Belen Meadows Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Belen Meadows Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF580Mar 16, 2023

  Based on record review and interview, the facility failed to notify the resident's guardian and the physician of blood sugar fluctuations for 1 (R #298) of 2 (R #34 and R #298) residents reviewed for insulin use and blood sugar management. If the facility is not monitoring for blood sugar fluctuations, then residents are likely at risk of serious harm or death. The findings are: A. Record review of the facility's policy Change in Condition: Notification of, last revised 06/01/21, revealed A center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: . […]

• No harm, potential for more than minimal, widespreadF812Nov 18, 2025

  Based on observation and interview, the facility failed to ensure the filters on the ice machine were replaced timely. This failure had the potential to affect all residents at the facility. This deficient practice could likely cause pollutants to enter the water causing contamination and illness. The findings are: A. On 09/16/25 at 9:29 am, an observation revealed the filters of the ice machine had a replacement date of 04/24/25. There were two filters, and they had the same change by date. The instructions on the filters recommended changing the filters at least once per year. B. On 09/16/25 at 9:31 am, during an interview, the District Manager stated the Maintenance Director was responsible for changing and ordering the filters. C. […]

• No harm, potential for more than minimal, widespreadF880Nov 18, 2025

  Based on observations, record reviews and interviews, the facility failed to:-Follow proper infection control practices for handling laundry when staff failed to ensure- laundry was free from used sharps. If staff fail to handle used laundry, then residents could be at risk of development and transmission of disease and infections.- Demonstrate its measures to minimize the risk of Legionella (bacteria naturally found in water that can cause a severe type of lung infection called legionnaires' disease when people inhale tiny water droplets containing the bacteria) in the building's water system, when the Water Management Program (WMP) team failed to develop and implement an adequate LWMP. […]

• No harm, potential for more than minimal, widespreadF725Mar 16, 2023

  Based on observation, record review, and interviews the facility failed to maintain appropriate staffing levels to meet the needs of all 103 residents on the census list provided by the Administrator on 03/06/23 by: 1. Visitors waiting extensively (lengthily) long time outside the facility on the weekends to have access into the facility. 2. Not answering call lights in a timely manner. This deficient practice could likely affect direct patient care and limit the residents abilities to obtain optimal well-being while in the facility. The findings are: Findings related to visitors access into the facility: A. On 03/08/23 at 1:46 pm, during an interview with friend of R #197, stated, I had to wait over 30 minutes to be let into the facility yesterday (03/07/23). […]

• No harm, potential for more than minimal, widespreadF803Mar 16, 2023

  This is a repeat citation. Based on record review, observation, and interview, the facility failed to maintain menu options by not following the menu and not placing all menu items on a resident's meal tray. This deficient practice has the potential to affect all 103 residents identified on the census list provided by the Administrator on 03/06/23 and could likely result in reduced food intake, weight loss, and a decline in a resident's psychosocial health (the health of someone's emotions, behaviors, and social abilities) due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. […]