Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Belmont Healthcare Center during CMS and state inspections, most recent first.
A resident with severely impaired cognition (BIMS 3) experienced an unwitnessed bathroom fall with head impact and a 3 cm swelling, and was found on the floor shortly after midnight. Nursing documentation shows the on‑call NP was notified and a post‑fall assessment completed, but the resident’s representative was not contacted until more than seven hours later, despite the facility’s policy to notify family and the physician in an appropriate time frame after a fall. The DON confirmed that immediate family notification was not documented, and the care plan intervention to notify the MD and responsible party for falls was not in place until after the resident’s discharge.
Surveyors found that two residents had inaccurate documentation of pressure injuries on their MDS assessments, with one resident's Stage 1 pressure injuries overcounted and another's Stage 3 pressure injuries also overcounted. These errors were confirmed through record review and staff interviews, and both residents had complex medical histories.
A facility failed to ensure staff implemented enhanced barrier precautions (EBP) and wore appropriate PPE for a resident with a feeding tube. Despite a policy requiring gowns and gloves during high-contact care, an RN was observed wearing only a mask and gloves while performing tasks related to the resident's gastrostomy tube. The resident, with a history of dysphagia following a stroke, required EBP due to the feeding tube. Interviews confirmed the expectation for proper PPE use, but the RN admitted to forgetting the protocol.
The facility failed to implement fall care plans for two residents, resulting in inadequate monitoring. One resident, with cognitive impairment and multiple health issues, experienced an unwitnessed fall with injuries, while another resident, also cognitively impaired, fell and sustained a hip fracture. Both residents' care plans required frequent monitoring, which was not documented, despite their high fall risk.
A facility failed to investigate an abuse allegation thoroughly after a PT reported seeing a nurse slap a resident's hand and yell at him. The facility's investigation only included an interview with the alleged perpetrator, contrary to its policy requiring interviews with all involved parties. The Administrator acknowledged the investigation should have included more interviews.
A resident with a history of acute kidney failure, heart failure, and diabetes experienced an unwitnessed fall in the facility. Despite the incident being documented, the fall care plan was not updated, contrary to the facility's policy requiring care plan revisions after status changes. The ADON confirmed the oversight during an interview.
The facility did not have a Registered Dietitian (RD) employed from January to April 2024, leading to a deficiency in the nutritional assessment and management of residents. The RD, contracted since 2022, was not continuously employed during this period, and the facility's policy requires a RD to provide regular consultation. The Administrator did not confirm if another RD covered the facility during the absence.
Delayed Notification of Representative After Unwitnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a significant change in condition following an unwitnessed fall with head injury. The resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognitive function, and a care plan focus area identifying impaired cognitive function/impaired thought processes. On the night in question, documentation shows the resident experienced an unwitnessed fall in the bathroom at 12:45 AM, during which the resident hit the right side of the head on the wall and was found lying on the right side on the floor near the toilet. A nurse’s progress note at 2:18 AM documented a 3 cm swelling on the right side of the head and that the on‑call NP was notified, but there was no indication that the resident’s representative was notified at that time. A post‑fall assessment completed at 3:25 AM documented that the resident had been ambulating to respond to bowel or bladder needs, had a history of falls, impaired safety awareness, and was alert with some forgetfulness. The assessment also recorded that the resident verbalized hitting the wall with the right side of the head and that the resident representative was notified of the fall at 8:00 AM. An NP note at 6:19 AM documented a video call evaluation for a fall with injury, confirming the head impact and 3 cm swelling, and that the resident would remain in the facility for monitoring. The resident representative later reported, based on personal phone records, that the facility’s call notifying them of the fall occurred at 8:20 AM, and stated they initially believed the fall had just occurred at the time of the call but then learned it had happened at 12:45 AM. Additional documentation shows that the resident reported an episode of vomiting to a family member later that morning, which was then relayed to nursing staff and the NP, resulting in an order for immediate transfer to the ER. The resident was transported to the hospital ER and subsequently admitted. Interviews with the DON confirmed that the nurse who first assessed the resident after the fall did not document immediate family notification, and the DON described the notification timeframe as possibly within eight hours, depending on the time. The facility’s fall policy stated that the resident’s family and attending physician should be notified in an appropriate time frame when a resident falls, but the care plan intervention specifying MD and responsible party notification related to falls was not initiated until after the resident had been discharged. Based on the documented timeline, the resident’s representative was not notified until more than seven hours after the unwitnessed fall with head injury, despite the resident’s severely impaired cognition and documented head injury.
Inaccurate Coding of Pressure Injuries on MDS Assessments
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two of six sampled residents. For one resident, the number of Stage 1 pressure injuries was incorrectly coded as two instead of one in section M of the MDS. This error was identified when the MDS Coordinator, upon reviewing the Treatment Administration Record and Nurse's Progress Notes, confirmed that only one Stage 1 pressure injury was present, not two as documented. The MDS assessment had been completed by a different coordinator, and the error was verified through record review and staff interviews. For another resident, the number of Stage 3 pressure injuries was inaccurately coded as four instead of three on the MDS. The Wound Care Nurse confirmed the presence of three pressure injuries, and the MDS Coordinator, after reviewing relevant records, verified that only three Stage 3 pressure injuries existed. Both residents had significant medical histories, including conditions such as subdural hematoma, vascular dementia, Parkinson's disease, acute blood loss, and chronic ulcer. The inaccurate coding of pressure injuries on the MDS had the potential to negatively affect the care and services provided to these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) and wore the appropriate personal protective equipment (PPE) while providing care for a resident with a feeding tube. The facility's policy on EBP, revised in November 2024, mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, such as feeding tubes. Despite this policy, an observation on December 4, 2024, revealed that a registered nurse (RN) entered the resident's room wearing only a surgical mask and gloves, without a gown, while performing tasks related to the resident's gastrostomy tube. The resident, who was readmitted to the facility in November 2020, had a medical history of dysphagia following a stroke and was dependent on a feeding tube for nutrition. The resident's care plan, revised in August 2024, required EBP due to the presence of the gastrostomy tube, directing staff to wear gloves and a gown for device care. Interviews with the RN, the Infection Control Preventionist, the Director of Nursing, and the Administrator confirmed the expectation for staff to use appropriate PPE, including gowns, when providing care to residents on EBP. However, the RN admitted to not wearing the proper PPE due to nervousness and forgetting the protocol, leading to the deficiency in infection control practices.
Failure to Implement Fall Care Plans for Two Residents
Penalty
Summary
The facility failed to implement fall care plans for two residents, leading to deficiencies in monitoring and care. Resident 1, a cognitively moderately impaired female with hypertension, diabetes, and hyperlipidemia, experienced an unwitnessed fall resulting in a bruise and nosebleed. Despite being at high risk for falls, there was no evidence of frequent monitoring as required by her care plan, which stipulated checks every two hours. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation for the required monitoring. Resident 2, a cognitively severely impaired male with dementia, hypertension, and diabetes, also experienced a fall. He was found on the floor after attempting to walk to the bathroom, resulting in a hip fracture discovered later via X-ray. His care plan also required safety checks every two hours, but there was no evidence of such monitoring. The ADON confirmed the absence of documentation for the required monitoring, despite the resident's high fall risk as indicated by the Morse Fall Scale. The facility's policies on comprehensive care plans and fall risk assessment emphasize the need for person-centered care plans with measurable objectives and adequate supervision to prevent accidents. However, the lack of evidence for frequent monitoring in both cases indicates a failure to adhere to these policies, potentially delaying the identification of residents' needs and health status.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. A Physical Therapist (PT) reported witnessing a nurse (RN1) slapping a resident's hand and yelling at him to wake him up for medication administration. The PT observed this incident at the end of her workday and reported it to her supervisor by leaving a message. Despite this report, the facility did not conduct a comprehensive investigation into the allegation. During a review of the facility's abuse/neglect documentation, it was found that the only interview conducted was with the alleged perpetrator, RN1. The facility's policy on abuse, neglect, and exploitation requires an immediate investigation, including interviews with all involved parties, such as the alleged victim, perpetrator, and any witnesses. However, this procedure was not followed, as confirmed by the Administrator, who acknowledged that the investigation should have included interviews with other residents and staff who might have had knowledge of the incident.
Failure to Update Fall Care Plan After Resident's Unwitnessed Fall
Penalty
Summary
The facility failed to update the fall care plan for a resident after an unwitnessed fall occurred. The resident, a cognitively intact female with a history of acute kidney failure, heart failure, and diabetes, was admitted to the facility and later transitioned to hospice care. Despite the fall incident being documented in the Resident Incident Report, there was no evidence that the fall care plan was revised to reflect this event, as confirmed by the Assistant Director of Nursing (ADON). The facility's policy mandates that care plans be reviewed and revised following a resident's status change, such as a fall. However, the fall care plan for the resident was not updated, which was acknowledged by the ADON during the interview. The facility's policy emphasizes the need for supervision and modification of care plan interventions to prevent avoidable accidents, but these procedures were not followed in this instance.
Deficiency in Nutritional Management Due to Absence of Registered Dietitian
Penalty
Summary
The facility failed to employ a Registered Dietitian (RD) on a full-time or part-time basis from January to April 2024, which resulted in a deficiency in the nutritional assessment and management of residents. During this period, the RD, who had been contracted since 2022, was not continuously employed, as he stopped working in January and resumed in early April. The facility's policy on Nutritional Management requires a RD to provide regularly scheduled on-premises consultation and guidance to the Administrator, food service director, residents, and other facility personnel as needed. However, the absence of a RD during the specified months meant that residents were not appropriately assessed to maintain their weight and other nutritional parameters. When questioned, the Administrator declined to confirm if another RD covered the facility during the RD's absence.
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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 Belmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Mateo Medical Center D/p Snf | 1.5 mi | ★★★★★ | 4 | 0 |
| Brookside Skilled Nursing Hospital | 2.6 mi | ★★★★★ | 10 | 0 |
| Devonshire Oaks Nursing Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Atherton Park Post-acute | 6.8 mi | ★★★★★ | 3 | 0 |
| Peninsula Post-acute | 7.6 mi | ★★★★★ | 12 | 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.