on two nursing units, A wing and B wing. Observations in the shower room on A wing found a sink with brown stains, a faucet with white stains, a toilet with a black ring inside, and open holes in the wall around the shower valve system in the central shower area. The bathtub room had a marred wall, blue and brown stains inside the tub and around the drain and faucet area, white stains on the faucet, and the shower stall had a brown ring where the floor met the wall and a large gray stain on the floor. In the bathroom shared by resident rooms [ROOM NUMBERS], surveyors observed stains on the mirror, a brown ring on the toilet base, a marred wall behind the toilet, a used brief opened and laying across the top of the garbage can, and paper garbage on the floor. In resident room [ROOM NUMBER] (bed 1), there were four plastic wrappers and a large syringe without a needle on the floor, and the clock displayed the wrong time. Additional observations included a hole in the wall in the hallway between resident rooms [ROOM NUMBERS], a plastic lid, tissue, and paper debris on the floor in another resident room [ROOM NUMBER] (bed 1), a full garbage can with paper and food debris on the floor around the bed in another resident room [ROOM NUMBER] (bed 1), and marred walls along the length of the wall adjacent to the toilet in bathrooms of resident rooms [ROOM NUMBERS].
Failure to Assess Resident for Self-Administration of Inhaler
Penalty
Summary
The facility failed to assess whether Resident 19 was clinically appropriate to self-administer an inhaler medication. Resident 19 had diagnoses including COPD and muscle weakness, and the MDS dated October 10, 2025, indicated that his cognitive ability was intact and that he used oxygen. On October 31, 2025, a consulting specialist physician recommended that Resident 19 start an inhaler for COPD daily and stated that the inhaler must be kept in his room so it could be taken immediately upon awakening; the attending physician agreed with this recommendation. The medication administration record showed an order dated October 31, 2025, updated November 14, 2025, directing staff to administer one puff of the inhaler in the morning at 7:00 a.m. There was no indication that Resident 19 was evaluated for self-administration of the inhaler before December 4, 2025. During an observation in his room on December 4, 2025, Resident 19 stated that the inhaler was not readily available and was locked in the medicine cart. He said the specialist told him to self-administer it when he awakened and expressed frustration that nursing staff were not following the physician's recommendation. On December 5, 2025, the DON confirmed that the resident had not been assessed to self-administer the medication in accordance with facility policy and the physician's orders prior to December 4, 2025.
Incomplete and Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the current status of two residents. For one resident, Section C of the MDS assessment was incomplete. For another resident, who began receiving hospice services on November 13, 2025, the MDS assessment incorrectly stated in Section O that hospice services were not received during the previous seven days. During interviews, the Administrator confirmed the first assessment was incomplete and the DON confirmed the second assessment was inaccurate.
Failure to Address Psychotropic Drug Use in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet Resident 1’s needs as identified in the comprehensive assessment. Resident 1 was admitted with diagnoses that included depression, and the MDS Care Area Assessment summary dated January 22, 2025 indicated that psychotropic drug use was to be addressed in the care plan. Review of the MAR from January through December 2025 showed the resident received trazodone, an antidepressant, during the review period, but there was no documented evidence that interventions to address the resident’s psychotropic drug use were included in the current care plan. During an interview on December 5, 2025, at 10:00 a.m., the DON confirmed there was no documented evidence that the care area was addressed in the resident’s current care plan.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of one resident. Review of the weekly menu showed that lunch on December 3, 2025, was spaghetti noodles with meat, breadstick, tossed salad, and fruit cocktail. Resident 54’s clinical record showed diagnoses of anxiety, gastroesophageal reflux disease, and major depressive disorder, and the MDS indicated she was alert and able to make her needs known. During an interview, the resident stated that her meals did not match what was on her ticket and that she received foods she did not like. Her lunch tray was observed on her bedside table with spaghetti noodles and meat sauce. The resident stated that she did not like pasta, did not want spaghetti noodles, and would not eat them, and her tray card indicated a regular diet and that she did not like pasta. The Administrator stated that the dietary department did not follow the resident’s food preferences identified on the meal ticket.
Failure to Use Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions and use PPE for one sampled resident during medication administration. Facility policy for Enhanced Barrier Precautions, last reviewed on November 20, 2025, stated that staff were to wear a gown and gloves during high-contact resident care activities, including use of a resident's feeding tube, and for residents with indwelling medical devices to help minimize the spread of multidrug resistant organisms. Resident 4 had diagnoses including dysphagia and lung cancer, and the MDS dated November 18, 2025, documented an enteral feeding tube. A physician's order dated November 3, 2025, directed staff to implement enhanced barrier precautions every shift for infection control, and the care plan stated that Resident 4 received nutrition and medications through the feeding tube and that staff were to follow enhanced barrier precautions when providing care. During observation on December 4, 2025, an LPN administered medications and food through Resident 4's feeding tube without wearing a gown while providing feeding tube-related care. In interview on December 5, 2025, the Administrator confirmed that the LPN should have worn a gown when providing care related to the feeding tube.
Failure to Implement Physician's Orders for Diagnostic Tests
Penalty
Summary
The facility failed to implement physician's orders for one resident who had multiple diagnoses, including congestive heart failure, atrial fibrillation, muscle weakness, angiodysplasia of the stomach and duodenum, and pulmonary hypertension. The clinical record showed that there were physician's orders to schedule a chest X-ray for pleural effusion hypoxia and to obtain a stool specimen to rule out clostridium difficile. However, there was no documented evidence that either the chest X-ray or the stool specimen was completed as ordered. This was confirmed by the Director of Nursing during an interview.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent pressure ulcers for three residents who were identified as being at risk. For one resident with diagnoses including congestive heart failure, atrial fibrillation, muscle weakness, and pulmonary hypertension, staff did not apply heel boots as ordered while the resident was in bed, despite the care plan identifying a risk for skin breakdown due to immobility. Another resident with vascular dementia, diabetes, heart disease, and muscle weakness, who was nonresponsive and at risk for pressure ulcers, was observed in bed without the ordered Prevalon boots. The care plan for this resident also noted a risk for skin breakdown related to immobility and medical condition. A third resident, with diabetes and muscle weakness and identified as at risk for pressure ulcers, had a physician's order to float heels while in bed. However, observation revealed that the resident's heels were directly on the bed, contrary to the order. The Director of Nursing confirmed that the protective devices and interventions were not in place for these residents as required by their care plans and physician orders.
Failure to Conduct Employee Screening and Training
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the screening and training of newly hired employees, which led to deficiencies in preventing abuse, neglect, and theft. Specifically, the facility did not conduct criminal background checks, verify professional licenses or registrations, or ensure that required abuse prevention training was completed in a timely manner for six newly hired employees, including registered nurses, nurse aides, and a dietary aide. These lapses were identified through a review of employee files and confirmed by the facility's administrator. The facility's policy, last reviewed in October 2024, mandates screening potential employees for a history of abuse, neglect, or mistreatment before employment, including obtaining information from previous employers and checking with licensing boards and registries. Additionally, the policy requires educating staff upon hire and annually on preventing abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. However, the facility failed to comply with these requirements for the six employees, as evidenced by missing background checks, unverified licenses, and incomplete training records.
Plan Of Correction
Employees RN1, RN2, RN3, NA1, NA2, and DA1 files were immediately reviewed and missing documents were obtained. These employees also received abuse training per policy. Current employee files were audited. Any missing documentation or education will be completed. NHA/designee will educate HR on the components of this regulation with emphasis to obtain required documents & employees receiving required education upon hire. NHA or designee will audit new hire files to ensure appropriate documentation & abuse training is present. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Assist Resident with Dignified Dining
Penalty
Summary
The facility failed to provide assistance with dining in a manner that promoted dignity for a resident with dysphagia, dementia, and a need for assistance with personal care. The resident, who had neurological deficiencies and a history of weight loss, was observed during lunch with more than 75% of the meal uneaten. The resident was sitting at a table with food on her sweater and was seen biting at and licking the food on her sweater instead of using utensils or eating from her tray. The resident continued to chew and suck on her sweater for the entire observation period without being redirected by staff.
Plan Of Correction
Resident 5 was offered assistance with the remaining portion of her meal but declined. Her sweater was properly cleaned. An audit of current residents was conducted to ensure residents were provided with proper assistance during meals. DON or designee will educate nursing staff on the components of this regulation, with emphasis on ensuring residents are assist/redirected as needed during meals. DON or designee will conduct audits at meal times to ensure residents are offered assistance/redirected as needed during meals. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the Administrator and the State Survey Agency as required by their policy. Resident 41, who has diagnoses including anxiety, cognitive decline, and Alzheimer's disease, was observed by staff to have placed a brief over Resident 16's head, punched Resident 16, and threatened to harm her with a heavy object. Resident 41 also expressed a desire to kill Resident 16 multiple times during the shift. Despite these serious allegations, there was no evidence that the staff notified the Administrator until the evening shift, and the incident was not reported to the State Survey Agency. The Director of Nursing confirmed these lapses in protocol during interviews conducted on January 16, 2025.
Plan Of Correction
NHA was notified of allegation of abuse related to Resident 41. Report to DOH will be submitted. A review of current residents was completed over the last 30 days to ensure any allegations of abuse were reported. DON and/or designee will educate staff on the components of this regulation with emphasis on timely reporting of abuse to the NHA. DON or designee will audit abuse allegations for timely reporting to NHA. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Implement Physician's Orders for Heel Elevation
Penalty
Summary
The facility failed to implement physician's orders for a resident with diagnoses including heart failure and reduced mobility. The resident was assessed to be at risk for pressure ulcers and had limited mobility in her lower legs. On March 12, 2024, a physician ordered that the resident's heels be floated while in bed to prevent pressure ulcers. However, observations on January 14 and 15, 2025, revealed that the resident's heels were directly on the bed, contrary to the physician's orders. The resident confirmed that staff had not been floating her heels as required.
Plan Of Correction
Resident 40 heels were elevated to float heels. Current residents with orders to float heels were audited to ensure heels were elevated. DON/designee will educate nursing staff on the components of this regulation with emphasis on elevating residents' heels. DON or designee will perform an audit of 5 residents with float heels orders to ensure heels are floated. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Provide Ostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate ostomy care for a resident with an ileostomy, as outlined in the resident's care plan. The care plan required staff to keep the skin around the stoma clean and dry, monitor for skin irritation, and observe the stoma for unusual changes. However, there was no evidence in the clinical record that ostomy care was provided or that supplies were changed from the time of the resident's admission until six days later. This lack of documentation was confirmed by the Director of Nursing. The resident, who had a diagnosis of dementia, was admitted to the facility without any physician orders for ostomy care until six days after admission. The orders, once in place, specified that the ileostomy wafer should be changed every three days and the ileostomy bag once daily or as needed. A family member reported that the resident's ostomy supplies had not been changed since admission, highlighting the facility's failure to adhere to the care plan and document the necessary care.
Plan Of Correction
Resident 158 received ostomy care immediately. Physician orders for Resident R158 were updated to include ostomy care orders. Current residents with an ostomy were audited to ensure ostomy care physician orders were in place. DON and/or designee is providing staff with education related to timely implementation of ostomy physician orders. DON/designee will perform audit of new admissions to ensure ostomy orders are present. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review of pharmacy recommendations by a physician for one of the sampled residents. Resident 41, who had diagnoses of anxiety and Alzheimer's disease, was prescribed melatonin and trazodone at bedtime. On August 1, 2024, a pharmacist recommended that the physician review the necessity of both medications and consider discontinuing melatonin to reduce the resident's medication load. However, there was no evidence that the physician addressed this recommendation until October 1, 2024, and the melatonin was not discontinued until October 2, 2024. During an interview on January 16, 2025, the Director of Nursing confirmed that pharmacy recommendations should be addressed by the physician within five to seven days, but acknowledged that this did not occur in the case of Resident 41.
Plan Of Correction
Unabe to retroactively correct for Resident 41. An audit of current resident's pharmacy recommendations over the last 30 days were reviewed to ensure they were presented to the provider for review. DON will be educated on the components of this regulation, with emphasis on ensuring pharmacy recommendations are addressed timely. DON/designee will perform audit of 5 pharmacy recommendations. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
QAA Meetings Lacked Required Attendance
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for two of the four quarterly meetings in 2024. Specifically, the Medical Director did not attend the QAA meetings in the first and fourth quarters of 2024. This was confirmed through a review of the facility's Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records, as well as an interview with the Administrator on January 16, 2025, who acknowledged the Medical Director's absence from these meetings.
Plan Of Correction
Unable to retroactively correct this alleged deficient practice. No residents were identified to have been affected by this alleged deficient practice. NHA educated on the components of this regulation with emphasis on the need for the Medical Director to attend the QAPI Meetings. RDCS will audit QAPI sign in sheets to ensure Medical Director is present at least quarterly for QAPI meetings. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Infection Control Policy Breach
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically the Enhanced Barrier Precautions, for two residents. Resident 27, who had a Stage 3 pressure sore on his lower back, was examined by a physician who did not wear a protective gown as required by the facility's policy during high-risk activities. Similarly, Resident 35, who had a history of stroke and received nutrition through a feeding tube, was attended to by an LPN who flushed the feeding tube without wearing a gown, contrary to the facility's guidelines. These actions were observed during specific encounters and were not in compliance with the established infection control procedures.
Plan Of Correction
Unable to retroactively correct this alleged deficient practice. Resident 27 & 35 had no negative outcome related to alleged deficient practice. MD1 & LPN1 were provided education on EBP. An audit of current residents will be completed to ensure EBP is being followed by staff. DON/designee will educate direct care staff on the components of this regulation with emphasis on Enhance Barrier Precautions. DON/designee will conduct random audits of staff performing care in EBP rooms to ensure proper PPE is worn. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers and information about the Ombudsman. This deficiency was identified for three residents who were transferred to the hospital due to changes in their conditions. Resident 11 was transferred on October 12, 2024, after a change in condition, Resident 13 was transferred on December 11, 2024, following a fall and change in condition, and Resident 56 was transferred on November 4, 2024, after a change in condition. In each case, there was no documentation to support that the residents or their representatives received the required written information. The Administrator confirmed in an interview that the written notices were not provided.
Plan Of Correction
Resident 11 and 56 no longer reside in the facility. Unable to retroactively correct for resident 13. All residents have the potential to be affected by this alleged deficient practice, however the facility cannot retroactively correct. DON & NHA will be educated on the components of this regulation with emphasis on the need to provide written notification of transfers. NHA or designee will audit 3 hospital transfers to ensure written notification was completed. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios as mandated by the regulation effective July 1, 2024. A review of nursing schedules for the period from December 27, 2024, to January 2, 2025, and January 9, 2025, to January 15, 2025, revealed that the facility did not maintain the minimum staffing levels on several occasions. Specifically, the day shift (7:00 a.m. to 3:00 p.m.) was understaffed on January 9, 11, 12, 13, 14, and 15, 2025, failing to provide one NA per ten residents. The evening shift (3:00 p.m. to 11:00 p.m.) on January 9, 2025, did not meet the required one NA per eleven residents. Additionally, the night shift (11:00 p.m. to 7:00 a.m.) was below the required one NA per fifteen residents on December 31, 2024, and January 9, 10, 11, 12, 13, and 15, 2025. These deficiencies were identified based on a review of the nursing time schedules, indicating a failure to comply with the staffing regulations over eight of the fourteen days reviewed.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review CNA staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of CNA staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review CNA ratios to ensure ongoing compliance and systematic change. 4) NHA/Designee will conduct audit of projected CNA ratios. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift from 7:00 a.m. to 3:00 p.m. on nine out of the fourteen days reviewed. The days in question were December 27, 28, 29, and 30, 2024, and January 1, 2, 13, 14, and 15, 2025. This deficiency was identified through a review of nursing schedules and staff interviews, indicating a consistent shortfall in staffing levels during the specified period.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review LPN staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of LPN staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review LPN ratios to ensure ongoing compliance and systematic change. 4) NHA/Designee will conduct audit of projected LPN ratios. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Implement Physician's Orders for Two Residents
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to deficiencies in care. Resident 1, diagnosed with intervertebral disc displacement and morbid obesity, had a physician's order to cleanse and dress a surgical incision on the lower back. The treatment was not documented as completed on several days in July 2024, indicating a lapse in following the prescribed care plan. Resident 2, with diagnoses including metabolic encephalopathy and cellulitis of the lower extremities, also did not receive treatments as ordered. The application of ammonium lactate lotion, administration of doxycycline monohydrate, and Suboxone were not documented on specific days in August 2024. Additionally, a treatment involving moisturizing lotion and an ACE bandage was not documented over several days. The Manager on Duty confirmed the lack of documentation for these treatments and medications, highlighting a failure in executing physician's orders.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility was found to be deficient in its infection prevention and control program due to the absence of a qualified Infection Preventionist (IP). The facility's policy, last reviewed on March 28, 2024, mandates that the IP should oversee the infection prevention and control program, conduct surveillance of infections, and serve as a resource for staff. However, during an interview on August 1, 2024, the Administrator admitted that the facility did not have a qualified IP who had completed specialized training in infection prevention and control. This deficiency is in violation of 28 Pa. Code 211.10(d) regarding resident care policies and 28 Pa. Code 211.12(d)(1)(5) concerning nursing services.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding the implementation of transmission-based precautions (TBPs) for residents diagnosed with communicable diseases. The facility's policy, last reviewed on March 28, 2024, mandates that TBPs, including contact, droplet, airborne, and enhanced barrier precautions, be initiated for residents with communicable diseases. Additionally, a sign should be posted on the door of affected residents' rooms to inform staff and visitors to consult the nurse for further instructions on necessary precautions and personal protective equipment (PPE). However, during a clinical record review and observation on August 1, 2024, it was found that no such signs were posted outside the rooms of 13 residents who tested positive for COVID-19, thereby failing to alert staff and visitors of the required precautions. The deficiency was confirmed during an interview with the Administrator on August 1, 2024, who acknowledged that signs should have been posted on the doors of resident rooms when TBPs were necessary. This oversight occurred on both nursing unit wings, A Wing and B Wing, and involved rooms 20, 21, 22, 27, 34, 36, and 41, where the COVID-19 positive residents were located. The failure to post signs as per the facility's policy potentially compromised the infection control measures intended to prevent the spread of COVID-19 within the facility.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike, and comfortable environment on two of its nursing units, A-wing and B-wing. During a tour of these units, several deficiencies were observed. In rooms 27, 32, 36, and 47, there were holes in the partition wall between the residents' sleeping area and the bathroom. Additionally, on the right side of the B-wing hallway, there was detached molding where the floor met the wall, exposing a large hole. In the shared bathroom located between certain rooms, two round holes in the sheetrock were observed. Furthermore, in room [ROOM NUMBER]-2, there was a hole in the wall under the window. These observations indicate a failure to maintain a safe, clean, and comfortable environment for the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 612 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Quakertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quakertown Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Lifequest Nursing Center | 1.9 mi | ★★★★★ | 5 | 0 |
| Phoebe Richland Hcc | 2.8 mi | ★★★★★ | 6 | 0 |
| Valley Manor Rehabilitation And Healthcare Center | 6.2 mi | ★★★★★ | 7 | 0 |
| Community At Rockhill, The | 6.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.