Beltline Healthcare Center

Review of Resident #2's ER hospital records provided by the DON on 09/21/25 reflected the resident seen by the ER on [DATE] due to a head laceration and a head injury from a fall.

She had a diagnosis of a closed head injury and a facial laceration. Resident #2 had a CT cervical spine without contrast and a CT head without contrast. Resident #2 had ice applied to the affected area and was given Lidocaine-Epinephrine.

The after-visit summary was completed at 2:56 pm on 09/14/25. An interview with LVN F on 09/21/25 at 2:36 PM revealed she was a PRN nurse who worked primarily on the weekends.

For a resident who had a fall with a head strike, LVN F stated she would assess the resident for injuries and start neurochecks on them every 15 minutes until they were sent out to the hospital.

She stated neurochecks included looking at the eyes to see if they were equal and reactive, checking if a resident could squeeze the nurse's hand and with what force, and if the resident was alert and oriented. LVN F stated she had not seen what neurochecks looked like for the facility's residents.

She stated, I actually have not seen one [neuro eval] per say, but I know there are questions pertaining to the neurological in the system itself. I am just learning [online e-charting system]. LVN F stated if neurochecks were not completed after a head strike, a resident could become comatose and the nurse would not be aware when their consciousness slipped if we are not on top of that. LVN F said she was present when Resident #2 fell.

She said that day she was working with two CNAs in another resident's room when she could hear the Resident's RP screaming that the resident was on the floor. LVN F entered the room and saw Resident #2 had hit her head on the right side of her forehead on the wooden dresser and her arm was bent in the back position and she was moaning in discomfort. LVN F stated Resident #2 never lost consciousness but was in a chronic state of dementia and due to the heavy bleeding coming from the wound, she called 911 to have her sent to the ER. LVN F stated another nurse named [LVN B] did the incident report for her because she was not as comfortable with the online charting as LVN B was.

Also, LVN F stated, I didn't know what to look for in order to generate the report.

When Resident #2 came back fro

675822 09/23/2025

Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

maybe that is why it looks like he is not doing his visits. An interview with the R-AD on 09/21/25 at

revealed the physician needed to see the residents for their initial visits immediately.

She stated, We

physician needed to complete the first visit in 24-48 hours.

After that, the physician would need to see the resident twice a week.

She stated, The PA, NP and MD come out weekly so there are three opportunities for the residents to be seen. ADON D stated it was the responsibility of herself and the DON to ensure the physician visits were completed.

675822 09/23/2025

Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM.

The facility remained out of

jeopardy to resident health or a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems safety that were put into place.

675822 09/23/2025

Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

documentation was consistent with the residents' assessed needs.

Record review of Ad HOC QAPI

jeopardy to resident health or reviewed the implementation of the corrective actions.

The R-AD was informed the Immediate safety Jeopardy was removed on 09/23/25 at 11:55 AM.

The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at a scope of pattern

place.

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Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

taken or documented, it could make the blood pressure spike or fall, cause lethargy and the resident

taken prior to administration, the e-chart would not let the nurse or med aide proceed if they entered

was unsuccessful, LVN F stated the nurse could document the parameters in a progress note and reflect why it was held. LVN F stated, The system should make the nurse tell the blood pressure, you can't get around just ignoring it.An interview with the DON on 09/21/25 at 3:10 PM revealed when medications were not given due to being out of parameters, she expected the nursing staff to notify the DON and the MD and then write a progress note immediately.

The DON stated a resident could have distress and heart problems if they were not administered their blood pressure medications per physician orders. A follow up interview with ADON D on 09/23/25 at 10:30 AM revealed when a medication was held due to being out of parameters, the MAR would indicate why it was not given and would generate an e-administration note the nurse or med aid could complete. ADON D stated if the med aide/nurse forgot to record the resident's blood pressure, they should immediately re-check it and administer the medication per orders, Don't wait for later.

She said the med aide/nurse should notify the MD, DON and ADON.

Record review of the facility's policy titled, Medication Administration and General Guidelines, revised March 2025 reflected, .2.

Medications are administered in accordance with written orders of the attending physician.12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation.

The physician must be notified when a dose of medication has not been given.

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Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

would cover, so it was okay for the DON to be a stand in for some of the ADM's responsibilities until a

would report it to ADON D. An interview with CNA on 09/19/25 at 1:45 PM revealed she did not know

was the R-AD. A follow-up interview with the R-AD on 09/21/25 at 9:46 AM revealed he was aware CMS required the facility to be continuously administered by a qualified administrator. He stated that during the period of 09/12/25 through 09/17/25, facility staff contacted corporate leadership of the clinical consultant nurse if issues arose and he remained in communication with the department heads remotely. He explained that from a financial standpoint, he monitored approvals and invoices, but clinical oversight during that time was handled by the clinical consultant nurse (CCN K).

The R-AD stated he was not aware that Resident #1's physician and responsible party had not been notified of her seizure until after the fact and he explained this would typically fall under clinical monitoring. He also stated he was not aware of Resident #3's medical refusals or that neurological assessments for Resident #2 had not been completed following her hall until those issues were brought forward by the HHSC investigator.

The R-AD stated the administrator would usually become aware of such incidents through daily review of resident chart, and if not notified at the time of the event, he expected to be informed the following day.

The R-AD stated in absence of an ongoing administrator, delays in addressing operational issues such as hiring approvals or staff injuries could occur and corporate oversight relied heavily on clinical leadership and department heads to communicate concerns promptly. He emphasized it was important for clinical leadership and staff to know who to notify when administrative leadership is off-site.

Record review of an Active Employee Roster provided by the DON on 09/17/25 at 12:27 PM listed the previous Administrator who resigned effective 09/12/25 as current one with a hire date of 07/01/24.

Record review of TULIP on 09/18/25 reflected the R-AD had a current NFA license with an expiration date on 02/03/27.

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Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

Review of Resident #2's ER hospital records provided by the DON on 09/21/25 reflected the resident seen by the ER on [DATE] due to a head laceration and a head injury from a fall.

She had a diagnosis of a closed head injury and a facial laceration. Resident #2 had a CT cervical spine without contrast and a CT head without contrast. Resident #2 had ice applied to the affected area and was given Lidocaine-Epinephrine.

The after-visit summary was completed at 2:56 pm on 09/14/25. An interview with LVN F on 09/21/25 at 2:36 PM revealed she was a PRN nurse who worked primarily on the weekends. LVN F said she was present when Resident #2 fell.

She said that day she was working with two CNAs in another resident's room when she could hear the resident's RP screaming that the resident was on the floor. LVN F entered the room and saw Resident #2 had hit her head on the right side of her forehead on the wooden dresser and her arm was bent in the back position and she was moaning in discomfort. LVN F stated Resident #2 never lost consciousness but was in a chronic state of dementia and due to the heavy bleeding coming from the wound, she called 911 to have her sent to the ER. LVN F stated another nurse named [LVN B] did the incident report for her because she was not as comfortable with the online charting as LVN B was.

Also, LVN F stated, I didn't know what to look for in order to generate the report.

When Resident #2 came back from the hospital with the RP, LVN F was still working the floor.

She said the RP told her she had the hospital ER paperwork but it was at home and she would provide them the next day. LVN F stated she assessed Resident #2 at that point to make sure she was alert. LVN F stated, She wasn't really oriented as such.

She could still tell me her name.

She had seven sutures in her head, no other injuries. LVN F stated she took a set of vitals on the resident, but did not complete any neuro follow up.

Subsequent record review of a revised incident report for Resident #2 revealed comprehensive information was entered into the record on 09/19/25 and 09/20/25, several days after the fall occurred and only after investigator inquiry.

The revised documentation included detailed assessments, injury descriptions, vital signs, notifications and care plan review. An interview with the DON on 09/21/25 at 3:10 PM revealed if a resident came back from the hospital ER without any discharge documentation, the charge nurse could call her and she could retrieve the documents through the online portal.

Review of the facility's policy titled, Documentation (not dated) reflected, Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing.

Special forms in the clinical record are utilized nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medications sheets, incident reports, and summary sheets.

Documentation also occurs in the clinical software PCC.Goal: 1) The facility will maintain complete and accurate documentation for each resident on all appropriate clinical sheets.