Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belmont Manor Nursing Home, In during CMS and state inspections, most recent first.
A resident with Alzheimer’s, dementia, a history of falls, and severe cognitive impairment had an MD order and care plan for a wander guard device on a walker, with nightly function checks required on the 11 P.M.–7 A.M. shift using a universal tester. On the day of the incident, the TAR showed no documentation that the required wander guard check was completed, and the assigned nurse later stated she did not test the device because she did not want to wake the resident, despite facility policy requiring such checks. The device was not functioning, allowing the resident to leave the unit, use the elevator, and exit to an outdoor courtyard without triggering the wander guard alarm system, where the resident was later found outside with the walker nearby.
The facility failed to maintain the dignity of a resident by not placing their urinary catheter bag in a privacy bag, leading to embarrassment. Another resident with impaired cognition was not provided a dignified dining experience, as they were left waiting for assistance with food out of reach. On two units, staff were observed standing over residents while feeding them, rather than sitting at eye level. Additionally, a CNA was seen using a cell phone while assisting a resident with their meal.
The facility did not develop baseline care plans within 48 hours for four residents with severe cognitive impairments, including dementia. Despite policy requirements, medical records lacked these plans, and comprehensive care plans did not reflect necessary interventions. Interviews with Nurse Unit Managers confirmed the oversight.
The facility failed to develop individualized dementia care plans for residents in the Dementia Special Care Unit (DSCU), affecting their ability to receive appropriate treatment and services. Despite severe cognitive impairments, residents lacked person-centered care plans, and staff interviews revealed unclear responsibilities for care plan development. This deficiency highlights a systemic issue in the facility's approach to dementia care planning.
The facility failed to accurately document care for several residents, including the use of padded side rails, oxygen tubing changes, and the application of a palmar guard. Observations revealed discrepancies between documented care and actual practices, affecting residents with conditions such as Alzheimer's, epilepsy, COPD, and hemiplegia.
A resident, assessed as unable to self-administer medications, was found with pills left at the bedside for self-administration. Despite facility policy requiring an interdisciplinary assessment to determine self-administration capability, the resident was left with medications unattended. Nursing staff interviews confirmed the oversight, and the DON acknowledged the resident should not have had access to self-administer medications.
A resident with Alzheimer's dementia and other conditions was found with bruises on both hands, which were not documented or investigated by the facility. Despite facility policy requiring investigation of unknown bruises, staff failed to report or investigate the bruises, and the Director of Nursing and Staff Development Coordinator were unaware of the full extent of the issue.
A facility failed to report bruises of unknown origin on a resident to the state agency within the required timeframe. The resident, with Alzheimer's dementia and other conditions, was observed with bruises on both hands, which were not documented in medical records. A nurse noticed the bruises but did not inform the charge nurse, and a CNA saw the bruises before an incident but did not report them immediately. The Staff Development Coordinator was only aware of one bruise and did not report it, assuming it was witnessed.
A facility failed to create individualized care plans for a resident's ADLs and psychotropic medication use. The resident, with severe cognitive impairment and dependence on ADLs, was taking antipsychotic medication. Despite these needs, the medical record lacked specific interventions, and staff interviews confirmed the absence of necessary care plans.
A facility failed to update a care plan for a resident's healed stage 3 pressure ulcer on the left heel. Despite the ulcer being healed, the care plan still listed it as an active problem. The resident, with diagnoses including type 2 diabetes and hemiplegia, was observed on an air mattress with a blanket cradle. Interviews with staff confirmed the ulcer had healed long ago, and the care plan should have been resolved during the quarterly MDS review.
A resident with hemiplegia and hemiparesis was not provided with a prescribed palmar guard for contracture management, as observed during multiple instances. Despite a physician's order, the device was not applied, and there was no documentation of refusal. Staff interviews revealed a lack of awareness and adherence to the intervention, with the Director of Rehabilitation unaware of the non-compliance. The Nurse Unit Manager emphasized the importance of accurate documentation and referrals to rehab if the resident did not use the recommended device.
The facility failed to implement physician-ordered padded side rails for two residents with severe cognitive impairments and specific medical conditions. One resident with Alzheimer's dementia was repeatedly observed without padded side rails, contrary to orders. Another resident with epilepsy and a history of falls had only one side rail padded instead of both, as required. Staff interviews confirmed the expectation to follow these orders, which was not met.
A resident experienced significant weight loss due to the facility's failure to implement timely interventions and communicate effectively with the dietitian. Despite having a healthy appetite, the resident lost 15% of their body weight over six months. The dietitian was not informed of the weight loss until a routine assessment, and the facility's policy for monitoring and addressing weight changes was not followed.
The facility failed to maintain clean oxygen concentrator filters and change oxygen tubing as ordered for two residents with chronic obstructive pulmonary disease. Observations revealed thick layers of dust on filters, and one resident's tubing was not changed weekly as prescribed. Staff were unaware of cleaning responsibilities, and there was no documentation or system to track maintenance. Additionally, a resident was not assessed for the ability to change their own tubing, contrary to facility policy.
A nurse failed to disinfect a portable vital sign caddy between uses on two residents under enhanced barrier precautions (EBP), contrary to the facility's infection control policy. The nurse admitted the oversight, and the nurse unit manager confirmed the requirement for disinfection between uses.
Failure to Test Wander Guard Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident at risk for elopement, with an MD order for a wander guard device, had that device consistently checked for proper function. The resident had diagnoses including Alzheimer’s, dementia, diabetes, history of falling, and difficulty in walking, and was assessed as cognitively impaired with a BIMS score of 7, indicating severe cognitive impairment. The resident’s care plan and elopement risk assessment identified a history of wandering and risk for elopement, and the resident’s wander guard was ordered to be placed on the walker, with a requirement that nursing staff check its function daily on the 11:00 P.M. to 7:00 A.M. shift using a universal tester. On the date of the incident, documentation on the Treatment Administration Record for the 11:00 P.M. to 7:00 A.M. shift showed no evidence that the required wander guard function check had been completed. Nurse #1 later stated that she did not perform the wander guard function test during her shift because she did not want to wake the resident, although she observed that the device was attached to the walker. Facility policy and staff development information indicated that universal testers were available on each unit and that wander guard checks were to be conducted on the night shift, but this process was not followed for this resident on the day in question. As a result of the wander guard device not being tested and not functioning, the resident was able to leave the unit undetected. According to staff interviews and the facility’s report, the resident was last seen in the room watching television at approximately 6:30 A.M. and was discovered missing around 7:00 A.M. A search was initiated, and the resident was found on the first floor outside in the courtyard, sitting on the ground with the walker nearby. Staff confirmed that the wander guard device did not trigger an alarm when the resident left the unit, accessed the elevator, and exited to the courtyard, and it also did not alarm when the resident was brought back inside, demonstrating that the system was not functioning at the time of the elopement.
Dignity and Dining Experience Deficiencies
Penalty
Summary
The facility failed to maintain the dignity of Resident #222 by not placing their urinary catheter bag in a privacy bag, as required by the facility's policy on indwelling Foley catheter care. Resident #222, who has intact cognition, expressed embarrassment over the exposed catheter bag, which was visible from the hallway during observations on two separate occasions. Charge Nurse #1 confirmed that it is the responsibility of the Certified Nurse's Aides and nurses to ensure catheter bags are placed inside privacy bags. Resident #23, who has severely impaired cognition and requires assistance with eating, was not provided a dignified dining experience. On multiple occasions, Resident #23 was observed with food placed out of reach and was left waiting for assistance while watching others eat. Staff members were observed standing over Resident #23 while feeding, rather than sitting at eye level and interacting with the resident, as recommended by the Nurse Unit Manager and the Director of Nursing. On the Station 2 unit, similar issues were observed where residents dependent on staff for eating were left waiting with food in front of them. Staff members were seen standing over residents while feeding them, rather than sitting at eye level. Additionally, on the Station 4 unit, a CNA was observed using a cell phone while assisting a resident with their meal, which was acknowledged as inappropriate by Nurse Unit Manager #3.
Failure to Develop Baseline Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents diagnosed with dementia, among other conditions. These residents were admitted or readmitted to the facility with severe cognitive impairments, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours to address immediate health and safety needs, the medical records for these residents did not indicate that such plans were created. This lack of baseline care plans meant that individualized interventions related to the residents' dementia and its progression were not documented. Interviews with Nurse Unit Managers confirmed that the nursing staff should have developed baseline care plans for these residents within the required timeframe. The absence of these plans was noted for residents with various diagnoses, including dementia, Parkinson's disease, bipolar disorder, depression, anxiety, metabolic encephalopathy, and acute kidney injury. The comprehensive care plans also failed to reflect the residents' dementia diagnoses and necessary interventions, highlighting a significant oversight in meeting professional standards of quality care for these individuals.
Failure to Develop Dementia Care Plans in DSCU
Penalty
Summary
The facility failed to ensure that residents with dementia received appropriate treatment and services through the development and implementation of individualized care plans. This deficiency was identified for five residents who were diagnosed with dementia and resided in the facility's Dementia Special Care Unit (DSCU). Despite the facility's disclosure of meeting state licensure requirements for specialized dementia care, the interdisciplinary team did not develop dementia-specific care plans for these residents. Resident #21, admitted with severe unspecified dementia and agitation, was found to have no person-centered care plan addressing their cognitive impairment and behaviors. Interviews with facility staff revealed that the responsibility for developing such a care plan was not clearly assigned, resulting in the absence of a tailored approach to managing the resident's dementia-related needs. Similarly, Residents #103, #41, and #25, all residing in the DSCU with severe cognitive impairments, also lacked interdisciplinary dementia care plans, as confirmed by the Nurse Unit Manager. Resident #69, who was readmitted with dementia and other medical conditions, did not have a baseline care plan for dementia upon readmission, nor were individualized interventions developed. The Nurse Unit Manager acknowledged the necessity for a specific care plan for residents with dementia, especially following readmission after hospitalization. The absence of these care plans indicates a systemic issue in the facility's approach to dementia care planning, affecting the residents' ability to attain or maintain their highest practicable well-being.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to accurately document the use of padded side rails for two residents, despite physician orders requiring them. Resident #77, diagnosed with Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, contrary to the documentation in the Treatment Administration Record (TAR) which indicated they were in place. Similarly, Resident #57, with epilepsy and a history of falls, was observed with only one side rail padded, while the TAR inaccurately documented that both side rails were padded. For Resident #53, who has chronic obstructive pulmonary disease (COPD) and is cognitively intact, the facility failed to change the oxygen tubing as per the physician's order. The tubing was observed to be unchanged for five weeks, despite the Medication Administration Record (MAR) indicating it had been changed weekly. This discrepancy highlights a failure in accurately documenting the care provided to the resident. Resident #32, with hemiplegia and moderately impaired cognition, was supposed to have a palmar guard applied to manage contractures. However, observations revealed that the palmar guard was not applied, and there was no documentation of refusal by the resident. The TAR inaccurately indicated that the palmar guard was applied, despite the absence of the device during multiple observations.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications, despite being assessed as unable to do so. The resident, who was admitted with diagnoses including adult failure to thrive and hypertension, was observed with pills left at the bedside for self-administration. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, and this assessment indicated that the resident was not a candidate for self-administration due to cognitive, physical, or visual limitations. On a specific date, a surveyor observed two brown pills in a medication cup on the resident's bedside table while the resident was out for an appointment. Interviews with nursing staff revealed that the pills were left by a nurse for the resident to take later, which was against the facility's policy. The Charge Nurse confirmed that the resident should not have been left with medications unattended, as the assessment had not changed since admission. The Director of Nursing reiterated that the resident was not permitted to self-administer medications, and the pills should not have been left at the bedside.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate bruises of unknown etiology for a resident, identified as Resident #4, who was admitted with diagnoses including Alzheimer's dementia, kidney disease, and diabetes. The resident was observed with dark purple bruises on both hands, which were not documented in the medical record or noted during weekly skin checks. The facility's policy required obtaining caregiver statements for bruises of unknown origin, but this was not followed. Nurse #2 noticed the bruises but did not report them to the charge nurse, and Charge Nurse #1 was unaware of the bruises and did not initiate an investigation or report to the state agency as required. CNA #1 observed the bruises before providing care and before the resident hit their hand on the bedrail, but failed to report them immediately. The Director of Nursing and the Staff Development Coordinator were not aware of the bruises on both hands, and the incident was not thoroughly investigated or reported. The facility's documentation was incomplete, failing to question other staff members or provide a comprehensive account of the bruises' origin.
Failure to Report Bruises of Unknown Origin
Penalty
Summary
The facility failed to report bruises of unknown origin on a resident to the state agency within the required two-hour timeframe. The resident, who was admitted in December 2016, has Alzheimer's dementia, kidney disease, and diabetes, and is severely cognitively impaired, requiring maximum assistance with activities of daily living. On a specific date, a surveyor observed dark purple bruises on both of the resident's hands, which were not documented in the medical record or noted in the weekly skin checks or progress notes for November and December. Nurse #2 noticed the bruises but did not inform the charge nurse, and Charge Nurse #1 was unaware of the bruises until the surveyor's observation. An incident report dated in November indicated a bruise on the resident's left hand, but not the right, and noted the resident was combative and hit their hand on the bedrail. CNA #1 reported seeing the bruises before providing care and before the resident hit the bedrail, but did not immediately report it to the manager. The Staff Development Coordinator was only aware of the left hand bruise and did not report it to administration, assuming it was witnessed. The Director of Nursing confirmed that all injuries of unknown origin should be reported to the state agency within the required timeframe.
Failure to Develop Individualized Care Plans for ADLs and Psychotropic Medication
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for a resident, specifically in relation to activities of daily living (ADLs) and the use of psychotropic medication. The resident, who was admitted in January 2024, had diagnoses including dementia with psychotic disturbance, Parkinson's disease, and difficulty walking. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment, dependence on ADLs, and the use of antipsychotic medication. However, the medical record did not include individualized interventions for the resident's ADL needs or psychotropic medication monitoring. Interviews with facility staff revealed that the MDS nurse did not develop a care plan for the resident's ADL and psychotropic medication needs, and the Care Area Assessment (CAA) referred to nursing for care plan development. The Nurse Unit Manager acknowledged that a care plan should have been developed based on the resident's diagnoses, medications, and other care needs, but it was not present in the resident's care plans.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after the quarterly review assessment. Specifically, the care plan for a stage 3 pressure ulcer on the resident's left heel was not updated or resolved, despite the ulcer having healed a long time ago. The resident, who was admitted in October 2020, has diagnoses including type 2 diabetes mellitus and hemiplegia and hemiparesis following a cerebral infarction. The most recent Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and did not have any unhealed pressure ulcers, yet the care plan still included an outdated problem related to the pressure ulcer. Observations and interviews revealed that the resident was resting on an air mattress with a blanket cradle, and did not respond when asked about any wounds. Nurse #5 confirmed that the pressure ulcer had healed a long time ago, and Nurse Unit Manager #3 acknowledged that the care plan should have been resolved during the care plan review after the quarterly MDS assessment. The failure to update the care plan reflects a lapse in the facility's process for reviewing and revising care plans in accordance with the MDS schedule.
Failure to Implement Contracture Management Intervention
Penalty
Summary
The facility failed to implement an intervention for contracture management in accordance with the medical plan of care for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who had moderately impaired cognition and functional limitation in the range of motion of the upper extremity, was observed multiple times without the prescribed palmar guard on the right hand. The medical record indicated a physician's order for the palmar guard to be worn during specific hours, but observations revealed that the device was not applied, and there was no documentation of refusal by the resident. Interviews with staff revealed a lack of awareness and adherence to the prescribed intervention. A CNA was unaware of any device for the resident's right hand, and a nurse mentioned that the resident might not wear the palmar guard due to behaviors, but this was not documented as a refusal. The Director of Rehabilitation confirmed the importance of the palmar guard in preventing skin issues and worsening contractures, and stated that she was not informed of the resident's non-compliance. The Nurse Unit Manager acknowledged that the palmar guard was necessary to prevent worsening contractures and emphasized that the intervention should be documented accurately, with referrals to rehab if the resident did not use the recommended device.
Failure to Implement Physician-Ordered Padded Side Rails
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent accidents for two residents. Resident #77, who has Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, despite a physician's order for them due to agitation. The observations occurred over several days, and interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the order to be followed, yet the padded side rails were not in place. Similarly, Resident #57, who has epilepsy, dementia, and a history of falling, was observed with only one side rail padded instead of both, as per the physician's order. This resident was also assessed to have severely impaired cognition and required total care. The observations were consistent over several days, and interviews with nursing staff and the Director of Nursing reiterated that both side rails should have been padded to prevent injury during a seizure, yet this was not adhered to.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss. The resident, who was admitted with conditions including dementia and dysphagia, experienced a 15% weight loss over six months. The facility's policy required a Nutrition Alert for significant weight loss, but this was not initiated in a timely manner. The resident's weight was not adequately monitored, and the dietitian was not informed of the weight loss until a routine quarterly assessment. Despite the resident's plan of care including interventions like nutritional supplements and weekly weights, these measures were not effectively implemented or adjusted in response to the resident's ongoing weight loss. The dietitian noted that the resident had a healthy appetite and consumed meals well, yet the weight loss continued. The dietitian was not notified of the resident's weight changes documented in the weight log, and the issue of obtaining timely weights was an ongoing problem reported to the Director of Nursing. The lack of timely communication and intervention contributed to the resident's significant weight loss, as the dietitian was unaware of the situation until much later. The facility's failure to adhere to its weight monitoring policy and communicate effectively with the dietitian and healthcare proxy resulted in a deficiency in maintaining the resident's nutritional status.
Failure to Maintain Oxygen Equipment and Change Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for two residents. For Resident #223, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator air filter to have a thick layer of gray fuzzy substance on it during multiple observations. Charge Nurse #1 was unaware of who was responsible for cleaning the filter or how often it should be cleaned. The Maintenance Director mentioned that a company was supposed to clean the filters weekly, but there was no documentation or system in place to track the cleaning of each machine. For Resident #53, who was admitted with chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator filter covered in a gray substance, indicating it had not been cleaned. Nurse Unit Manager #4 confirmed that the filter should be cleaned weekly and deferred to the maintenance department for ensuring the filters were cleaned. The Maintenance Director reiterated the lack of documentation and tracking system for the cleaning of the filters. Additionally, Resident #53's oxygen tubing was not changed as ordered. The tubing was dated 10/29/24, despite a physician's order to change it weekly. Resident #53 reported that nurses left new tubing for self-change, but there was no documentation of refusal or assessment of the resident's ability to change the tubing. Nurse #4 and the Director of Nursing confirmed that the tubing should be changed weekly and that residents should be assessed for their ability to change their own tubing, which had not been done for Resident #53.
Infection Control Breach in Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards for cleaning shared resident equipment, specifically the vital sign machine. According to the facility's policy, equipment should be cleaned immediately after use. However, a surveyor observed a nurse using a portable vital sign caddy on a resident under enhanced barrier precautions (EBP) and then using the same caddy on another resident without disinfecting it in between. During interviews, the nurse admitted to not disinfecting the equipment, acknowledging that she should have done so. The nurse unit manager confirmed that shared equipment should be disinfected before being used on another resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 945 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sancta Maria Nursing Facility | 1.9 mi | — | 0 | 0 |
| Maristhill Nursing & Rehabilitation Center | 2 mi | — | 24 | 0 |
| Pine Knoll Nursing Center | 2.3 mi | — | 33 | 1 |
| Neville Center At Fresh Pond For Nursing & Rehab | 2.3 mi | — | 0 | 0 |
| Watertown Rehabilitation And Nursing Center | 2.5 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Belmont Manor Nursing Home, In.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.