Deficiency Records for Belen Meadows Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Belen Meadows Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-14 | 2024-01-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-14 | 2024-01-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-14 | 2024-01-26 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-03-16 | 2023-05-31 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-16 | 2023-05-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-16 | 2023-05-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-16 | 2023-05-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-16 | 2023-05-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-16 | 2023-05-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-16 | 2023-05-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-16 | 2023-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-16 | 2023-05-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-03-16 | 2023-05-31 | N |
| Provide appropriate foot care. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-03-16 | 2023-05-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-16 | 2023-05-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-16 | 2023-05-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-16 | 2023-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-16 | 2023-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-05-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-16 | 2023-05-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-07 | 2023-04-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-03-07 | 2023-04-28 | N |
| Meet other general requirements. | Fire Safety | 2023-03-07 | 2023-04-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-07 | 2023-04-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-30 | 2023-02-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2023-02-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2023-02-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-30 | 2023-02-06 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-30 | 2023-02-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-06 | 2022-03-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-06 | 2022-03-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-01-06 | 2022-03-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-06 | 2022-03-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-06 | 2022-03-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-01-06 | 2022-03-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-06 | 2022-03-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-01-06 | 2022-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-06 | 2022-03-03 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-28 | 2022-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-28 | 2022-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-28 | 2021-12-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-28 | 2021-11-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-28 | 2021-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-28 | 2021-11-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-28 | 2021-11-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-28 | 2021-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-11-19 | 2021-01-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-11-19 | 2021-01-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-11-19 | 2021-01-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-19 | 2021-01-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-11-19 | 2021-01-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-11-19 | 2021-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-11-19 | 2021-01-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-11-19 | 2021-01-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-11-19 | 2021-01-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-11-19 | 2021-01-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-11-19 | 2021-01-05 | N |
| Provide or obtain dental services for each resident. | Health | 2020-11-19 | 2021-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-19 | 2021-01-05 | N |
