Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Belvedere Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with nicotine dependence and intact cognition was found searching for a vape while a MAC assisted and even charged and returned a vape device. The care plan identified nicotine dependence but did not address repeated possession of vapes, family bringing vapes into the room, or staff guidance for non-compliant behavior related to the facility’s no-smoking policy. Interviews confirmed staff knew vapes were not allowed, yet the issue was not included in the resident’s care plan.
A resident with moderate cognitive impairment and a history of osteoporosis was injured during a transfer when a CNA failed to use a gait belt as required by the care plan. The resident sustained a shoulder dislocation and fractures. Interviews with staff confirmed awareness of the need for gait belts, but the policy was not followed, resulting in harm.
The facility failed to lock the central bath and soiled utility room, exposing residents to hazards like chemicals and wet floors. A resident was transferred using a mechanical lift with missing parts, despite staff acknowledging the risk. The facility lacked policies and maintenance logs to ensure safety.
The facility was found deficient in ensuring proper hand hygiene and food safety practices. Dietary staff failed to wash hands after contamination, and cold dairy products were not maintained at safe temperatures. Additionally, the ice machine was not kept clean, posing potential risks to residents.
A facility failed to include prescribed medications in a resident's care plan, which were essential for managing severe dementia with agitation, sleep disorder, major depressive disorder, and other conditions. The omission was confirmed by the MDS Coordinator, despite the medications being ordered since September and October. The resident's severe cognitive impairment highlighted the need for a comprehensive care plan.
A facility failed to ensure proper hand hygiene during perineal care, risking cross-contamination and infection spread. Two CNAs were observed not changing gloves or washing hands after cleaning a resident, contrary to facility policy. Interviews revealed a misunderstanding of hand hygiene protocols, and the DON confirmed the need for handwashing before handling clean items.
Incomplete Care Plan for Resident Possessing Vapes
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with a history of nicotine dependence and non-compliant behaviors related to bringing electronic cigarettes (vapes) into the facility. Resident #9 was admitted with diagnoses including malignant neoplasm of the brain, anxiety, pneumonia, and nicotine dependence with withdrawal, and the MDS indicated the resident was cognitively intact. The electronic health record did not show a smoking assessment indicating the resident had been assessed as being able to safely use electronic cigarettes. During an observation, the resident was seen searching for a black vape in bed while a MAC assisted in locating it. The MAC placed the black vape on a charger and handed the resident an orange-colored vape device, which was identified as an actual vape. The resident’s care plan, initiated on admission, identified nicotine dependence and risk for complications from nicotine, but it did not address the resident’s repeated possession of electronic cigarettes or provide interventions related to the facility’s smoking policy. Interviews showed staff knew the facility was non-smoking and that vapes should not be in residents’ possession, but the resident’s spouse frequently brought vape devices into the facility. Social Services, the MDS Coordinator, the DON, and the Administrator all acknowledged that vaping-related non-compliant behaviors were not addressed in the care plan. The Administrator later displayed a box of confiscated vape devices, including multiple black devices, an orange device, and a green device, and stated they had been confiscated from the resident.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff followed care-planned interventions requiring one staff member to perform transfers with a gait belt to promote resident safety and prevent injury. This failure resulted in actual harm to a resident who was transferred without the use of a gait belt, leading to a dislocation of the shoulder, proximal humerus fracture, ligamentous injury, and clavicle injury. The resident had a history of moderate cognitive impairment and various diagnoses, including age-related osteoporosis and osteoarthritis. The resident's care plan, revised in December 2023, indicated that the resident required extensive assistance from one staff member and a gait belt for transfers. However, on January 8, 2025, a CNA assisted the resident to bed without using a gait belt, instead grasping the resident's left upper arm. During the transfer, the resident's arm popped, and the resident complained of pain. The CNA did not follow the care plan instructions, which were also posted in the resident's closet, indicating the need for a gait belt during transfers. Interviews with other CNAs confirmed that they were aware of the requirement to use a gait belt for one-person assistance transfers, as indicated in the closet care plan. The Director of Nursing confirmed that staff were trained to refer to the closet care plan before providing care. Despite this, the improper transfer occurred, resulting in significant injury to the resident. The facility's policies and procedures for using gait belts during transfers were not adhered to, leading to the resident's injury.
Facility Fails to Secure Hazardous Areas and Maintain Equipment
Penalty
Summary
The facility failed to ensure that the central bath and soiled utility room on the 300 Hall were locked, which exposed residents to potential hazards such as dirty linens, chemicals, and wet floors. During observations, surveyors found the central bath door unlocked with hazardous chemicals and personal hygiene products accessible. The soiled utility room was also unlocked, containing soiled linens and sanitizing wipes with poison control warnings. Interviews with staff, including a CNA and the DON, confirmed that these areas should remain locked to prevent resident access to potential hazards. However, there was no policy or maintenance log to ensure the locks were functioning properly. Additionally, the facility failed to maintain a mechanical lift in good working order, which posed a risk to a resident with a history of stroke, type II diabetes, and seizure disorder. The lift was observed with a missing clip and broken plastic, yet it was used by CNAs to transfer the resident. The CNAs acknowledged the missing clip but proceeded with the transfer, assuming it was a safety feature. The DON later confirmed that the lift should not have been used in its condition, and maintenance should have been notified to remove it from service until repaired. Despite a recent service inspection, the lift was not safe for use. The facility lacked proper documentation and procedures for maintaining secure and safe environments for residents. There was no policy addressing the locking of hazardous areas, and the mechanical lift was used despite visible damage and missing parts. The DON and Assistant Administrator provided documents and manuals that did not adequately address the deficiencies observed, indicating a gap in the facility's safety protocols and equipment maintenance procedures.
Deficiencies in Hand Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and food safety practices among dietary staff, as observed during a survey. Dietary Aide #7 was seen handling cookies with gloved hands that were contaminated after touching a refrigerator and glove box, without washing hands in between. Additionally, Dietary Aide #8 did not wash hands after using the restroom before handling tray cards and napkins intended for resident use. These actions were contrary to the facility's policy requiring handwashing before, during, and after food preparation and after activities that contaminate hands. The facility also failed to maintain cold dairy products at the required temperature of 41 degrees Fahrenheit or below. Leftover dairy products, including milk and ice cream, were found at temperatures above the safe limit, with some ice cream and sherbets having melted. Furthermore, the ice machine used by CNAs to fill beverages and water pitchers was found to have a wet black residue, indicating it was not maintained in a clean and sanitary condition. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Document Medications in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident residing in the Memory Unit. The care plan did not identify the medications ordered for the resident, which included Risperidone, Trazodone, Duloxetine, Mirtazapine, Quetiapine Fumarate, and Clonazepam. These medications were prescribed for conditions such as severe dementia with agitation, sleep disorder, major depressive disorder, moderate protein-calorie malnutrition, and agitation related to dementia. The absence of these medications in the care plan indicates a lack of comprehensive documentation of the resident's medical needs. The deficiency was confirmed through a review of the resident's care plan, physician's orders, and the Minimal Data Set (MDS). The MDS Coordinator acknowledged that the resident's care plan did not address the prescribed medications, despite the orders being in place since September and October. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, underscoring the importance of a detailed and accurate care plan to address the resident's complex medical needs.
Failure in Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during perineal care, leading to a risk of cross-contamination and infection spread for a resident reviewed for bowel and bladder care. During an observation, two CNAs were seen cleaning a resident of urine and stool without changing gloves or washing hands before placing a clean brief and lift pad under the resident, adjusting the resident's clothing, and touching the bedside table. This action was contrary to the facility's policy, which required changing gloves after perineal care before handling clean items. Interviews with the CNAs revealed a misunderstanding of the hand hygiene protocol, with one CNA believing hand hygiene was only necessary at the beginning and end of perineal care. The DON confirmed that staff should wash their hands before touching anything clean to prevent bacterial spread and infection. The facility's in-service training on perineal care did not provide educational information, which may have contributed to the staff's lack of adherence to proper hand hygiene practices.
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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.
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Nursing homes near Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Of Park Ave | 1.9 mi | ★★★★★ | 0 | 0 |
| The Blossoms At The Village Rehab & Nursing Center | 3 mi | ★★★★★ | 4 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 5.7 mi | ★★★★★ | 0 | 0 |
| The Pines Nursing And Rehabilitation Center | 6 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 7 mi | ★★★★★ | 2 | 0 |
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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.