Belle Terrace

In the surveyor’s words

From the most serious findings on record at Belle Terrace, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Aug 1, 2024

  Based on policy review and staff interview, it was determined that the facility did not have a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control. Findings include: Review of the facility policy entitled, Infection Prevention and Control Plan, last reviewed March 28, 2024, revealed that the IP was to provide oversight for the infection prevention and control program, conduct surveillance of any facility and community associated infections, and serve as a resource to all staff regarding infection prevention and control. In an interview on August 1, 2024, at 1:15 p.m., the Administrator stated the facility did not have a qualified Infection Preventionist. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. […]

• No harm, potential for more than minimal, widespreadF812Nov 6, 2023

  Based on observation, review of facility documentation, and interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on the nursing unit. Findings include: Observation of the kitchen on November 6, 2023, at 9:41 a.m., revealed a white substance on the shelves in the walk-in refrigerator. There was a black substance and particles of debris on the floor of the same refrigerator. There were two opened packages of cheese with open dates of September 2, 2023, and October 15, 2023. There were no use-by dates on the packages. In an interview at the time, the Director of Dining Services stated that the opened packages should be used or discarded within seven days. […]

• No harm, potential for more than minimal, patternF584Dec 5, 2025

  Based on observation, it was determined that the facility failed to maintain the environment in a clean, comfortable, and homelike manner on two of two nursing units. (A and B wing)Findings include: Observations on December 3, 2025, from 10:45 a.m. through 2:00 p.m., and on December 4, 2025, from 10:45 a.m. through 2:00 p.m., revealed the following environmental issues: In the shower room on A wing, the first room to the right of the door had a sink with brown stains and the faucet had white stains on it. The toilet had a black ring inside. In the shower room's central shower area, there were open holes in the wall around the shower valve system where the water flow and temperature were controlled. […]

• No harm, potential for more than minimal, patternF607Jan 16, 2025

  Based on facility policy review, employee file review, and staff interview, it was determined that the facility failed to initiate an employee criminal background check, verify professional license/registration, and/or ensure employees completed required abuse training in a timely manner for six of six newly hired employees. (Employees RN 1, RN 2, RN 3, NA 1, NA 2, DA 1) Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, last reviewed October 10, 2024, revealed that the facility was to screen potential employees for a history of abuse, neglect, or mistreating residents prior to employment. […]

• No harm, potential for more than minimal, patternF880Aug 1, 2024

  Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on two of two nursing unit wings. (A Wing, B Wing) Findings include: Review of the facility policy entitled, Transmission Based Precautions, last reviewed March 28, 2024, revealed that transmission based precautions (TBPs) may include contact precautions, droplet precautions, airborne precautions, and enhanced barrier precautions that vary with how restrictive they are in requiring certain personal protective equipment (PPE). If a resident is identified as having a communicable disease, then TBPs are to be initiated. […]