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🔎 The Belmont At Twin Creeks

Inspection Results


Inspection Overview

The Belmont At Twin Creeks has been cited for a total of 30 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2025-05-22
Correction Date: 2025-05-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-05-22
Correction Date: 2025-05-30
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2025-05-22
Correction Date: 2025-05-30
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2025-05-22
Correction Date: 2025-05-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2025-01-30
Correction Date: 2025-01-30
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2025-01-30
Correction Date:
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide or obtain dental services for each resident.

Survey Date: 2025-01-30
Correction Date:
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2024-08-23
Correction Date: 2024-08-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-07-06
Correction Date: 2024-07-06
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2024-04-13
Correction Date: 2024-05-12
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-04-13
Correction Date: 2024-05-12
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2024-03-22
Correction Date: 2024-05-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2024-03-22
Correction Date: 2024-03-23
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-03-22
Correction Date: 2024-03-23
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2024-03-22
Correction Date: 2024-03-23
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2024-03-22
Correction Date: 2024-03-23
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2024-03-22
Correction Date: 2024-03-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-03-22
Correction Date: 2024-03-23
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-06-16
Correction Date: 2023-06-17
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2023-02-07
Correction Date: 2023-02-09
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2023-01-05
Correction Date: 2023-01-31
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-01-05
Correction Date: 2023-01-31
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2022-01-21
Correction Date: 2022-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2022-01-21
Correction Date: 2022-01-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-11-09
Correction Date: 2021-11-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-11-09
Correction Date: 2021-11-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-07-07
Correction Date: 2021-07-29
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2021-02-04
Correction Date: 2021-03-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-06-09
Correction Date: 2020-07-07
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-10-17
Correction Date: 2019-11-16
Category: Nutrition and Dietary Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**