Beltline Healthcare Center: Fall Records Falsified - TX
The resident, identified in inspection records only as Resident #2, fell at Beltline Healthcare Center sometime before September 14, 2025. A licensed vocational nurse named LVN F was working the floor that day when she heard screaming from another room. She walked in and found the resident on the floor, her right forehead bleeding from a gash, her arm bent behind her back, moaning. LVN F called 911.
At the emergency room, Resident #2 was diagnosed with a closed head injury and a facial laceration. Staff performed a CT scan of her head and cervical spine without contrast. They applied ice, administered Lidocaine-Epinephrine, and sutured the wound. The after-visit summary was completed at 2:56 p.m. on September 14.
When the resident returned to the facility that evening, LVN F was still on the floor. She assessed the resident herself. "She wasn't really oriented as such," LVN F told inspectors during an interview on September 21. "She could still tell me her name. She had seven sutures in her head, no other injuries." LVN F took a set of vitals. She did not complete any neurological follow-up monitoring.
That monitoring matters after a head injury. The facility's own director of nursing told inspectors that neurological assessments should be completed over four days, beginning with checks every 15 minutes, then hourly, then once per shift. None of that happened.
LVN F also told inspectors she had not written the incident report herself because she wasn't comfortable with the facility's online charting system. Another nurse, LVN B, filled it out for her. LVN F said she didn't know what to look for to generate the report.
The resident's responsible party brought her back from the hospital with the ER discharge paperwork in hand, then told LVN F she had left the originals at home and would bring them the next day. According to the director of nursing, those records were never placed in the resident's chart. The DON said she eventually located them herself through the facility's online hospital portal, but only after investigators prompted her to look.
The DON, who told inspectors she had only started the job on September 15, said she had not yet gotten around to checking whether the neurological assessments had been completed. She had been employed at the facility for six days before the inspection began.
What inspectors found when they reviewed the incident report told its own story. The comprehensive version of the report, with detailed assessments, injury descriptions, vital signs, notifications, and care plan review, was entered into the record on September 19 and September 20. The fall happened on September 14. The detailed documentation appeared only after the investigator began asking about it.
The facility's own documentation policy, reviewed by inspectors, describes the clinical record as a legal document requiring accuracy, completeness, and proper timing. The policy lists incident reports among the forms that must be maintained in the clinical record.
What the record showed, instead, was a chart with no hospital discharge paperwork, no neurological follow-up, and an incident report that sat incomplete for days before being filled in retroactively. A resident who had just sustained a closed head injury, who was in a chronic state of dementia and could not reliably report her own symptoms, went without the post-fall monitoring that her own facility said she needed.
LVN F told inspectors the resident was never unconscious after the fall. She was moaning. She was disoriented. She could say her name.
Whether anyone checked on her neurological status in the days that followed, the record does not show. The record was written later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beltline Healthcare Center from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
Beltline Healthcare Center in Garland, TX was cited for violations during a health inspection on September 23, 2025.
The resident, identified in inspection records only as Resident #2, fell at Beltline Healthcare Center sometime before September 14, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.