Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Belen Meadows Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and major depression had an unwitnessed fall in her room that resulted in a swollen hand. Staff performed an assessment, notified a provider via Telehealth, and obtained an x-ray to rule out injury, which showed no fracture or dislocation. Despite the facility’s abuse prohibition policy requiring immediate reporting of alleged injuries and injuries of unknown source to the State Agency, the DON and ADM acknowledged that this unwitnessed fall with potential injury met reporting criteria but was not reported.
The facility did not replace the ice machine filters by the recommended date, as observed on two occasions. Both the District Manager and Maintenance Director confirmed the filters were overdue for replacement and acknowledged responsibility for this task.
The facility did not ensure proper infection control practices when laundry staff repeatedly found used shaving razors in dirty towels, with incidents not reported to the Infection Control Preventionist or DON. Additionally, the Water Management Program lacked procedures, control limits, monitoring protocols, and interventions to minimize Legionella risk, and facility leadership was unaware of these deficiencies.
A resident with a chronic sacral pressure ulcer repeatedly refused wound care during the night shift, expressing a preference for daytime care. Despite these requests, staff continued to attempt wound care at night, and there was no documentation of any change to the care plan or physician orders to accommodate the resident's wishes. Nursing notes and interviews confirmed the resident's refusals and preferences, but the facility did not adjust care practices or document reasons for missed wound care.
Staff did not maintain a safe and homelike environment, as evidenced by burnt-out lights, damaged walls, and missing blinds in the dining area, as well as broken fixtures, water leaks, foul odors, and pest infestations in several resident rooms and bathrooms. Residents reported ongoing maintenance issues and discomfort, while maintenance staff acknowledged responsibility but did not complete necessary repairs.
Surveyors found that staff administered medications with an error rate of 8.6%, exceeding the 5% threshold. Errors included a resident receiving levothyroxine and apixaban outside of prescribed timeframes, and another resident being given Artificial Tears without an active provider order. CMAs cited workload and misunderstanding of order status as contributing factors, and the DON confirmed that medications should only be given as ordered and within specified timeframes.
A treatment cart containing wound care supplies and medical tools was left open and unattended by a nurse, making its contents accessible. The DON confirmed that all treatment carts are expected to be locked when not attended by staff.
A resident with diabetes, morbid obesity, and legal blindness was not provided with meals that matched her documented vegetarian diet preference, including no eggs or meat. Despite repeated reminders to staff, the resident continued to receive meals containing meat, such as pork sandwiches, and was left hungry. Facility records showed conflicting diet orders, and staff interviews confirmed the resident's dietary needs were not consistently met.
Two residents experienced deficiencies in medical record-keeping, including discrepancies in documentation of fall events and missing entries in ADL flow sheets. The Corporate Nurse and DON acknowledged issues with inaccurate records and incomplete documentation, with contributing factors including staff access to electronic records and short duration of stay.
A resident with a documented diagnosis of major depressive disorder and related symptoms was not accurately identified as having a mental illness on the PASARR Level I Identification Screening. The facility's records and staff interview confirmed that the screening failed to reflect the resident's mental health diagnosis, contrary to policy and assessment findings.
A resident with dementia and a history of left femur fracture experienced a fall resulting in increased pain and visible distress. Despite escalating pain levels and abnormal physical findings, there was a significant delay in obtaining x-rays and transferring the resident to the hospital. Staff interviews revealed lapses in communication and timely intervention, leading to prolonged pain before the resident received appropriate care.
A resident with multiple health conditions was found sleeping on a deflated alternating air mattress, despite provider orders and care plans specifying its use. Staff interviews confirmed that nursing staff were responsible for checking such equipment, but the mattress was not properly inflated at the time of observation.
Staff did not date the oxygen humidifier bottle for a resident with CHF and anemia, despite facility policy and provider orders requiring dating and weekly replacement of oxygen equipment. The undated humidifier was observed in use, and both a nurse and the DON acknowledged the requirement for proper labeling and replacement.
Staff did not dispose of a completed medication after a resident's treatment ended, leaving an opened bottle of artificial tears in the medication cart and failing to document its removal as required by facility policy. The nurse responsible for medication destruction did not receive the medication, and the DON confirmed that completed medications should not remain in carts.
A resident did not receive required annual dental care, with the last documented dental visit occurring nearly two years prior. Although there was an order for a dental appointment, there was no evidence the appointment occurred, and the order was discontinued. The facility relied primarily on the driver to track and schedule dental appointments, while other staff were unaware of the missed care. The DON stated that the responsibility should have been shared by the IDT.
A resident with a history of falls and limited mobility was observed using a wheelchair with a detached back bar, which had been broken for an extended period. An LPN noticed the issue and verbally reported it but did not document it, and the PT confirmed the wheelchair was unsafe and missing necessary parts. The resident continued to use the unsafe wheelchair until the issue was addressed.
The facility failed to provide written notification to residents and their representatives about room changes due to a flooding event. Although families were informed by phone, there was no written documentation provided, affecting eight residents. The Director of Nursing confirmed the lack of written notifications, which is required for room changes.
The facility failed to document medication refrigerator temperatures, as required, for several days. This was discovered through record review and observation, revealing that insulin and other medications requiring refrigeration were stored without proper temperature monitoring. The DON confirmed that staff must check and document temperatures twice daily to ensure they remain within the necessary range.
The facility failed to serve meals according to dietary meal tickets for three residents. One resident did not receive double portions as required, another had multiple missing items and incorrect meals, and a third reported frequent mismatches between the menu and served food. The Regional Dietary Manager confirmed these issues.
A resident's bathroom doorknob was broken for several weeks, preventing access to the restroom. Despite a work order being submitted, the repair was not completed, and the facility's administrator was unaware of the status. The resident, who was continent and able to toilet independently, had informed CNAs about the issue.
The facility failed to maintain an accurate care plan for a resident, including conflicting statements about smoking status. The care plan initially prohibited smoking, then allowed supervised smoking, despite the resident having no history of smoking. The DON confirmed the inaccuracies during an interview.
A facility failed to revise a resident's care plan accurately, which continued to indicate an active UTI despite the resident not having one since February. The care plan, dated June, should have reflected the resident's risk for developing UTIs. The DON confirmed the oversight during an interview.
The facility failed to obtain wound care orders for a resident with pressure sores, leading to confusion and lack of documented care. Despite the wound care nurse documenting the sacral wound and an order being placed, the treatment administration record did not reflect this, causing inconsistencies in wound care management.
Failure to Report Unwitnessed Fall With Potential Injury to State Agency
Penalty
Summary
The facility failed to report an alleged incident involving an unwitnessed fall with potential injury to the State Agency as required by its Abuse Prohibition policy. The policy, revised on 11/14/25, prohibits neglect and requires immediate reporting, investigation, documentation, and follow-up of alleged injuries, including injuries of unknown source. It directs the facility to initiate an investigation within 24 hours of receiving information about an injury or suspected neglect, document interviews and findings, notify the physician and resident representative, and submit findings of completed investigations within five days to the State Agency. Record review showed that a resident with dementia, muscle weakness, and major depression experienced an unwitnessed fall in her room, after which staff documented a swollen left hand. A Telehealth provider was contacted and ordered an x-ray of the hand, which later showed no fracture or dislocation. The DON stated that an unwitnessed fall with hand swelling and an x-ray to rule out injury met the criteria for reporting to the State Agency due to the potential for injury. The Administrator confirmed awareness of the fall and acknowledged that the incident should have been reported to the State Agency but was not, resulting in the failure to follow the facility’s abuse/neglect reporting requirements.
Failure to Replace Ice Machine Filters Timely
Penalty
Summary
The facility failed to ensure timely replacement of the filters on the ice machine, as observed on two separate occasions. The filters displayed a replacement date of 04/24/25, and instructions on the filters indicated they should be changed at least once per year. Despite this, the filters had not been replaced by the time of the second observation. During interviews, the District Manager confirmed that the Maintenance Director was responsible for changing and ordering the filters, and the Maintenance Director acknowledged that the filters needed to be changed.
Deficient Infection Control in Laundry Handling and Legionella Water Management
Penalty
Summary
The facility failed to follow proper infection control practices in two key areas: handling of laundry contaminated with used sharps and implementation of an adequate Water Management Program (WMP) to minimize the risk of Legionella. Observations revealed that laundry staff found used shaving razors in dirty towels brought to the laundry room, and these razors were subsequently placed in sharps disposal containers. The laundry technician reported finding razors in the laundry but could not recall when or to whom the incidents were reported. Both the Infection Control Preventionist and the Director of Nursing were unaware of these incidents, indicating a lack of communication and reporting regarding the presence of sharps in laundry. Facility policy on needle handling and sharps injury prevention did not address the risk of sharps contaminating linen or provide guidance on preventing such occurrences. Additionally, the facility's WMP was found to be inadequate in several areas. The policy lacked procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system, did not specify control limits or parameters, and failed to include monitoring procedures or environmental testing protocols for Legionella. There were also no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case. During interviews, facility leadership acknowledged that the WMP was reviewed annually but were unaware of its deficiencies in addressing Legionella risk.
Failure to Honor Resident's Preference for Wound Care Timing
Penalty
Summary
The facility failed to honor a resident's preference regarding the timing of wound care. The resident, who had quadriplegia, chronic pain, anxiety, depression, and a chronic sacral pressure ulcer, had physician orders for wound care to be performed twice daily on both day and night shifts. Documentation showed that wound care was frequently attempted during the night shift, but the resident repeatedly refused, stating a preference for wound care to be done during the day. Despite these refusals and the resident's clear requests, staff continued to attempt wound care at night, and there was no documentation of any adjustment to the care plan or physician orders to accommodate the resident's wishes. Nursing progress notes indicated multiple instances where the resident refused wound care at night and requested it be performed during the day. Interviews with the DON and Unit Manager confirmed awareness of the resident's refusals and preferences, but there was no evidence in the medical record, care plan, or orders that the timing of wound care was discussed or changed in response. Additionally, there was a lack of documentation explaining missed wound care opportunities or refusals on certain days.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Staff failed to maintain a safe, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies in the dining room and resident rooms. Observations revealed that the dining room had several burnt-out fluorescent and chandelier bulbs, scuffed walls with missing paint, and window blinds with missing slats. The Maintenance Director acknowledged responsibility for these areas and confirmed that the lights, walls, and blinds should have been maintained in good condition. In resident rooms and bathrooms, issues included non-functional hot water faucets, broken and uneven floor tiles, slow-draining sinks, standing water, foul odors, cracked windows, broken bed footboards, and partially detached window screens. Residents reported water leaks during rain, persistent foul odors, and unaddressed maintenance requests. The Maintenance Director was aware of some issues but stated repairs were not completed. Additionally, one resident's bathroom was repeatedly observed to have a significant presence of flies over several days, with the resident confirming the ongoing issue and expressing discomfort. Certified Nurse Aide (CNA) staff stated they would report hazards but were unaware of the specific problems observed, including the presence of flies. The Maintenance Director was not aware of the fly infestation and agreed the issue should have been addressed. These failures affected both common areas and multiple resident rooms, impacting the environment and comfort of the residents.
Medication Error Rate Exceeds 5% Due to Timing and Order Lapses
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in an observed error rate of 8.6% during the survey. For one resident with a history of venous thrombosis, embolism, and hypothyroidism, a Certified Medication Aide (CMA) administered levothyroxine and apixaban outside of the prescribed timeframes. Levothyroxine was not given 30 to 60 minutes before breakfast as ordered, and apixaban was not administered within the specified two-hour window. The CMA attributed the late administration to being assigned to two resident halls, which delayed medication delivery. The resident had already eaten breakfast before receiving the morning medications, contrary to the provider's orders and facility policy. In another instance, a different CMA administered Artificial Tears to a resident who exhibited redness and irritation around the eyes. However, the order for Artificial Tears had expired, and the medication was given without an active provider order. The CMA believed there was an active order but acknowledged that all medications require a current order before administration. The Director of Nursing confirmed that medications should not be administered without an active order and that it is the responsibility of both the CMAs and nurses to ensure orders are up to date before giving any medication.
Unattended and Unlocked Treatment Cart Exposes Medical Supplies
Penalty
Summary
Staff failed to secure a treatment cart on the 200 Unit, leaving the top drawer open and unattended while staff were away from the area. Observations revealed that the cart contained wound care dressings, wound cleanser, tweezers, barrier cream, irrigation solution, and scissors, all of which were accessible due to the unlocked and open drawer. During interviews, a registered nurse acknowledged responsibility for the unlocked cart, stating he had stepped away to assist a resident and left the cart open. The Director of Nursing confirmed that staff are expected to lock all treatment and medication carts when not in attendance and reiterated that carts should never be left open and unattended.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
A deficiency occurred when a resident with a documented vegetarian diet preference, including no eggs and no meat, was not provided with meals that honored these preferences. The resident's admission diet order specified a regular vegetarian diet with no eggs or meat, but the care plan did not address these dietary restrictions. The Minimum Data Set (MDS) listed a diabetic diet, and the resident's lunch ticket indicated a regular diet, resulting in the resident being served meals containing meat, such as a pork sandwich. The resident reported consistently receiving meat with meals and only being able to eat the salad, leading to hunger and repeated reminders to staff about her dietary needs. Interviews with facility staff revealed confusion regarding the resident's diet orders, with multiple conflicting diet orders present in the system, including regular, consistent carbohydrate (CCHO), and vegetarian diets. The Dietary Director acknowledged the lunch ticket was incorrect and confirmed the resident should have been on a CCHO and vegetarian diet. The DON was unaware the resident had received the incorrect diet and stated the expectation was for all residents to receive the correct diet. The failure to provide the appropriate diet was confirmed through record review, observation, and interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with dementia, osteoarthritis, chronic pain, and a left femur fracture, discrepancies were found between the times documented in the electronic medical record and the facility's after-hours provider notification records regarding falls and subsequent provider notifications. The Corporate Nurse was unable to explain why the times did not match and acknowledged the documentation was not accurate. For another resident with quadriplegia, chronic pain, anxiety, and depression, significant gaps were identified in the Activities of Daily Living (ADL) flow sheet documentation. Missing entries were noted for bathing, bed mobility, dressing, hygiene, toileting, and eating over an eleven-day period. The DON confirmed that the documentation was unacceptable and attributed the issue in part to agency staff not having access to the electronic medical record, as well as the resident's short stay at the facility.
Failure to Accurately Complete PASARR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected a resident's diagnosis of major depressive disorder. According to the facility's policy, the Social Worker or designated staff are responsible for ensuring that all patients with mental disorders receive appropriate pre-admission screenings in accordance with federal and state regulations. Record review showed that a resident was admitted with diagnoses including liver disease, dementia, and major depressive disorder. The resident's Minimum Data Set (MDS) assessment documented symptoms consistent with depression, such as little interest or pleasure in activities, feeling down, poor appetite, low energy, trouble concentrating, and impaired memory and decision-making. The MDS also indicated a moderate cognitive impairment and specifically noted depression as a psychiatric/mood disorder. Despite this documented diagnosis and symptoms, the PASARR Level I Identification Screening completed for the resident indicated that the resident did not have a diagnosis of or a suspected mental illness. During an interview, the Social Services Director confirmed that the PASARR screening was incorrect and acknowledged that staff should have documented the resident's diagnosis of major depressive disorder.
Delayed Hospital Transfer Following Resident Fall with Injury
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, osteoarthritis, chronic pain, and a previous left femur fracture experienced a fall resulting in pain to the left shoulder and left groin area. Documentation showed that the resident's pain level increased from 2 to 5 on a 1-10 scale following the fall, and later reached a 7. Despite these symptoms and visible signs of distress, there was a significant delay in sending the resident to the hospital. X-rays were ordered but not completed until later in the day, eventually revealing a displaced fracture of the left femoral neck. The resident was not transferred to the hospital until after the abnormal x-ray results were obtained. Interviews with staff indicated confusion and lack of timely communication regarding the fall and the resident's condition. The unit manager and DON both stated they were not promptly notified of the incident, and an LPN expressed concern about the delay in assessment and intervention, noting that the resident was visibly in pain and her hip appeared abnormal. The delay in response and transfer to the hospital resulted in the resident remaining in pain for an extended period before receiving appropriate medical care.
Failure to Ensure Proper Inflation of Specialized Air Mattress
Penalty
Summary
A deficiency occurred when a resident with reduced mobility, legal blindness, type 2 diabetes mellitus, and morbid obesity was found sleeping on a deflated alternating air mattress. The resident's medical records and provider orders indicated the need for a specialty alternating air mattress to prevent or treat pressure injuries. The care plan also documented the use of this therapeutic mattress. However, during an observation, the mattress was found to be off, deflated, and without any power lights while the resident was in bed. Interviews with facility staff confirmed that the mattress was not properly inflated. An LPN acknowledged that the deflated mattress could cause entrapment or additional pressure wounds and stated that all nursing staff were responsible for checking resident care equipment. The DON also stated that it was her expectation for nursing staff to check equipment during daily rounds and that malfunctioning equipment could lead to negative outcomes for residents. The failure to ensure the resident's air mattress was properly inflated constituted the deficiency.
Failure to Date Oxygen Humidifier for Resident Receiving Respiratory Care
Penalty
Summary
Staff failed to properly maintain respiratory care equipment for a resident with congestive heart failure and anemia by not dating the oxygen humidifier bottle attached to the resident's oxygen concentrator. Facility policy required staff to label oxygen humidifiers with the date and replace disposable oxygen equipment every seven days. Provider orders also specified that oxygen components should be changed and labeled with the date and initials as needed and every week for infection control. During observation, the resident's oxygen humidifier was found undated, and interviews with nursing staff and the DON confirmed that the humidifier should have been dated and replaced according to policy and orders.
Failure to Dispose of Completed Medication as Required
Penalty
Summary
Staff failed to dispose of a completed medication for a resident after the prescribed treatment period had ended. Specifically, a resident had an order for artificial tears to be administered every two hours as needed for seven days, with a documented end date. After the order was completed, the medication was not removed from the medication cart as required by facility policy. During an observation, an opened and used bottle of artificial tears was found in the medication cart, and a Certified Medication Aide confirmed it belonged to the resident and should have been disposed of after the order ended. Further review showed that the facility's Medication Disposal Form did not include documentation of the completed artificial tears for this resident. Interviews with staff revealed that the nurse responsible for destroying discontinued medications did not receive the completed eye drops, and the DON stated that completed medications should not be kept in medication carts. The facility's policy requires discontinued medications to be promptly removed and documented, which was not followed in this instance.
Failure to Ensure Routine Dental Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental care as required. Record reviews showed that the resident had not received annual dental services, with the last documented dental visit occurring nearly two years prior. Although there was a provider order for a dental appointment, there was no documentation that the resident attended the appointment, and the order was later discontinued. Interviews with the resident confirmed that she had not received dental services in a while and was experiencing dental pain. Further investigation revealed that the facility's process for arranging dental appointments was unclear and inconsistently followed. The facility's driver was primarily responsible for tracking and scheduling dental appointments, with occasional input from social services and nurse managers. However, both the Social Services Director and Nurse Manager were unaware that the resident had missed annual dental appointments. The Director of Nursing clarified that the responsibility for arranging dental appointments should have been shared by the Interdisciplinary Team, not solely the driver.
Failure to Maintain Resident Wheelchair in Safe Condition
Penalty
Summary
A resident with a history of repeated falls, generalized muscle weakness, and a need for assistance with personal care was observed sitting in a wheelchair that was not maintained in safe operating condition. The back bar of the wheelchair was detached and hanging on one side, and the resident reported that the wheelchair had been broken for an extended period. The resident's care plan included interventions for assistance with activities of daily living, transfers, and mobility due to limited mobility. A Licensed Practical Nurse noticed the broken wheelchair and verbally informed the night nurse to notify therapy staff, but did not document the issue in the resident's progress notes. The Physical Therapist stated that staff were expected to submit a work order in the maintenance reporting system to repair the wheelchair and to place the resident in a different wheelchair until repairs were completed. The therapist confirmed that the wheelchair was missing a securing knob and was unsafe for use.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to inform residents and their representatives in writing about room changes due to a flooding event on the 200 wing. This affected eight residents who were moved without receiving written notification, including the reason for the change. Interviews with staff, including a Nurse Manager and the Director of Nursing (DON), revealed that while families were notified by phone, there was no written documentation provided to the residents or their representatives. The flooding began on 01/06/25, and residents were moved on the same day, but written notifications were not issued. Record reviews for several residents showed a lack of documentation regarding written notifications for room changes. For instance, one resident's medical record indicated that the resident was moved for safety reasons due to a plumbing issue, and the resident's Power of Attorney (POA) was notified by phone, but not in writing. Another resident's POA stated they were not informed of the room change and would have liked to know what was happening. The DON confirmed that while phone notifications were made, written notifications were not provided, which is a requirement for room changes.
Failure to Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that staff documented the medication refrigerator temperatures in the medication storage room. This deficiency was identified through record review, observation, and interviews. Specifically, the temperature log book for the medication #1 refrigerator, medication #2 refrigerator, and the specimen refrigerator showed that staff did not document temperature recordings for several dates, including the evening of 06/21/24, both morning and evening of 06/22/24, and both morning and evening of 06/23/24. During an observation on 06/24/24, it was noted that the medication storage room contained insulin and other medications requiring refrigeration. The Director of Nursing (DON) confirmed in an interview that staff are required to check and document the refrigerator and freezer temperatures twice daily to ensure they remain within the range of 36 to 46 degrees Fahrenheit, which is necessary to preserve temperature-controlled medications and specimens.
Failure to Serve Meals According to Dietary Meal Tickets
Penalty
Summary
The facility failed to ensure that residents received meals according to their dietary meal tickets, which are individualized descriptions of what staff should serve each resident. This deficiency was observed in three residents. One resident, who was supposed to receive double portions of all items, reported not getting enough food and was observed receiving only single portions, missing items like ice cream. The Regional Dietary Manager confirmed that the resident should have received double portions as per the meal ticket. Another resident provided meal tickets for May and June, noting missing items on each ticket and stating that complaints to the Dietary Manager had not resolved the issue. The resident's meal tickets showed multiple instances where items were missing from her food tray, including margarine, jelly, sugar, eggs, and more. Additionally, the resident was served meals that did not match the menu, such as receiving Mexican spiced chicken instead of the listed cowboy casserole. The Regional Dietary Manager acknowledged these discrepancies. A third resident reported that the food rarely matched the menu, leading her to obtain food from outside the facility.
Failure to Repair Resident's Bathroom Doorknob
Penalty
Summary
The facility failed to maintain a homelike environment by not repairing a broken doorknob for a resident's bathroom door. The deficiency was observed when the resident reported that the doorknob had been broken for several weeks, preventing access to the restroom. The resident, who was continent and able to toilet independently, had informed the CNAs about the issue. A work order for the doorknob replacement was submitted on 06/17/24, but the repair had not been completed by the time of the survey. The facility's administrator was unaware of the work order's status and mentioned that the maintenance director was unavailable due to a medical emergency during the period the work order was submitted.
Inaccurate Care Plan for Resident's Smoking Status
Penalty
Summary
The facility failed to ensure the comprehensive care plan was accurate for a resident reviewed for care plan accuracy. The care plan for the resident, dated June 4, 2024, included conflicting focus areas regarding smoking. Initially, the care plan stated that the resident may not smoke per a smoking evaluation initiated on February 26, 2023. However, it was later updated to indicate that the resident may smoke with supervision per a smoking evaluation initiated on May 5, 2023. During an interview on June 28, 2024, the Director of Nursing (DON) confirmed that the resident did not smoke and had no history of smoking, indicating that neither smoking statement should have been included in the care plan.
Care Plan Revision Deficiency for UTI Risk
Penalty
Summary
The facility failed to accurately revise the comprehensive care plan for a resident who was reviewed for care plans. The resident had an active urinary tract infection (UTI) and was at risk for sepsis, as noted in the care plan dated June 4, 2024, with the condition initially identified on February 10, 2024. However, a review of the resident's quarterly Minimum Data Set (MDS) dated May 22, 2024, indicated that the resident did not have a UTI in the past 30 days. During an interview on June 28, 2024, the Director of Nursing (DON) confirmed that the resident had a UTI in February 2024 but had not had one since. The DON acknowledged that the care plan should have been updated to reflect that the resident was at risk for developing UTIs, rather than indicating an active UTI.
Failure to Obtain Wound Care Orders for Resident with Pressure Sores
Penalty
Summary
The facility failed to meet professional standards of quality by not obtaining wound care orders for a resident with pressure sores. The resident was admitted with wounds on the left heel and right big toe, and later developed a stage II pressure wound on the sacrococcygeal area. Although the wound care nurse documented the sacral wound and an order was put in place on 12/16/23, the treatment administration record (TAR) did not reflect this order, leading to confusion and lack of documented wound care for the sacral wound. The Director of Nursing and the wound care nurse were unclear why the order did not appear on the TAR, despite conversations indicating that wound care was being completed. The issue was further complicated when a nurse found multiple wounds on the sacrum during a routine check and noted that the resident's tail bone was red and inflamed due to bowel movements. The Unit Manager confirmed that orders need to be in place for treatment to occur and that any discrepancies should be addressed by obtaining the necessary orders. A CNA also confirmed that the resident always had a dressing on the sacrum, but the lack of proper documentation and orders on the TAR led to inconsistencies in wound care management.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Las Estancias By Pure Health | 25.5 mi | ★★★★★ | 1 | 0 |
| South Valley Care Center Llc | 28.7 mi | ★★★★★ | 2 | 0 |
| Manzano Del Sol By Purehealth | 31.9 mi | ★★★★★ | 1 | 0 |
| Ladera Center | 32 mi | ★★★★★ | 44 | 0 |
| Odelia Healthcare | 32.1 mi | ★★★★★ | 3 | 0 |
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