Rehabilitation Center of Belmond

In the surveyor’s words

From the most serious findings on record at Rehabilitation Center of Belmond, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF760Apr 17, 2025

  Based on clinic record review, staff interviews, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #10 and #133) for significant medication errors. Resident #10 didn't receive his insulin medications the morning of 12/15/24. In addition, Resident #10 received short acting insulin with a blood sugar (BS) below 200 mg/dl (milligrams per deciliter) when the physician order directed staff to hold the insulin with a BS below 200 mg/dl. In addition, a nurse gave Resident #133 (a noninsulin treated diabetic) insulin instead of Resident #10 using Resident #10's insulin pen. The facility reported a census of 30 residents. Findings include: 1. […]

• No harm, potential for more than minimal, patternF689Feb 9, 2023

  Based on observation, facility record review, staff and resident interviews, the facility failed to ensure resident ' s environment remained as free as possible from hazards that had the potential to cause injury for 4 out of 4 residents reviewed, by utilizing space heaters in the resident rooms overnight where they slept, (Residents #19, #11, #4, and #9). The facility reported a census of 34 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview For Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF686Apr 23, 2026

  Based on record review, policy review, and interviews, the facility failed to ensure 1 of 1 resident (Resident #7) reviewed for pressure ulcers received the necessary care and services to promote the healing of an existing pressure ulcer and prevent the development of new ulcers. Specifically, the facility failed to clean and apply medication to Resident #7's wounds on four separate shifts, failed to document weekly pressure ulcer measurements including depth, and failed to identify the wounds as pressure ulcers on the appropriate clinical record. […]

• No harm, potential for more than minimal, isolatedF727Apr 23, 2026

  Based on review of the nursing schedules and staff interviews, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) hours per day on 4/5/26 and 4/12/26. The facility reported a census of 42 residents. Findings include:Review of the facility's nursing schedules for April 2026 lacked 8 hours of RN coverage on 4/5/26 and 4/12/26. In E-mail communication dated 4/21/26 at 12:49 PM, the facility Administrator reported the facility didn't have 8 consecutive hours of RN coverage on 4/5/26 and 4/12/26. In E-mail communication dated 4/22/26 at 1:08 PM, the Nurse Consultant explained the facility didn't have a policy for RN coverage as they just follow the regulation. […]

• No harm, potential for more than minimal, isolatedF686Apr 17, 2025

  Based on clinical record review, observations, staff interviews, and policy review the facility failed to assure a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to promote healing of an unstageable pressure ulcer for 1 of 2 residents reviewed (Resident #24). The facility reported a census of 30 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the following definition of pressure ulcers: Stage I is an intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. […]