Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Rehabilitation Center Of Belmond during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, extreme obesity, aphasia, and a stroke history had a Stage 2 pressure injury and bilateral thigh wounds, but the facility missed wound cleansing and Triad application on multiple shifts, failed to document weekly wound depth measurements, and did not consistently identify the wounds as pressure ulcers. Staff also could not locate several weekly wound records, and the ADON confirmed the wound clinic had diagnosed the area as a Stage 2 pressure ulcer while the facility had treated it as moisture-related.
Lack of Required RN Coverage: The facility failed to maintain the required 8 hours of RN coverage in the building on two dates. Review of nursing schedules and staff statements confirmed there was not 8 consecutive hours of RN coverage, and the Nurse Consultant stated the facility had no RN coverage policy and only followed the regulation.
The facility failed to provide sufficient staff to meet the needs of residents, resulting in prolonged call light response times for two residents with intact cognition. One resident reported waiting up to half an hour, particularly on weekends, while another experienced bowel incontinence due to delayed responses. Staff confirmed the expectation to respond within 15 minutes, but the facility's staffing levels were inadequate.
The facility failed to submit a Level 2 PASRR evaluation for a resident with a new mental health diagnosis and new psychotropic medications. The resident had moderately impaired cognition and was diagnosed with psychotic disorder, adjustment disorder with depressed mood, and visual hallucinations. Despite these new diagnoses and medications, no additional PASRR evaluations were conducted after the initial Level 1 PASRR. The DON acknowledged the oversight and reported that the facility did not have a PASRR policy.
A resident with severe cognitive impairment and diabetes mellitus did not receive the prescribed 1 mg dose of Ozempic due to unavailability, receiving only 0.5 mg instead. The DON acknowledged the nurse should have contacted the physician before administering the incorrect dosage. The facility lacks a specific policy for following physician orders.
The facility failed to maintain sanitary conditions during food preparation. A cook was observed handling food and various kitchen items without washing or sanitizing her hands, violating the facility's handwashing policy and increasing the risk of contamination and foodborne illness.
Pressure ulcer care and wound documentation failures
Penalty
Summary
The facility failed to ensure Resident #7 received necessary care and services for existing pressure ulcers and to prevent new ulcers from developing. Resident #7 had diagnoses including extreme obesity, aphasia, and cerebral infarction, and a Brief Interview for Mental Status score of 7 out of 15 indicating severely impaired cognition. The MDS documented that the resident refused several mobility activities, and the wound center record identified a Stage 2 pressure injury of the buttock with debridement of left inner buttock and right buttock wounds and measurements including length, width, and depth. The resident’s records showed problems with wound identification and documentation. The Non-Pressure Skin Condition Record lacked documentation for the bilateral medial thigh wounds for a prolonged period, and the records alternated between a first observed date of 9/3/25 and a later first observed date of 1/16/26. The facility’s weekly wound documentation did not identify the wounds as pressure ulcers, most weekly records did not include depth measurements, and one record listed two wounds instead of one wound on each weekly assessment. The facility was also unable to locate several weekly pressure ulcer wound records. The April 2026 MAR lacked documentation for wound cleansing and Triad application on four separate shifts for the bilateral medial thigh wounds. During interviews, the ADON confirmed the resident had a pressure area and stated the wound clinic had diagnosed a Stage 2 pressure ulcer, but the facility had believed it was moisture-related because it was located in the thigh fold area. The ADON acknowledged the missing weekly records, the lack of depth measurements, and that the wounds should have been documented on a Pressure Ulcer wound record rather than a Non-Pressure weekly wound record. A former DON stated that if the pressure ulcer wound records were completed, they would be in the skin book or progress notes, but the facility could not produce them.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) in the building for eight hours per day on 4/5/26 and 4/12/26. Review of the nursing schedules for April 2026 showed that RN coverage did not meet the required 8 hours on those dates. The facility reported a census of 42 residents. In email communication dated 4/21/26, the Administrator confirmed the facility did not have 8 consecutive hours of RN coverage on 4/5/26 and 4/12/26. In a 4/22/26 email, the Nurse Consultant stated the facility did not have a policy for RN coverage and simply followed the regulation. During an interview on 4/22/26, the Administrator acknowledged the lack of 8 hours of continuous RN coverage on both dates.
Insufficient Staffing Leading to Prolonged Call Light Response Times
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, specifically Residents #4 and #19. Resident #4, with intact cognition as indicated by a BIMS score of 15, reported experiencing long wait times for call light responses on all shifts. The call light report for Resident #4 from 3/23/24 to 4/23/24 showed multiple instances where the call light was on for 15 minutes or more, with the longest wait time being 25 minutes and 4 seconds. The Director of Nursing (DON) confirmed that the expectation was to answer call lights within 15 minutes, although the facility did not have a formal call light policy in place. Resident #4 also reported an incident of bowel incontinence while waiting for a call light to be answered, highlighting the impact of the staffing deficiency on resident care. Resident #19, also with intact cognition as indicated by a BIMS score of 15, reported waiting up to half an hour for call light responses, particularly on weekends. The call light report for Resident #19 from 3/23/24 to 4/23/24 revealed several instances where the call light was on for 15 minutes or more, with the longest wait time being 34 minutes and 21 seconds. Staff B, a Certified Nursing Assistant (CNA), confirmed that staff are trained to respond to call lights within 15 minutes and use iPhones to monitor call light durations. Despite this, the facility's staffing levels were insufficient to meet the needs of the residents, as evidenced by the prolonged call light response times for both residents.
Failure to Submit Level 2 PASRR Evaluation for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a new mental health diagnosis and the start of new psychotropic medications. The resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition, and was diagnosed with psychotic disorder, adjustment disorder with depressed mood, and visual hallucinations. The resident's care plan included the use of psychotropic medications for these conditions, specifically Sertraline HCL and Risperdal. Despite these new diagnoses and medications, the clinical record revealed that no additional PASRR evaluations were conducted after the initial Level 1 PASRR completed on 4/20/22, which documented that the resident did not have a major mental illness at that time. The Director of Nursing (DON) acknowledged that the PASRR had not been updated and stated that it was her expectation for the PASRR to be updated when there was a new diagnosis or a new classification of medication. The DON also reported that the facility did not have a PASRR policy in place. This oversight led to the deficiency identified during the survey, as the facility did not comply with the requirement to coordinate assessments with the pre-admission screening and resident review program and refer for services as needed.
Failure to Follow Physician's Order for Diabetic Medication
Penalty
Summary
The facility failed to follow a physician's order for a resident with severe cognitive impairment and multiple medical conditions, including diabetes mellitus. The resident had an order to receive 1 mg of Ozempic once a week, but on February 13, 2024, only 0.5 mg was administered due to the unavailability of the correct dosage. The Director of Nursing (DON) acknowledged that the nurse should have contacted the physician before administering the incorrect dosage. The physician was informed of the issue on February 14, 2024, but no new orders were given until the correct dosage was delivered on February 15, 2024. The DON stated that the facility does not have a specific policy for following physician orders but expects nurses to adhere to professional standards and follow physician orders. The failure to administer the correct dosage was identified during a review of the resident's clinical records and staff interviews. The administrator confirmed the lack of a formal policy and acknowledged the expectation for nurses to follow physician orders. The incident highlights a lapse in communication and adherence to prescribed medical protocols within the facility.
Failure to Maintain Sanitary Conditions in Food Preparation
Penalty
Summary
The facility failed to prepare food under sanitary conditions, increasing the risk of contamination and foodborne illness. During an observation, a cook was seen handling food and various kitchen items without washing or sanitizing her hands. The cook, while wearing gloves, tore chicken off the bone and then removed the gloves without washing her hands. She proceeded to touch multiple surfaces and items, including a gallon of milk, a robot coupe machine, a drawer handle, a spatula, a box of tin foil, a marker, and a warming oven, all with bare hands. The cook also touched the inside of the robot coupe container and the blade that would puree the food, again without washing her hands throughout the entire process. In an interview, the cook admitted to washing her hands often but could not specify when handwashing should occur. The Dietary Manager confirmed that staff are expected to wash their hands before and after putting on gloves, after handling raw food, and after touching surfaces or equipment that will come in contact with food. The facility's handwashing policy, dated 5/16/03, also mandates handwashing before and after using disposable gloves and after completing a dirty task before starting a clean one. The cook's actions were in direct violation of these guidelines, leading to the deficiency noted in the report.
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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 Belmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clarion Wellness And Rehabilitation Center | 11.2 mi | ★★★★★ | 12 | 0 |
| Kanawha Community Home, Inc. | 11.3 mi | ★★★★★ | 3 | 0 |
| Concord Care Center | 16.4 mi | ★★★★★ | 7 | 0 |
| Westview Care Center | 19.7 mi | ★★★★★ | 0 | 0 |
| Sheffield Care Center | 19.7 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.