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 Belgrade Nursing Home during CMS and state inspections, most recent first.
A resident with intact cognition requested the most recent re-certification survey results due to concerns about infection control but was not provided with the information. Although the DON stated the results were posted, only outdated and incomplete survey results were observed on the bulletin board. The resident's request was relayed to other staff, but the information was not made available as required.
A resident with severe cognitive impairment and a history of falls was able to exit the facility unsupervised on multiple occasions, despite wearing a wander alert device. Staff checked the resident's device for functionality but did not routinely test the door alarm boxes, and alarms were not always audible to staff. The facility's policy required daily testing of the wander management system, but only the wearable devices were checked, leading to a failure in providing adequate supervision and accident hazard prevention.
The facility did not conduct a comprehensive facility-wide assessment, missing input from residents and families, and lacking a recruitment, retention, and contingency staffing plan. The administrator confirmed these omissions and the absence of a facility assessment policy.
A resident with a history of UTIs reported symptoms of a urinary tract infection, but the facility delayed in obtaining a urinalysis and urine culture. Despite standing orders for suspected UTIs, the process was not followed promptly, leading to a four-day delay in addressing the resident's symptoms. The DON confirmed the lack of documentation and timely action, which was crucial to prevent further complications.
A resident with cognitive impairment and multiple diagnoses was prescribed medications without documented indications for use. Facility staff, including a case manager and the DON, acknowledged that the process for entering and verifying new admission orders was not properly followed, resulting in missing diagnoses for the resident's medications.
A facility failed to identify indications for psychotropic medications for a resident with cognitive impairment and multiple diagnoses. The resident was prescribed several medications without including the reason for use or associated diagnosis. Staff interviews revealed that orders were entered and checked by multiple staff members, but the necessary information was missing and not clarified with the provider, contrary to facility policy.
Failure to Provide Survey Results to Resident Upon Request
Penalty
Summary
The facility failed to provide a resident with access to the most recent re-certification survey results upon request, as required by resident rights policies. The resident, who was cognitively intact according to a recent Minimum Data Set, reported requesting the survey results due to concerns about infection control practices after experiencing multiple illnesses during the year. Despite asking the activity director at a resident council meeting, the resident was told the results were not available. The DON stated the survey results were posted on a bulletin board, but observation revealed that only outdated results starting from page 9 were displayed, and not the most recent survey. The activity director confirmed the resident's request had been relayed to the social services designee and the administrator, but the request was not fulfilled.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm System Testing
Penalty
Summary
A resident with severe cognitive impairment, anxiety, unsteadiness, and a history of falls was admitted to the facility and later identified as being at risk for wandering due to confusion and impaired safety awareness. The resident's care plan included the use of a wander alert device, which was to be checked each shift and tested nightly. Despite these measures, the resident was able to exit the facility on multiple occasions without staff knowledge, remaining on campus but unsupervised. On one occasion, the resident was observed outside by a staff member, and it was discovered that the wander alert device did not trigger an alarm when the resident exited, although it functioned when the resident returned inside. Interviews with staff revealed that while the wander alert devices worn by residents were checked for functionality, the alarm boxes at the facility doors were not routinely tested to ensure they would sound when a resident with a device approached or exited. Staff also reported that alarms were not always audible from resident rooms, and some staff only became aware of the resident's exit after being informed by others. Documentation showed that the wander alert device was replaced after the incident, but subsequent testing of the original device indicated it was still operational, and the reason for the malfunction during the incident could not be determined. The facility's policy required daily testing and documentation of the wander management alarms, but the investigation found that only the wearable devices were checked, not the door alarm boxes. Additionally, the facility was unable to provide the operation manual for the wander alert system when requested. The lack of comprehensive testing and supervision allowed the resident to leave the building undetected, constituting a failure to provide adequate supervision and maintain a safe environment free from accident hazards.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment necessary for providing adequate care and services to its 22 residents. The assessment lacked input from residents and their families, which is a required component. Additionally, the facility did not have a recruitment or retention plan for employees, nor did it have a contingency staffing plan that could be activated without invoking the emergency preparedness plan. During an interview, the administrator confirmed these omissions and acknowledged that no facility assessment policy was available upon request.
Delayed Response to UTI Symptoms in Resident
Penalty
Summary
The facility failed to provide timely treatment for a resident, R20, who reported symptoms of a urinary tract infection (UTI). R20, who was cognitively intact and required substantial assistance with toileting, reported experiencing pain and burning during urination over a weekend. Despite having a history of UTIs and recognizing the symptoms, R20's complaints were not promptly addressed. The facility's progress notes indicated that a request for a urinalysis and urine culture (UA/UC) was made on 2/15/25, but the physician's order for the test was not approved until 2/18/25, and the urine sample was not collected until the evening of 2/18/25, with further delays in sending it to the lab. Interviews with staff revealed that the facility had standing orders to address suspected UTIs, but these were not followed in a timely manner. The Licensed Practical Nurse (LPN) stated that the process for obtaining a UA/UC was the same on weekends as during the week, yet there was a delay in both obtaining the physician's order and transporting the urine sample to the lab. The Director of Nursing (DON) confirmed that the facility's protocol, including the use of LOEB's criteria for assessing UTI symptoms, was not documented in R20's medical record. The DON acknowledged that the four-day delay in addressing R20's symptoms was excessive and emphasized the importance of immediate action to prevent complications such as sepsis from a bladder infection.
Failure to Document Medication Indications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, as evidenced by the lack of documented indications for medications prescribed to a resident with moderate cognitive impairment and diagnoses of hypertension, depression, and schizoaffective disorder. The resident's medication orders for amlodipine besylate, lisinopril, and psyllium did not include reasons for use or associated diagnoses. This oversight was identified during a review of the resident's admission Minimum Data Set and order summary report. Interviews with facility staff, including a registered nurse case manager and the director of nursing, revealed that the process for entering and verifying new admission orders was not adequately followed. The case manager and floor nurses were responsible for entering orders, which were supposed to be checked by additional staff members. However, the orders for the resident in question were missing associated diagnoses, and this error was not corrected within the expected 14-day timeframe. The director of nursing confirmed the importance of including diagnoses in medication orders to ensure clarity regarding the purpose of each medication.
Failure to Identify Indications for Psychotropic Medications
Penalty
Summary
The facility failed to identify the indications for psychotropic medications for a resident, leading to a deficiency in medication management. The resident, who had moderate cognitive impairment and diagnoses of hypertension, depression, and schizoaffective disorder, was prescribed several medications, including deutetrabenazine, risperidone, and trazodone. However, the medication orders did not include the reason for use or associated diagnosis, which is a critical component of medication management. Interviews with facility staff revealed that the orders were entered by the case manager or a floor nurse upon the resident's admission and were supposed to be checked by two additional staff members. Both the RN case manager and the DON acknowledged that the orders should have included an associated diagnosis or reason for use and that any missing information should have been clarified with the provider. The facility's policy required that all orders include a diagnosis and that any unclear orders be clarified, but this was not adhered to in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 1 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belgrade
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenoaks Senior Living Campus | 10.4 mi | ★★★★★ | 5 | 0 |
| Cura Of Paynesville | 16 mi | ★★★★★ | 4 | 0 |
| Cura Of Melrose | 18.1 mi | ★★★★★ | 14 | 0 |
| Cura Of Sauk Centre | 20.7 mi | ★★★★★ | 7 | 0 |
| Glenwood Village Care Center | 22.8 mi | ★★★★★ | 2 | 1 |
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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.