Inspection Reports for
Belen Meadows Healthcare and Rehabilitation Center, LLC
1831 CAMINO DEL LLANO, BELEN, NM, 87002
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to allow a resident to choose the time for wound care treatment.
Complaint Details
The complaint was substantiated as the resident repeatedly refused wound care due to timing issues, and the facility did not document or accommodate the resident's request to change the wound care schedule.
Findings
The facility failed to accommodate a resident's request to have wound care performed during preferred daytime hours, resulting in multiple refusals of care. Documentation did not reflect any changes to the wound care schedule despite resident complaints and staff awareness.
Deficiencies (1)
Failure to allow a resident to choose the time wound care would take place, leading to refusals and potential worsening of the wound.
Report Facts
Wound care opportunities missed: 8
Resident refusals: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident wound care refusals and facility expectations for accommodating resident preferences. |
| Unit Manager #2 | Unit Manager | Interviewed about resident non-compliance with wound care and staff addressing the issue. |
Inspection Report
Deficiencies: 15
Date: Nov 18, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, environment, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident preferences for wound care timing, unsafe and unmaintained environment, inaccurate PASARR screening, delayed hospital transfer after a fall, improper maintenance of specialized equipment, medication errors exceeding 5%, failure to dispose of completed medications, unlocked treatment cart, failure to provide routine dental care, failure to honor dietary preferences, outdated ice machine filters, incomplete resident documentation, infection control lapses including sharps in laundry and inadequate water management plan, and failure to maintain resident wheelchair in safe condition.
Deficiencies (15)
Failed to allow a resident to choose the time wound care would take place, resulting in refusals and incomplete wound care.
Failed to maintain a safe, comfortable, and homelike environment including lighting, repairs, and pest control.
Failed to ensure PASARR screening accurately reflected resident's diagnosis of major depressive disorder.
Failed to send a resident to hospital in a timely manner after a fall with pain and possible injury.
Failed to ensure a resident's specialized alternating air mattress was properly inflated.
Failed to properly maintain respiratory care equipment by not dating oxygen humidifier.
Failed to dispose of completed medications, resulting in medication remaining in medication cart.
Medication error rate exceeded 5% due to late administration and administration without active orders.
Failed to lock treatment cart when unattended, exposing wound care supplies and equipment.
Failed to ensure residents obtained routine dental care at least annually.
Failed to honor a resident's dietary preference for vegetarian diet, serving meat instead.
Failed to replace ice machine filters timely, with filters last changed over 5 months prior.
Failed to keep accurate and complete resident records, including inconsistent documentation of falls and missing ADL entries.
Failed to follow proper infection control practices for handling laundry with sharps and failed to implement an adequate water management plan for Legionella control.
Failed to maintain a resident's wheelchair in safe operating condition, with broken back bar not repaired.
Report Facts
Medication error rate: 8.6
Medication administrations: 26
Medication errors: 3
Missing ADL documentation entries: 141
Ice machine filter replacement date: Apr 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide #1 | Certified Medication Aide | Named in medication error findings and late medication administration. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding wound care, medication errors, infection control, and documentation deficiencies. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Reported concerns about delayed hospital transfer after resident fall. |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental maintenance and ice machine filter replacement. |
| Social Services Director | Social Services Director | Interviewed regarding PASARR screening and dental appointment scheduling. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding sharps disposal and environmental hazards. |
| Physical Therapist | Physical Therapist | Interviewed regarding wheelchair maintenance and safety. |
| Corporate Nurse | Corporate Nurse | Interviewed regarding discrepancies in after-hours provider notification documentation. |
| Dietary Director | Dietary Director | Interviewed regarding dietary preference and meal service errors. |
| Nurse Manager #1 | Nurse Manager | Interviewed regarding dental appointment scheduling and documentation. |
| Facility Driver | Facility Driver | Interviewed regarding responsibility for scheduling dental appointments. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding unlocked treatment cart. |
| Nurse #2 | Nurse | Interviewed regarding medication disposal process. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to inform residents and their representatives in writing about room changes caused by a flooding event on the 200 wing.
Complaint Details
The complaint investigation found that the facility did not notify residents or their representatives in writing about room changes caused by flooding on 01/06/25. Phone notifications were made by 01/07/25, but no written documentation was provided. The Director of Nursing confirmed these findings.
Findings
The facility failed to provide written notice to residents and their representatives about room changes due to flooding, resulting in potential confusion and frustration. Staff notified families by phone but did not document written notifications for any of the eight residents moved.
Deficiencies (1)
Failed to inform residents and resident representatives in writing of a room change, including the reason for the change, when residents were moved due to flooding.
Report Facts
Residents moved: 8
Residents on 200 wing: 18
Residents able to ambulate: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager #1 | Nurse Manager | Interviewed regarding moving residents and notification procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding resident moves and family notifications |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, medication management, dietary services, and care planning at Belen Meadows Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in maintaining a safe and homelike environment, accurate and timely care planning, proper medication storage documentation, and ensuring residents received food according to their dietary meal tickets. All deficiencies were cited with minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failed to maintain a safe, clean, and homelike environment by not repairing a broken bathroom doorknob for resident #52.
Failed to ensure the comprehensive care plan was accurate for resident #37, including incorrect smoking status documentation.
Failed to ensure the comprehensive care plan was accurately revised within 7 days for resident #37 regarding urinary tract infection status.
Failed to document medication refrigerator temperatures consistently, risking potency of medications for all residents.
Failed to ensure residents #30, #62, and #64 received food according to their dietary meal tickets, including missing items and incorrect meals served.
Report Facts
Residents reviewed for homelike environment: 4
Residents reviewed for care plan accuracy: 1
Residents reviewed for dietary services: 4
Residents affected by dietary deficiencies: 3
Dates with missing medication temperature documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding maintenance and work order submission for broken doorknob | |
| Director of Nursing (DON) | Interviewed regarding care plan accuracy, medication storage temperature documentation, and resident care | |
| Regional Dietary Manager | Interviewed regarding dietary service deficiencies and meal ticket compliance |
Inspection Report
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in wound care at Belen Meadows Healthcare and Rehabilitation Center, specifically related to wound care orders and treatment documentation for residents with pressure sores.
Findings
The facility failed to obtain wound care orders for one resident with pressure sores, resulting in missing treatment orders on the treatment administration record despite wound care being provided. Interviews confirmed the wound care nurse and Director of Nursing acknowledged the issue with order documentation.
Deficiencies (1)
Failure to obtain wound care orders for one resident with pressure sores, leading to missing treatment orders on the treatment administration record.
Report Facts
Residents reviewed for pressure sores: 3
Residents affected: 1
Wound length: 4.25
Wound width: 3.11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding wound care order documentation and treatment administration record issues |
| CNA #1 | Certified Nurse Assistant | Interviewed about care provided to resident #12 including shower and dressing changes |
| Wound care nurse | Wound Care Nurse | Interviewed about involvement with wound care for resident #12 and order documentation |
| Unit Manager #1 | Unit Manager | Interviewed about the necessity of orders for treatment to occur |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation to evaluate grievances and allegations related to resident care, including failure to document grievance investigations, incomplete investigations of injuries of unknown origin, and failure to document nursing assessments after changes in condition.
Complaint Details
The complaint investigation found failures in grievance documentation, incomplete investigation of an injury of unknown origin, and lack of nursing assessments after changes in condition. The facility did not document investigation summaries or resolutions for grievances filed by residents R #2 and R #5. The injury of unknown origin for resident R #6 was not properly investigated, and family follow-up was lacking. Nursing assessments were missing for residents R #2 and R #6 after reported health irregularities.
Findings
The facility failed to document summaries of grievance investigations and resolutions for residents, did not complete thorough investigations regarding an injury of unknown origin for one resident, and failed to document nursing assessments for residents after changes in condition. These deficiencies could result in residents feeling unimportant, being at risk for further injury, and not receiving proper care.
Deficiencies (3)
Failed to ensure grievance documentation included a summary of the investigation and findings or conclusions and no resolution for 2 of 3 residents reviewed for grievances.
Failed to complete a thorough investigation regarding an injury of unknown origin for 1 of 3 residents reviewed during complaint investigation.
Failed to document a resident assessment when receiving a report of a health status irregularity and to document observations of the irregularity for 2 of 5 residents reviewed after a change in condition.
Report Facts
Residents reviewed for grievances: 3
Residents affected by grievance deficiency: 2
Residents reviewed during complaint investigation: 3
Residents affected by injury investigation deficiency: 1
Residents reviewed for nursing assessments after change in condition: 5
Residents affected by nursing assessment deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Center Executive Director (CED) | Confirmed lack of grievance investigation summaries and resolution documentation; described attempts to investigate injury of unknown origin. | |
| Nurse Manager #1 | Confirmed unresolved grievances, lack of grievance investigation summaries, failure to document nursing assessments, and described investigation procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to ensure a safe, planned discharge for resident #95, who was discharged and subsequently refused re-admission after a hospital transfer.
Complaint Details
The complaint involved resident #95 who self-initiated a 911 call due to anxiety, seizures, and withdrawal symptoms. The facility refused to accept her back after hospital transfer, leaving her temporarily homeless and without medications. The complaint was substantiated through record reviews and multiple staff and resident interviews.
Findings
The facility failed to provide a safe discharge plan for resident #95, who was discharged without medications or proper arrangements and was refused re-admission after hospital transfer. Interviews and record reviews revealed issues with medication management, resident agitation, and communication failures between the hospital and facility.
Deficiencies (1)
Failure to prepare residents for a safe transfer or discharge from the nursing home.
Report Facts
Residents reviewed for discharge: 3
Resident affected: 1
Oxygen liters: 4
Hospital stay duration: 200
Admission date: Jan 16, 2023
Discharge date: Jan 18, 2023
Inspection Report
Routine
Deficiencies: 21
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication administration, resident rights, care planning, infection control, staffing, and food service.
Findings
The facility had multiple deficiencies including failure to ensure residents were informed about medications, maintain personal possessions, complete advance directives, notify physicians of blood sugar fluctuations, maintain sanitary conditions, file grievances, develop accurate care plans, provide adequate assistance with ADLs, offer vision services, ensure timely physician visits, maintain adequate staffing, follow infection control protocols, and provide palatable food.
Deficiencies (21)
Failed to ensure residents were aware of and understood the risks and benefits of medications administered.
Failed to maintain the right for residents to preserve personal items, resulting in missing clothing and improper labeling.
Failed to ensure Medical Orders for Scope of Treatment (MOST) forms were complete and properly signed.
Failed to notify resident's guardian and physician of blood sugar fluctuations, resulting in immediate jeopardy.
Failed to maintain sanitary conditions in resident rooms, leaving floors dirty and sticky.
Failed to file grievances for residents regarding missing personal property.
Failed to create accurate baseline care plans within 48 hours of admission for multiple residents.
Failed to develop and implement comprehensive person-centered care plans for residents, including care for transfers using Hoyer lifts.
Failed to provide assistance with activities of daily living (ADLs) including bathing, grooming, and toileting.
Failed to offer vision services and address broken or missing glasses for residents.
Failed to arrange foot care services for residents with toenail overgrowth.
Failed to ensure resident safety by leaving bed in high position despite fall risk.
Failed to ensure residents and their doctors met face-to-face at all required visits within 60 days.
Failed to properly store medications in medication carts, including loose medications.
Failed to maintain menu options as planned and provide palatable, attractive food at appropriate temperatures.
Failed to store and serve food under sanitary conditions including undated and unsealed food items, missing temperature logs, and uncovered food during transport.
Failed to ensure proper infection control practices for residents on contact precautions, including hand hygiene and use of personal protective equipment.
Continued to administer psychotropic medication to a resident with documented refusal and failed to notify physician of repeated refusals.
Failed to accurately document resident information related to activities of daily living (ADLs).
Failed to ensure residents received necessary behavioral health care and psychiatric assessments.
Failed to track and monitor vaccination status for pneumococcal and influenza vaccines.
Report Facts
Refusals of Trazodone: 27
Residents on census: 103
Call lights observed on: 4
Shower sheets missing: 1
Documentation blanks: 39
Documentation blanks: 58
Documentation blanks: 19
Documentation blanks: 30
Documentation blanks: 49
Documentation blanks: 13
Documentation blanks: 37
Documentation blanks: 7
Documentation blanks: 24
Documentation blanks: 6
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