Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation and interview, the facility failed to ensure dependent residents received
assistance with activities of daily living (ADL) and grooming as needed. This affected two residents (#7,
#53) of three sampled residents. The census was 48.
Residents Affected - Few
Findings include:
1. Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including chronic
respiratory failure with hypercapnia, end stage renal disease, hemodialysis and ventilator dependence.
Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #7 was
cognitively intact for daily decision-making.
Review of the Shower Sheets and Bathing Daily Task List dated April and May 2024 revealed Resident #7
receives a bed bath daily. There was no documentation of her hair being washed or assistance provided to
remove her facial hair.
Review of the care plan: Require Assistance with ADL's related to debility and weakness dated 03/13/24
revealed Resident #7's ADL goal was to remain well-groomed and free of odors at all times. Interventions
included weight bearing assistance with care including personal hygiene.
On 05/06/24 at 8:55 A.M., observation revealed Resident #7 had long black facial hairs extending from her
chin, around her mouth and sides of her face. Her black hair had large white dandruff-like skin loosely
scattered throughout her hair that was readily observed. Interview with Resident #7 at the time of the
observation revealed it had been at least three weeks since staff washed her hair, she requires medicated
shampoo and she wanted her facial hair removed. Resident #7 further stated sometimes she will wear a hat
when out of her room or at the dialysis center to cover up the loose, white flakes of skin in her hair from
being seen.
On 05/08/24 at 4:36 P.M., interview with State Tested Nurse Aide #10 stated showers were completed on
day shift and Resident #7 required assistance with shaving and washing her hair. STNA #10 verified she
had noticed the above observations prior to today.
On 05/08/24 at 4:45 P.M., observation of Resident #7 revealed her facial hair was removed and hair
washed. Resident #7 voiced appreciation to have her facial hair removed and hair washed.
2. Medical record review revealed Resident #53 was admitted on [DATE] with diagnoses including
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
366443
Printed: 05/15/2026
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
366443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
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 0677
unspecified dementia, hypertension, hyperlipidemia, GERD, osteoporosis, anxiety disorder and depression.
Level of Harm - Minimal harm
or potential for actual harm
Review of the 5-day MDS assessment dated [DATE] revealed Resident #53 was severely impaired for daily
decision-making.
Residents Affected - Few
Review of the Task List revealed Resident #53 required supervision or touching assist with hygiene.
Review of the care plan: Requires Assistance with ADL's dated 02/26/24 revealed goals included for
Resident #53 to remain well-groomed and free of odors at all times. Resident #53's interventions included
non-weight bearing assistance with personal hygiene.
On 05/06/24 at 10:23 A.M., observation revealed Resident #53 was sitting in a chair in the lounge area.
Observation of the fourth and fifth digit on her right hand revealed her fingernails were broken and jagged.
The resident stated it had been like that for three days and she did not have a file or clippers to trim her
nails.
On 05/06/24 at 10:27 A.M., interview with Therapy #14 verified the observation and stated she would inform
the aide because the resident required staff assistance with nail care.
This deficiency represents non-compliance investigated under Complaint Number OH00152983.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366443
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
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
366443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
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
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review and interview, the facility failed to ensure competent nursing staff
administered intravenous medications. This affected one (#47) of five residents observed for medication
admininstration. The census was 48.
Findings include:
Medical record review revealed Resident #47 was admitted on [DATE] with diagnoses including sepsis,
diabetes mellitus, and history of embolism.
Review of the electronic Physician Orders dated May 2024 revealed intravenous medications including
Meropenem (antibiotic) 1000 milligrams (mg) intravenous (IV) every 12 hours.
On 05/06/24 at 10:53 A.M., observation revealed Licensed Practical Nurse (LPN) #4 flushed Resident #47's
left upper extremity PICC line (peripherally inserted central catheter) with 10 cc of normal saline and then
administered Meropenem 1000 mg IV.
Review of the eLicense Ohio Professional Licensure dated 05/09/24 revealed LPN #4's license was issued
on 04/24/17 and was currently active for sub-category: medications. There was no evidence LPN #4 was
certified for IV administration.
On 05/06/24 at 10:53 A.M., interview with Licensed Practical Nurse #4 verified the Meropenem IV was
scheduled to be administered at 8:00 A.M. and it was administered late due to training new staff and being
behind.
On 05/09/24 at 12:01 P.M., electronic interview with the Director of Nursing (DON) revealed LPN #4
received her training on 08/17/23 through the company staff educator. The facility provided check marked
skill competency from the company staff educator; however, the facility did not provide evidence the IV
training provided met the Ohio Board of Nursing requirements. The DON further provided an electronic
quote stating the following, On April 6, 2023 House [NAME] 509: The implication of 4723.17 being
rescinded, and the rule being eliminated, is that LPNs will no longer be required to take education specific
to IV skills and knowledge in order to perform specific IV skills. In other words, performing IV skills as
outlined in the LPN scope is now a default ability for all LPN's.
This deficiency represents incidental findings of non-compliance investigated under Complaint Number
OH00152983.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366443
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
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
366443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, policy review and interview, the facility failed to ensure medications
were stored appropriately and administered when dispensed. This affected two residents (#1, #3) from one
of three medication carts observed during medication administration. The census was 48.
Findings include:
Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including asthma and
atrial fibrillation.
Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including
arteriosclerotic heart disease.
On 05/06/24 between 7:12 A.M. and 7:16 A.M., interview and observation revealed the 100 hall medication
cart top drawer was opened by Registered Nurse (RN) #2 and she stated unfortunately she had already
pre-poured several resident medications for the morning medication administration. RN #2 stated she
sometimes did this depending on what kind of day it was going to be and what all was going on.
Observation of the top medication drawer revealed two clear medication cups labeled with a number written
in black marker on the outside of the cup. The medication administration cup labeled '#3' contained five
tablets and one capsule. A second medication administration cup labeled '#4' contained eight tablets. The
medications were unable to be identified and there was no resident name or date/time on the cup to identify
who's medications they were.
On 05/06/24 at 7:16 A.M., interview with Registered Nurse #2 verified she dispensed the medications
earlier that morning. RN #2 was observed removing the medication cup out of the drawer and then
administered it to the resident.
Review of the policy: Medication Administration General Guidelines (dated December 2012) revealed
medications were to be administered at the time they were prepared.
This deficiency represents incidental findings of non-compliance investigated under Complaint Number
OH00152983.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366443
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
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
366443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, policy review and interview, the facility failed to ensure medications
were administered without error. This affected two (#5, #47) of five residents observed during 25 medication
opportunities with four medications errors. The medication administration error rate was 16%. The census
was 48.
Residents Affected - Few
Findings include:
1. Medical record review revealed Resident #5 was admitted on [DATE] with diagnoses including atrial
fibrillation, unspecified sequelae of cerebral infarction and constipation.
Review of the electronic Physician Orders dated May 2024 revealed an order for Resident #5 to receive
senna (laxative) 8.6 milligrams (mg) for bowel management.
On 05/06/24 at 7:19 A.M., observation of Resident #5's morning medication administration revealed
Registered Nurse (RN) #2 administered lisinopril, Hydralazine, toprol xl, benicar and senna plus
(combination of a stool softener and laxative) 8.6 mg/50 mg.
On 05/06/24 at 7:23 A.M., interview with RN #2 verified the above medications were administered to
Resident #5. RN #2 verified the resident was ordered a laxative (senna) and received a stool softener and a
laxative (senna plus).
2. Medical record review revealed Resident #47 was admitted on [DATE] with diagnoses including sepsis,
diabetes mellitus, and history of embolism.
Review of the electronic Physician Orders dated May 2024 revealed scheduled orders including lispro
flexpen (insulin) 16 units before meals, Meropenem (antibiotic) 1000 milligrams (mg) intravenous every 12
hours and Lactobacillus 100 mg orally every morning.
On 05/06/24 at 10:53 A.M., observation revealed Resident #47 was administered her morning medications
including her insulin that was scheduled to be administered between 7:00 A.M. and 8:00 A.M., IV antibiotic
that was scheduled to be administered at 8:00 A.M. and only 50 mg of Lactobacillus was administered.
On 05/06/24 at 10:53 A.M., interview with Licensed Practical Nurse #4 verified the above medications were
not administered as ordered (insulin was administered after breakfast and not before a meal, IV antibiotic
was not administered within 12 hours of the previous dose, and Lactobacillus was only administered at 50
mg instead of the physician ordered 100 mg).
Review of the policy: Medication Administration General Guidelines dated December 2012 revealed
medication were to be administered in accordance with written orders of the prescriber
This deficiency represents non-compliance investigated under Complaint Number OH00152983.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366443
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
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
366443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, policy review and interview, the facility failed to initiate enhanced barrier
precautions as required. This affected one (Resident #37) of three sampled residents and the potential to
affect all 48 residents. The facility identified 21 residents on enhanced barrier precautions (EBP).
Residents Affected - Many
Findings include:
Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including Parkinson's
disease, diabetes mellitus and a history of Extended-spectrum beta-lactamases (ESBL).
Review of the Physician Orders dated 04/01/24 revealed the resident was on enhanced barrier precautions
due to a history of ESBL and multi-drug resistant organism E-coli.
On 05/06/24 at 9:00 A.M., observation revealed no EBP sign was posted outside Resident #37's room.
On 05/08/24 at 10:01 A.M., observation revealed EBP sign was posted outside Resident #37's room and
Licensed Practical Nurse (LPN) #16 was observed in the room removing a trash bag of soiled items without
the use of gloves or gown. Soiled bed linens and a hospital-like gown was observed on the floor just inside
the resident's room by the door. As LPN #16 was leaving Resident #37's room, she asked State Tested
Nurse Aide (STNA) #18 to gather up the soiled linen and remove it from the room. At that time, STNA #18
was observed entering Resident #37's room without washing her hands or applying personal protective
equipment. STNA #18 proceeded to gather the soiled linens with her bare hands, placed them in a clear
bag, left the room without washing her hands and walked down the hallway. At the time of the observation,
Housekeeping Supervisor (HSKP) #20 was walking down the hallway and was informed of the observation.
HSKP #20 verified Resident #37's EBP were not implemented as ordered for Resident #37.
Review of the policy Enhanced Barrier Precautions revised March 2024 revealed the purpose was to
reduce the transmission of multidrug resistant organism (MDRO) during high contact resident care activities
for residents with colonized or infected, as well as, those at increased risk to acquire MDRO.
This deficiency represents non-compliance investigated under Complaint Number OH00152983.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366443
If continuation sheet
Page 6 of 6
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the May 10, 2024 survey of BELPRE LANDING NURSING AND REHABILITATION?
This was a inspection survey of BELPRE LANDING NURSING AND REHABILITATION on May 10, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BELPRE LANDING NURSING AND REHABILITATION on May 10, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.