Belen Meadows Healthcare and Rehabilitation Center Inspection Report, Violations & Safety Grade (Belen, New Mexico)

1831 Camino Del Llano, Belen, New Mexico 87002

Phone: 5058641600

CMS Overall:4/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

107.2

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Valencia

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall4/5

Health3/5

Staffing3/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	New Mexico Avg	Difference
RN Hours per Resident per Day	0.53	0.65	-0.12
Total Nurse Hours per Resident per Day	3.31	3.58	-0.27
CMS Staffing Rating	3/5	2.8/5	-
Nursing Staff Turnover	56.9%	53.5%	-

Health Citation History

52 health citations on record

Date	Category	Description	Severity
2026-07-02	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	E – Moderate Harm Potential
2026-07-02	Quality of Life and Care Deficiencies	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.	D – Moderate Harm Potential
2026-02-10	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2025-11-18	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2025-11-18	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2025-11-18	Resident Rights Deficiencies	Ensure that residents are fully informed and understand their health status, care and treatments.	E – Moderate Harm Potential
2025-11-18	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2025-11-18	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2025-11-18	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2025-11-18	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	E – Moderate Harm Potential
2025-11-18	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2025-11-18	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2025-11-18	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-11-18	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-11-18	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2025-11-18	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2025-11-18	Quality of Life and Care Deficiencies	Provide routine and 24-hour emergency dental care for each resident.	D – Moderate Harm Potential
2025-11-18	Environmental Deficiencies	Keep all essential equipment working safely.	D – Moderate Harm Potential
2025-01-07	Resident Rights Deficiencies	Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.	E – Moderate Harm Potential
2024-06-28	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2024-06-28	Nutrition and Dietary Deficiencies	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.	E – Moderate Harm Potential
2024-06-28	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2024-06-28	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2024-06-28	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2024-03-14	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2023-12-14	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-12-14	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2023-12-14	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2023-03-16	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	K – Immediate Jeopardy
2023-03-16	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	F – Moderate Harm Potential
2023-03-16	Nutrition and Dietary Deficiencies	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.	F – Moderate Harm Potential
2023-03-16	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-03-16	Resident Rights Deficiencies	Ensure that residents are fully informed and understand their health status, care and treatments.	E – Moderate Harm Potential
2023-03-16	Resident Rights Deficiencies	Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	E – Moderate Harm Potential
2023-03-16	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-03-16	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-03-16	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	E – Moderate Harm Potential
2023-03-16	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2023-03-16	Quality of Life and Care Deficiencies	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	E – Moderate Harm Potential
2023-03-16	Quality of Life and Care Deficiencies	Assist a resident in gaining access to vision and hearing services.	E – Moderate Harm Potential
2023-03-16	Quality of Life and Care Deficiencies	Provide appropriate foot care.	E – Moderate Harm Potential
2023-03-16	Nursing and Physician Services Deficiencies	Ensure that the resident and his/her doctor meet face-to-face at all required visits.	E – Moderate Harm Potential
2023-03-16	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2023-03-16	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2023-03-16	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2023-03-16	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2023-03-16	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	E – Moderate Harm Potential
2023-03-16	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-03-16	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2023-03-16	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential

Showing 50 of 52 citations.

Fire Safety Citation History

11 fire safety citations on record

Date	Category	Description	Severity
2025-01-07	Smoke Deficiencies	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	D – Moderate Harm Potential
2025-01-07	Smoke Deficiencies	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	D – Moderate Harm Potential
2024-06-28	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	F – Moderate Harm Potential
2024-06-28	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2024-06-28	Smoke Deficiencies	Have properly installed hallway dispensers for alcohol-based hand rub.	D – Moderate Harm Potential
2023-03-16	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	F – Moderate Harm Potential
2023-03-16	Emergency Preparedness Deficiencies	Provide a means of sharing information on occupancy/needs.	F – Moderate Harm Potential
2023-03-16	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	F – Moderate Harm Potential
2023-03-16	Construction Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2022-01-06	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2022-01-06	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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