Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Manor Nursing Home, In during CMS and state inspections, most recent first.
A resident with Alzheimer’s, dementia, a history of falls, and severe cognitive impairment had an MD order and care plan for a wander guard device on a walker, with nightly function checks required on the 11 P.M.–7 A.M. shift using a universal tester. On the day of the incident, the TAR showed no documentation that the required wander guard check was completed, and the assigned nurse later stated she did not test the device because she did not want to wake the resident, despite facility policy requiring such checks. The device was not functioning, allowing the resident to leave the unit, use the elevator, and exit to an outdoor courtyard without triggering the wander guard alarm system, where the resident was later found outside with the walker nearby.
A resident in respiratory distress was placed on oxygen even though the tank gauge showed zero refill and was not delivering oxygen, with staff later recognizing the tank was empty after the resident’s O2 sat remained low. In addition, multiple emergency code carts had dirty, expired, or nonworking suction and ventilation equipment, including contaminated canisters, used Yankauer tubing, and sticky, deflated Ambu bags that were not ready for use.
Failure to submit PBJ staffing data timely. The facility did not electronically submit complete and accurate direct care staffing information to CMS for the required reporting period. HR staff stated the deadline was missed and that an attempted late submission was rejected by the reporting system, despite the facility policy requiring quarterly PBJ submissions through the CMS portal.
Failure to Follow Droplet Precautions for Resident with Influenza: A resident with influenza, Parkinson's disease, and renal disease was placed on droplet precautions, but staff did not consistently follow the posted PPE requirements. Observations showed a staff member assisting the roommate with a surgical mask worn below the nose and without a gown or eye protection, and an RN entered the room wearing gloves and a surgical mask but no gown or eye protection. The resident was awake and coughing without a mask, and the IP stated that anyone entering the unit should wear a surgical mask to help prevent spread of influenza.
The facility failed to offer pneumococcal vaccines to 35 of 71 eligible residents. Records showed the residents were due for the vaccine, had no contraindication, and physician orders allowed the pneumonia vaccine unless contraindicated. The IP stated many eligible residents had not declined the vaccine, the vaccine was available from the pharmacy, but payment arrangements had not yet been facilitated.
Failure to Invite Resident to Care Plan Meeting: A cognitively intact resident with COPD and SOB was not invited to attend care plan meetings after stating a desire to participate. Staff reported that invitations were sent to the resident’s proxy/family member instead, even though the resident did not have an activated HCP and should have been invited.
Resident Council concerns were not thoroughly documented or tracked through the facility’s grievance process. Residents reported missing clothing and repeated unresolved issues, and said concerns brought up in meetings were not documented or answered. Grievance logs showed no grievances for the reported issues, the SW said forms were not available on the units and could not be found, and the Administrator stated staff handled Resident Council issues without completing grievance forms for every concern.
Failure to process grievances and provide accessible grievance forms: A resident with dementia, muscle weakness, and depression reported missing sneakers, but the grievance record showed no completed facility action or clear resolution, and staff were unaware of the issue. Surveyors also found grievance information was not posted in resident care areas and grievance forms were not accessible on the units, with staff describing inconsistent locations and processes for reporting concerns.
Failure to implement a fall care plan intervention: A resident with dementia, severely impaired cognition, and a history of falls was assessed as high risk and had a care plan directing call don't fall signs in the room and bathroom. Surveyors observed the resident attempting to toilet independently and later found no signs in the room or bathroom, despite staff stating the signs should have been in place and that the resident was a fall risk with prior falls.
Failure to implement pressure ulcer treatments. A resident with severe cognitive impairment and a left foot wound was identified as needing heel booties to offload pressure, but the devices were not in place and staff said the resident had never had them. The record also showed a Wound MD ordered skin prep for a DTI on the left foot, but the treatment was not entered and started until several days later; staff and the DON were unaware of the delay.
The facility failed to maintain the dignity of a resident by not placing their urinary catheter bag in a privacy bag, leading to embarrassment. Another resident with impaired cognition was not provided a dignified dining experience, as they were left waiting for assistance with food out of reach. On two units, staff were observed standing over residents while feeding them, rather than sitting at eye level. Additionally, a CNA was seen using a cell phone while assisting a resident with their meal.
The facility did not develop baseline care plans within 48 hours for four residents with severe cognitive impairments, including dementia. Despite policy requirements, medical records lacked these plans, and comprehensive care plans did not reflect necessary interventions. Interviews with Nurse Unit Managers confirmed the oversight.
The facility failed to develop individualized dementia care plans for residents in the Dementia Special Care Unit (DSCU), affecting their ability to receive appropriate treatment and services. Despite severe cognitive impairments, residents lacked person-centered care plans, and staff interviews revealed unclear responsibilities for care plan development. This deficiency highlights a systemic issue in the facility's approach to dementia care planning.
The facility failed to accurately document care for several residents, including the use of padded side rails, oxygen tubing changes, and the application of a palmar guard. Observations revealed discrepancies between documented care and actual practices, affecting residents with conditions such as Alzheimer's, epilepsy, COPD, and hemiplegia.
A resident, assessed as unable to self-administer medications, was found with pills left at the bedside for self-administration. Despite facility policy requiring an interdisciplinary assessment to determine self-administration capability, the resident was left with medications unattended. Nursing staff interviews confirmed the oversight, and the DON acknowledged the resident should not have had access to self-administer medications.
A resident with Alzheimer's dementia and other conditions was found with bruises on both hands, which were not documented or investigated by the facility. Despite facility policy requiring investigation of unknown bruises, staff failed to report or investigate the bruises, and the Director of Nursing and Staff Development Coordinator were unaware of the full extent of the issue.
A facility failed to report bruises of unknown origin on a resident to the state agency within the required timeframe. The resident, with Alzheimer's dementia and other conditions, was observed with bruises on both hands, which were not documented in medical records. A nurse noticed the bruises but did not inform the charge nurse, and a CNA saw the bruises before an incident but did not report them immediately. The Staff Development Coordinator was only aware of one bruise and did not report it, assuming it was witnessed.
A facility failed to create individualized care plans for a resident's ADLs and psychotropic medication use. The resident, with severe cognitive impairment and dependence on ADLs, was taking antipsychotic medication. Despite these needs, the medical record lacked specific interventions, and staff interviews confirmed the absence of necessary care plans.
A facility failed to update a care plan for a resident's healed stage 3 pressure ulcer on the left heel. Despite the ulcer being healed, the care plan still listed it as an active problem. The resident, with diagnoses including type 2 diabetes and hemiplegia, was observed on an air mattress with a blanket cradle. Interviews with staff confirmed the ulcer had healed long ago, and the care plan should have been resolved during the quarterly MDS review.
A resident with hemiplegia and hemiparesis was not provided with a prescribed palmar guard for contracture management, as observed during multiple instances. Despite a physician's order, the device was not applied, and there was no documentation of refusal. Staff interviews revealed a lack of awareness and adherence to the intervention, with the Director of Rehabilitation unaware of the non-compliance. The Nurse Unit Manager emphasized the importance of accurate documentation and referrals to rehab if the resident did not use the recommended device.
The facility failed to implement physician-ordered padded side rails for two residents with severe cognitive impairments and specific medical conditions. One resident with Alzheimer's dementia was repeatedly observed without padded side rails, contrary to orders. Another resident with epilepsy and a history of falls had only one side rail padded instead of both, as required. Staff interviews confirmed the expectation to follow these orders, which was not met.
A resident experienced significant weight loss due to the facility's failure to implement timely interventions and communicate effectively with the dietitian. Despite having a healthy appetite, the resident lost 15% of their body weight over six months. The dietitian was not informed of the weight loss until a routine assessment, and the facility's policy for monitoring and addressing weight changes was not followed.
The facility failed to maintain clean oxygen concentrator filters and change oxygen tubing as ordered for two residents with chronic obstructive pulmonary disease. Observations revealed thick layers of dust on filters, and one resident's tubing was not changed weekly as prescribed. Staff were unaware of cleaning responsibilities, and there was no documentation or system to track maintenance. Additionally, a resident was not assessed for the ability to change their own tubing, contrary to facility policy.
A nurse failed to disinfect a portable vital sign caddy between uses on two residents under enhanced barrier precautions (EBP), contrary to the facility's infection control policy. The nurse admitted the oversight, and the nurse unit manager confirmed the requirement for disinfection between uses.
Failure to Test Wander Guard Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident at risk for elopement, with an MD order for a wander guard device, had that device consistently checked for proper function. The resident had diagnoses including Alzheimer’s, dementia, diabetes, history of falling, and difficulty in walking, and was assessed as cognitively impaired with a BIMS score of 7, indicating severe cognitive impairment. The resident’s care plan and elopement risk assessment identified a history of wandering and risk for elopement, and the resident’s wander guard was ordered to be placed on the walker, with a requirement that nursing staff check its function daily on the 11:00 P.M. to 7:00 A.M. shift using a universal tester. On the date of the incident, documentation on the Treatment Administration Record for the 11:00 P.M. to 7:00 A.M. shift showed no evidence that the required wander guard function check had been completed. Nurse #1 later stated that she did not perform the wander guard function test during her shift because she did not want to wake the resident, although she observed that the device was attached to the walker. Facility policy and staff development information indicated that universal testers were available on each unit and that wander guard checks were to be conducted on the night shift, but this process was not followed for this resident on the day in question. As a result of the wander guard device not being tested and not functioning, the resident was able to leave the unit undetected. According to staff interviews and the facility’s report, the resident was last seen in the room watching television at approximately 6:30 A.M. and was discovered missing around 7:00 A.M. A search was initiated, and the resident was found on the first floor outside in the courtyard, sitting on the ground with the walker nearby. Staff confirmed that the wander guard device did not trigger an alarm when the resident left the unit, accessed the elevator, and exited to the courtyard, and it also did not alarm when the resident was brought back inside, demonstrating that the system was not functioning at the time of the elopement.
Respiratory Care and Emergency Equipment Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident who was newly admitted with diagnoses including anemia, urinary tract infection, and dementia. On the morning of the event, the resident was found unresponsive and in respiratory distress. Staff placed the resident on oxygen, but the oxygen concentrator was set to 0.5 liters per minute and the pressure gauge indicator was in the red section at zero refill. The resident was observed lying in bed with a nasal cannula in place, but there were no staff members in the room at that time. During the event, a nurse checked the resident’s oxygen saturation and found it to be 88%, then observed that the oxygen tank gauge still indicated zero refill. The nurse left the room. A unit manager later entered, increased the oxygen to 2 liters, and noted the resident’s oxygen saturation was 86%, then left the room. The resident’s oxygen saturation later dropped to 83% while the concentrator remained set at 2 liters and the gauge still showed zero refill. The unit manager then recognized the tank was empty, stated it was not delivering oxygen, and obtained a new oxygen tank. After the new tank was applied, the resident was placed on 5 liters of oxygen via nasal cannula and the oxygen saturation fluctuated between 86% and 88%. Interviews confirmed staff were unaware the tank was empty and had assumed oxygen was being delivered through the nasal cannula. The unit manager stated the resident had been placed on oxygen because of respiratory distress and that staff must check the tank settings and assess the resident’s response to oxygen therapy. The DON stated the resident should have been placed on appropriate oxygen therapy when first identified as having breathing difficulty and that staff must check the oxygen tank before and after administration to ensure the equipment is working. The Medical Director stated staff must respond appropriately and efficiently to residents requiring oxygenation therapy and that the resident should not have been placed on an oxygen tank that was not functioning appropriately. The facility also failed to maintain respiratory emergency equipment in clean, working condition. The policy for cleaning respiratory equipment required suction machines to be rinsed and disinfected every shift, tubing to be rinsed every shift and replaced every 72 hours, and used suction equipment to be returned to the dirty utility room for disinfection. However, surveyors and the Infection Preventionist observed multiple code carts with suction machines, canisters, Yankauer tubing, and Ambu bags that were dirty, used, expired, sticky, yellow, deflated, or otherwise not in working condition. One cart had a canister partially filled with opaque yellow liquid, dirty tubing with brown substance inside, and an Ambu bag that was sticky, yellow, and deflated. Other carts had Yankauer tubing removed from sterile packaging, Ambu bags that were sticky and deflated, one expired Ambu bag, and an open expired bottle of sterile water stored with the equipment. The IP stated the equipment appeared to have been used and not cleaned or replaced, and that the emergency carts were not stocked with the necessary items needed to respond to an emergency at that time.
Failure to Submit PBJ Staffing Data Timely
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the entire FY Quarter 4 2025 reporting period, July 1 through September 30, in accordance with the CMS submission schedule. Review of the facility’s Payroll Based Journal policy, revised February 2024, showed that the facility is required to submit staffing hours to CMS every 3 months through the PBJ Data Submission portal, with Fiscal Quarter 4 for the reporting period due by 11/14/25. During an interview on 12/30/2025 at 9:06 A.M., Human Resource Staff #1 stated he missed the deadline and attempted to submit the PBJ report after the deadline, but the reporting system would not accept it. He also stated that quarterly reports should be submitted timely as required by CMS.
Failure to Follow Droplet Precautions for Resident with Influenza
Penalty
Summary
The facility failed to implement infection prevention and control measures for a resident diagnosed with influenza and placed on droplet precautions. The resident had diagnoses including Parkinson's disease and renal disease, was admitted in November 2025, and had moderate cognitive impairment with a Brief Interview for Mental Status score of 11. The resident also ambulated with a walker or wheelchair and required partial to moderate assistance with activities of daily living. The resident was diagnosed with influenza on 12/31/25 and was prescribed Tamiflu. Physician orders dated 12/31/25 directed droplet precautions every shift, day, evening, and night. During observation, the isolation sign at the resident's bed indicated droplet and standard contact precautions and stated that staff and visitors entering the room should wear gloves, a gown, a surgical mask or N-95 respirator, and eye protection. However, eye protection was not available on the cart outside the room. Inside the room, the resident was awake, coughing, and not wearing a mask. A staff member assisted the roommate without wearing a gown or eye protection and wore a surgical mask below the nose and gloves. Another nurse entered the room to obtain vital signs and administer medications wearing gloves and a surgical mask, but not a gown or eye protection. The unit manager and infection preventionist stated that staff entering the room should wear full PPE, and the infection preventionist also stated that anyone entering the unit should wear a surgical mask to prevent spread of influenza.
Failure to Offer Pneumococcal Vaccines to Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal vaccines were offered to 35 of 71 eligible residents. Review of CDC guidance showed that adults age 50 or older who have never received a pneumococcal conjugate vaccine and whose vaccination history is unknown should receive PCV15, PCV20, or PCV21. Review of the facility’s immunization records and an audit showed that 19 of 35 eligible residents on the 400 unit and 16 of 36 eligible residents on the 300 unit had not been offered or received the pneumococcal vaccine. Physician orders for the 71 residents indicated they may receive the pneumonia vaccine unless contraindicated, and the facility’s immunization audit showed the 35 identified residents were due for the vaccine and had no contraindication. During interview, the Infection Preventionist stated there were many residents eligible and due for the pneumococcal vaccine who had not declined it, and that the vaccine was available from the pharmacy, but the facility had not yet facilitated payments for these.
Failure to Invite Resident to Care Plan Meeting
Penalty
Summary
The facility failed to ensure that invitations to attend care plan meetings were provided to one resident. Resident #20 was admitted with diagnoses including chronic obstructive pulmonary disease and shortness of breath, and the Minimum Data Set assessment showed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident’s care plan included a problem noting an HCP that was not activated and interventions for staff to educate the resident and surrogate decision makers regarding their roles. During interview, Resident #20 stated that he or she had initially declined to attend care plan meetings but later wanted to start attending and had told multiple staff members and the nurse supervisor, yet had still not been invited. The Social Worker stated the receptionist was responsible for sending invitations and said the resident should have been invited. The receptionist stated she sent an invitation to the resident’s activated health care proxy for the December 2025 care plan meeting, while Social Worker #2 stated the resident had the right to attend care plan meetings, did not have an activated healthcare proxy, and should have been invited.
Resident Council Concerns Not Documented or Resolved
Penalty
Summary
The facility failed to ensure concerns from the Resident Council were thoroughly documented and that residents received timely responses to issues raised in group meetings. The facility’s Grievance Policy stated that the Record of Resident and Family Concerns was to be the only form used to document grievances and recommendations, and that it would be completed by the person receiving the concern with disposition coordinated by Social Services. However, review of Resident Council minutes from October 2025 showed a missing long winter coat, and the November 2025 minutes contained no additional follow-up notes. During the resident group meeting, 3 of 10 participating residents reported missing clothing that had been reported to staff without follow-up or reimbursement, and said this was an ongoing issue discussed at every meeting but not resolved. Five of 10 participating residents also stated that when issues were reported, they were not documented or resolved, and that the same concerns were discussed month after month without facility response. Review of the grievance logs for 2024 and 2025 showed no grievances filed for the issues reported in Resident Council meetings, including no documented grievances for September, October, November, or December 2025. The Social Worker, who was also the Facility Grievance Officer, stated grievance forms were not located on the nursing units and said he could not find any grievance forms from August through December 2025. The Administrator stated staff take care of issues reported during Resident Council meetings and do not need to fill out grievance forms for every issue.
Failure to Process Grievances and Provide Accessible Grievance Forms
Penalty
Summary
The facility failed to ensure residents had the right to voice and formulate grievances, have grievances responded to promptly, and receive a resolution. The facility’s grievance policy stated that resident and family concerns were to be documented and acted on through an orderly and timely process, and that the Record of Resident and Family Concerns was to be readily available in all nursing units and other appropriate departments. The policy also stated that the form would be completed by the person receiving the grievance and its disposition coordinated by Social Services. Resident #16 was admitted in April 2024 with diagnoses including unspecified dementia, muscle weakness, and depression. The MDS dated [DATE] showed the resident was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A grievance form in the binder documented that the resident’s HCP called asking where the resident’s shoes were and staff were advised to look for them, but the form did not show a completed facility action or follow-up. During interview, the resident stated the sneakers had been in the room, then went missing, and were never replaced, and said staff had been told about the missing sneakers. Staff interviews showed CNA #2 and Charge Nurse #3 were not aware of the missing sneakers or a grievance form, while Social Worker #2 said he notified the Administrator and DON and expected reimbursement to occur, but did not know if it had been done. The Administrator stated he would reimburse the resident for the shoes if proof of cost was submitted and said he was not aware of the status of the missing shoes. The survey also found residents did not have accessible grievance or concern forms to submit grievances anonymously. During tour, no grievance process information was posted in resident care areas, and the only information observed was near the Social Services office, which was not accessible to all residents. Review of the grievance binder showed no documented grievances for September, October, or November 2025. Staff interviews indicated forms were not available on the units, with some staff saying concerns were passed to nurses or the charge nurse, while others said forms were kept behind the nurse’s station or only near Social Services. The Facility Grievance Officer stated the forms were not currently located on the nursing units and expected them to be accessible on all units so residents, visitors, and staff could report issues for follow-up.
Failure to Implement Fall Care Plan Intervention
Penalty
Summary
The facility failed to implement the fall-related interventions listed on the care plan for one resident. The resident was admitted in September 2019 with diagnoses including non-traumatic brain dysfunction, dementia, and a history of falls. The MDS indicated the resident was unable to participate in the Brief Interview for Mental Status Exam, had severely impaired cognitive skills, and required assistance with transfers, bathing, dressing, and toileting. A fall risk assessment identified the resident as high risk for falls, and the care plan dated 3/24/24 included the intervention to place call don't fall signs in the room and bathroom. Surveyors observed the resident attempting to toilet independently in the bathroom on 12/29/25, and no call don't fall sign was in place. Later that day, the resident was observed lying in bed, and there were still no signs in the room. On 12/30/25, the room was observed again and no call don't fall signs were present. During interview, the Unit Manager stated the resident was a fall risk with multiple prior falls, that the signs should have been in place since they were implemented, and that interventions on resident care plans should be in place. A CNA who had cared for the resident for about a year and a half stated the resident was a fall risk and had some falls in the past.
Failure to Implement Pressure Ulcer Treatments
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Resident #48 was admitted with diagnoses including unspecified dementia and osteoarthritis, had severe cognitive impairment with a BIMS score of 2 out of 15, and was identified as being at risk for pressure ulcers. The care plan addressed increased risks of complications related to a left foot wound and included treatment per MD orders. A Nurse Practitioner note stated that because both lower extremities were rigid and the resident’s left foot pressed into the right foot, heel booties should be worn at all times to offload pressure, and nursing was informed to order them. However, the physician orders and care plan did not show that heel booties were implemented, and when the resident was observed in bed and later in a reclining wheelchair, no heel booties were in place. Staff interviews indicated the resident had never had heel booties and that nursing should have implemented them based on the note. The record also showed a Wound Physician note for an unstageable deep tissue injury of the left distal medial foot with intact skin, measuring 1 cm by .08 cm, with treatment ordered as skin prep applied once daily and as needed. The physician orders did not show skin prep was implemented until six days after the recommendation. During interviews, the Wound Physician stated he rounds weekly with nursing staff who input his treatment recommendations as orders, and nursing staff and the DON stated they were not aware of the delay in implementing skin prep. The report documents that the facility failed to implement both the heel booties recommendation and the timely skin prep treatment for Resident #48’s pressure-related foot wound.
Dignity and Dining Experience Deficiencies
Penalty
Summary
The facility failed to maintain the dignity of Resident #222 by not placing their urinary catheter bag in a privacy bag, as required by the facility's policy on indwelling Foley catheter care. Resident #222, who has intact cognition, expressed embarrassment over the exposed catheter bag, which was visible from the hallway during observations on two separate occasions. Charge Nurse #1 confirmed that it is the responsibility of the Certified Nurse's Aides and nurses to ensure catheter bags are placed inside privacy bags. Resident #23, who has severely impaired cognition and requires assistance with eating, was not provided a dignified dining experience. On multiple occasions, Resident #23 was observed with food placed out of reach and was left waiting for assistance while watching others eat. Staff members were observed standing over Resident #23 while feeding, rather than sitting at eye level and interacting with the resident, as recommended by the Nurse Unit Manager and the Director of Nursing. On the Station 2 unit, similar issues were observed where residents dependent on staff for eating were left waiting with food in front of them. Staff members were seen standing over residents while feeding them, rather than sitting at eye level. Additionally, on the Station 4 unit, a CNA was observed using a cell phone while assisting a resident with their meal, which was acknowledged as inappropriate by Nurse Unit Manager #3.
Failure to Develop Baseline Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents diagnosed with dementia, among other conditions. These residents were admitted or readmitted to the facility with severe cognitive impairments, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours to address immediate health and safety needs, the medical records for these residents did not indicate that such plans were created. This lack of baseline care plans meant that individualized interventions related to the residents' dementia and its progression were not documented. Interviews with Nurse Unit Managers confirmed that the nursing staff should have developed baseline care plans for these residents within the required timeframe. The absence of these plans was noted for residents with various diagnoses, including dementia, Parkinson's disease, bipolar disorder, depression, anxiety, metabolic encephalopathy, and acute kidney injury. The comprehensive care plans also failed to reflect the residents' dementia diagnoses and necessary interventions, highlighting a significant oversight in meeting professional standards of quality care for these individuals.
Failure to Develop Dementia Care Plans in DSCU
Penalty
Summary
The facility failed to ensure that residents with dementia received appropriate treatment and services through the development and implementation of individualized care plans. This deficiency was identified for five residents who were diagnosed with dementia and resided in the facility's Dementia Special Care Unit (DSCU). Despite the facility's disclosure of meeting state licensure requirements for specialized dementia care, the interdisciplinary team did not develop dementia-specific care plans for these residents. Resident #21, admitted with severe unspecified dementia and agitation, was found to have no person-centered care plan addressing their cognitive impairment and behaviors. Interviews with facility staff revealed that the responsibility for developing such a care plan was not clearly assigned, resulting in the absence of a tailored approach to managing the resident's dementia-related needs. Similarly, Residents #103, #41, and #25, all residing in the DSCU with severe cognitive impairments, also lacked interdisciplinary dementia care plans, as confirmed by the Nurse Unit Manager. Resident #69, who was readmitted with dementia and other medical conditions, did not have a baseline care plan for dementia upon readmission, nor were individualized interventions developed. The Nurse Unit Manager acknowledged the necessity for a specific care plan for residents with dementia, especially following readmission after hospitalization. The absence of these care plans indicates a systemic issue in the facility's approach to dementia care planning, affecting the residents' ability to attain or maintain their highest practicable well-being.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to accurately document the use of padded side rails for two residents, despite physician orders requiring them. Resident #77, diagnosed with Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, contrary to the documentation in the Treatment Administration Record (TAR) which indicated they were in place. Similarly, Resident #57, with epilepsy and a history of falls, was observed with only one side rail padded, while the TAR inaccurately documented that both side rails were padded. For Resident #53, who has chronic obstructive pulmonary disease (COPD) and is cognitively intact, the facility failed to change the oxygen tubing as per the physician's order. The tubing was observed to be unchanged for five weeks, despite the Medication Administration Record (MAR) indicating it had been changed weekly. This discrepancy highlights a failure in accurately documenting the care provided to the resident. Resident #32, with hemiplegia and moderately impaired cognition, was supposed to have a palmar guard applied to manage contractures. However, observations revealed that the palmar guard was not applied, and there was no documentation of refusal by the resident. The TAR inaccurately indicated that the palmar guard was applied, despite the absence of the device during multiple observations.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications, despite being assessed as unable to do so. The resident, who was admitted with diagnoses including adult failure to thrive and hypertension, was observed with pills left at the bedside for self-administration. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, and this assessment indicated that the resident was not a candidate for self-administration due to cognitive, physical, or visual limitations. On a specific date, a surveyor observed two brown pills in a medication cup on the resident's bedside table while the resident was out for an appointment. Interviews with nursing staff revealed that the pills were left by a nurse for the resident to take later, which was against the facility's policy. The Charge Nurse confirmed that the resident should not have been left with medications unattended, as the assessment had not changed since admission. The Director of Nursing reiterated that the resident was not permitted to self-administer medications, and the pills should not have been left at the bedside.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate bruises of unknown etiology for a resident, identified as Resident #4, who was admitted with diagnoses including Alzheimer's dementia, kidney disease, and diabetes. The resident was observed with dark purple bruises on both hands, which were not documented in the medical record or noted during weekly skin checks. The facility's policy required obtaining caregiver statements for bruises of unknown origin, but this was not followed. Nurse #2 noticed the bruises but did not report them to the charge nurse, and Charge Nurse #1 was unaware of the bruises and did not initiate an investigation or report to the state agency as required. CNA #1 observed the bruises before providing care and before the resident hit their hand on the bedrail, but failed to report them immediately. The Director of Nursing and the Staff Development Coordinator were not aware of the bruises on both hands, and the incident was not thoroughly investigated or reported. The facility's documentation was incomplete, failing to question other staff members or provide a comprehensive account of the bruises' origin.
Failure to Report Bruises of Unknown Origin
Penalty
Summary
The facility failed to report bruises of unknown origin on a resident to the state agency within the required two-hour timeframe. The resident, who was admitted in December 2016, has Alzheimer's dementia, kidney disease, and diabetes, and is severely cognitively impaired, requiring maximum assistance with activities of daily living. On a specific date, a surveyor observed dark purple bruises on both of the resident's hands, which were not documented in the medical record or noted in the weekly skin checks or progress notes for November and December. Nurse #2 noticed the bruises but did not inform the charge nurse, and Charge Nurse #1 was unaware of the bruises until the surveyor's observation. An incident report dated in November indicated a bruise on the resident's left hand, but not the right, and noted the resident was combative and hit their hand on the bedrail. CNA #1 reported seeing the bruises before providing care and before the resident hit the bedrail, but did not immediately report it to the manager. The Staff Development Coordinator was only aware of the left hand bruise and did not report it to administration, assuming it was witnessed. The Director of Nursing confirmed that all injuries of unknown origin should be reported to the state agency within the required timeframe.
Failure to Develop Individualized Care Plans for ADLs and Psychotropic Medication
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for a resident, specifically in relation to activities of daily living (ADLs) and the use of psychotropic medication. The resident, who was admitted in January 2024, had diagnoses including dementia with psychotic disturbance, Parkinson's disease, and difficulty walking. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment, dependence on ADLs, and the use of antipsychotic medication. However, the medical record did not include individualized interventions for the resident's ADL needs or psychotropic medication monitoring. Interviews with facility staff revealed that the MDS nurse did not develop a care plan for the resident's ADL and psychotropic medication needs, and the Care Area Assessment (CAA) referred to nursing for care plan development. The Nurse Unit Manager acknowledged that a care plan should have been developed based on the resident's diagnoses, medications, and other care needs, but it was not present in the resident's care plans.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after the quarterly review assessment. Specifically, the care plan for a stage 3 pressure ulcer on the resident's left heel was not updated or resolved, despite the ulcer having healed a long time ago. The resident, who was admitted in October 2020, has diagnoses including type 2 diabetes mellitus and hemiplegia and hemiparesis following a cerebral infarction. The most recent Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and did not have any unhealed pressure ulcers, yet the care plan still included an outdated problem related to the pressure ulcer. Observations and interviews revealed that the resident was resting on an air mattress with a blanket cradle, and did not respond when asked about any wounds. Nurse #5 confirmed that the pressure ulcer had healed a long time ago, and Nurse Unit Manager #3 acknowledged that the care plan should have been resolved during the care plan review after the quarterly MDS assessment. The failure to update the care plan reflects a lapse in the facility's process for reviewing and revising care plans in accordance with the MDS schedule.
Failure to Implement Contracture Management Intervention
Penalty
Summary
The facility failed to implement an intervention for contracture management in accordance with the medical plan of care for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who had moderately impaired cognition and functional limitation in the range of motion of the upper extremity, was observed multiple times without the prescribed palmar guard on the right hand. The medical record indicated a physician's order for the palmar guard to be worn during specific hours, but observations revealed that the device was not applied, and there was no documentation of refusal by the resident. Interviews with staff revealed a lack of awareness and adherence to the prescribed intervention. A CNA was unaware of any device for the resident's right hand, and a nurse mentioned that the resident might not wear the palmar guard due to behaviors, but this was not documented as a refusal. The Director of Rehabilitation confirmed the importance of the palmar guard in preventing skin issues and worsening contractures, and stated that she was not informed of the resident's non-compliance. The Nurse Unit Manager acknowledged that the palmar guard was necessary to prevent worsening contractures and emphasized that the intervention should be documented accurately, with referrals to rehab if the resident did not use the recommended device.
Failure to Implement Physician-Ordered Padded Side Rails
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent accidents for two residents. Resident #77, who has Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, despite a physician's order for them due to agitation. The observations occurred over several days, and interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the order to be followed, yet the padded side rails were not in place. Similarly, Resident #57, who has epilepsy, dementia, and a history of falling, was observed with only one side rail padded instead of both, as per the physician's order. This resident was also assessed to have severely impaired cognition and required total care. The observations were consistent over several days, and interviews with nursing staff and the Director of Nursing reiterated that both side rails should have been padded to prevent injury during a seizure, yet this was not adhered to.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss. The resident, who was admitted with conditions including dementia and dysphagia, experienced a 15% weight loss over six months. The facility's policy required a Nutrition Alert for significant weight loss, but this was not initiated in a timely manner. The resident's weight was not adequately monitored, and the dietitian was not informed of the weight loss until a routine quarterly assessment. Despite the resident's plan of care including interventions like nutritional supplements and weekly weights, these measures were not effectively implemented or adjusted in response to the resident's ongoing weight loss. The dietitian noted that the resident had a healthy appetite and consumed meals well, yet the weight loss continued. The dietitian was not notified of the resident's weight changes documented in the weight log, and the issue of obtaining timely weights was an ongoing problem reported to the Director of Nursing. The lack of timely communication and intervention contributed to the resident's significant weight loss, as the dietitian was unaware of the situation until much later. The facility's failure to adhere to its weight monitoring policy and communicate effectively with the dietitian and healthcare proxy resulted in a deficiency in maintaining the resident's nutritional status.
Failure to Maintain Oxygen Equipment and Change Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for two residents. For Resident #223, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator air filter to have a thick layer of gray fuzzy substance on it during multiple observations. Charge Nurse #1 was unaware of who was responsible for cleaning the filter or how often it should be cleaned. The Maintenance Director mentioned that a company was supposed to clean the filters weekly, but there was no documentation or system in place to track the cleaning of each machine. For Resident #53, who was admitted with chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator filter covered in a gray substance, indicating it had not been cleaned. Nurse Unit Manager #4 confirmed that the filter should be cleaned weekly and deferred to the maintenance department for ensuring the filters were cleaned. The Maintenance Director reiterated the lack of documentation and tracking system for the cleaning of the filters. Additionally, Resident #53's oxygen tubing was not changed as ordered. The tubing was dated 10/29/24, despite a physician's order to change it weekly. Resident #53 reported that nurses left new tubing for self-change, but there was no documentation of refusal or assessment of the resident's ability to change the tubing. Nurse #4 and the Director of Nursing confirmed that the tubing should be changed weekly and that residents should be assessed for their ability to change their own tubing, which had not been done for Resident #53.
Infection Control Breach in Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards for cleaning shared resident equipment, specifically the vital sign machine. According to the facility's policy, equipment should be cleaned immediately after use. However, a surveyor observed a nurse using a portable vital sign caddy on a resident under enhanced barrier precautions (EBP) and then using the same caddy on another resident without disinfecting it in between. During interviews, the nurse admitted to not disinfecting the equipment, acknowledging that she should have done so. The nurse unit manager confirmed that shared equipment should be disinfected before being used on another resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,389 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sancta Maria Nursing Facility | 1.9 mi | ★★★★★ | 11 | 0 |
| Maristhill Nursing & Rehabilitation Center | 2 mi | ★★★★★ | 24 | 0 |
| Pine Knoll Nursing Center | 2.3 mi | — | 47 | 1 |
| Neville Center At Fresh Pond For Nursing & Rehab | 2.3 mi | ★★★★★ | 0 | 0 |
| Watertown Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.