Beltline Healthcare Center

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

could be considered neglect. Also, failure to notify the RP immediately could prolong decisions for the resident's care. B. Notification of Change in Condition Policy: charge nurses will notify the MD and RP immediately of all changes in conditions to include seizure activity. Signs and symptoms of seizures include shaking, jerking, twitching, stiffening of the body, loss of muscle control, falling to the ground, nausea and vomiting. The nurses will notify the MD and implement the seizure management protocol. Any additional orders by MD will be implemented by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notifications. Notifications will be documented in PCC in the SBAR or progress notes. C. Documentation: Charge nurses will document changes in condition, notification to the MD/RP, orders, and subsequent assessments and monitoring ordered by the MD.Monitoring the Plan of Removal implementation occurred on 09/19/25 through 09/23/25 daily onsite visits. Facility monitoring activities included review of 24-hour reports, risk management logs,, change in condition documentation and hospital transfer records to identify any additional incidents that involved seizures, falls, medication refusals or changes in condition. Additional records for three residents were reviewed to verify timely assessments, physician notifications, orders and follow-up actions to verify that timely physician and RP notifications were completed. Additionally, staff in-service records and competency validation tools were reviewed for charge nurses, medication aides and CNAs. In-services covered neurological assessments, changes in conditions protocols, documentation standards, medication refusal and abuse/neglect reporting procedures. Twenty nursing staff were interviewed across all shifts (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD , CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V) and demonstrated awareness of the facility's expectations, policies and procedures. An Ad Hoc QAPI Committee meeting dated 09/18/25 and 09/21/25 were reviewed to confirm the facility had analyzed the notification system failure, implemented corrective actions and established enhanced monitoring processes to ensure compliance with physician and RP notification requirements. No additional failures were identified related to notifications during the monitoring period . An

interview with the R-AD on 09/23/25 at 11:22 AM revealed his expectation as the interim ADM for a change

in condition would be for the charge nurse to call the physician right away, call the DON, call the RP and then the DON would let the R-AD know what happened and keep him up to date. The R-AD stated if a resident had a seizure going forward, the nursing staff were to make sure the resident was safe remove anything from around the head and then call the physician and get an order, get labs if ordered and monitor, but we also want to make sure the resident is not acting different. If interventions were not implemented, the R-AD stated the resident's health could be affected. The R-AD was informed the Immediate 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 isolated due to

the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

10:23 AM revealed she was an extender for MD J and came every Thursday to the facility and MD J came every Tuesday. PA E stated if a new resident admitted and she was the first in the building, then she could complete the first visit. PA E stated from what MD J had explained to her and his team was that he completed the official Health and Physical Assessment, but if an extender saw the resident before he came to the facility, they still can see the resident, but not for an H&P. PA E stated, We have it that a clinician has to see the resident for 90 days every 30 days and it can alternate between the MD and the extenders. PA E looked for some visits for Residents #1 and #3 and stated she thought there were some MD visits on her end that had not been uploaded into the residents' e-charts yet. PA E stated there had been a lot of turnover recently with staff and there was no current staff for medical records, and that person was the one who uploaded the visits into the e-chart. She stated MD J's team faxed their progress notes to the facility and also emailed the medical records staff with the information. PA E stated, So maybe that is why it looks like he is not doing his visits. An interview with the R-AD on 09/21/25 at 2:00 PM revealed MD J was presently on vacation and one of his fellow attendings was sitting in as the physician on duty for emergencies. A follow-up interview with ADON D on 09/23/25 at 10:30 AM revealed the physician needed to see the residents for their initial visits immediately. She stated, We can facetime them, do it in person, maybe the NP or PA comes in to see them. ADON D stated the 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors. Monitoring the Plan of Removal implementation occurred on 09/21/25, 09/22/25 and 09/23/25 through daily onsite visits. Facility monitoring activities included review of 24-hour reports, risk management logs, medication refusal logs, behavior monitoring logs and care plan revisions to ensure interventions were implemented for residents with behavioral health needs. Record reviews for additionally sampled residents with psychotropic medication refusals to verify the assessments, physician notifications, psychiatric referrals and care plan updated were completed. No concerns were noted. Record review of staff in-services conducted on 09/21/25, 09/22/25 and 09/23/25 for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services reflected that training was completed for all shifts and addressed required documentation, behavioral health concerns and notification procedures. Interview with twenty nursing staff were conducted on 09/21/25, 09/22/25 and 09/23/25 across all shifts (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD, CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V. All staff interviewed were able to verbalize the facility's procedures for identifying and documenting medication refusals, to include immediate notification of the charge nurse, documentation in the medication administration record and timely notification to the physician and psychiatric provider. Staff also verbalized the process for escalating behavioral changes, including notifying supervisory staff, initiating behavior monitoring and contacting psychiatric services as needed. Record

review of the facility's Ad HOC QAPI meeting on 09/21/25 was conducted to review the facility progress, monitor for additional resident medication refusals or escalations, and verify interventions and physician/psychiatric notifications were completed timely. The R-AD was informed the Immediate 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 the potential for more than minimal harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors. Monitoring

the Plan of Removal implementation occurred on 09/21/25 through 09/23/25 through daily onsite visits.

Facility monitoring activities included review of 24-hour reports for 09/21/25, 09/22/25 and 09/23/25, medication administration records, risk management logs and physician notification to verify that interventions for dementia medication refusal and escalating behaviors were implemented. Additionally, staff in-services were reviewed and verified they were conducted on 09/21/25 and 09/23/25 for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services.

Twenty nursing staff were interviewed across all shifts on 09/21/25, 09/22/25 and 09/23/25 (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD, CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V. All staff interviewed were able to verbalize dementia care protocols, recognition of escalating behaviors and required notification procedures. Nurses were able to correctly identify procedures for notifying physicians and responsible parties after three or more medication refusals and demonstrated understanding of non-pharmacological intervention expectations. Review of the facility's 24-hour report for other sampled residents with dementia diagnoses from 09/21/25-09/23/25 reflected there were no changes in condition, no behavioral symptoms or care interventions occurred that required documentation during the monitoring period. Review of dementia care plans and behavior monitoring logs from 09/21/25-09/23/25 reflected interventions were the in the process of being updated with individualized, non-pharmacological approaches were identified and documentation was consistent with the residents' assessed needs. Record review of Ad HOC QAPI meeting on 09/21/25 reflected the medical director and interdisciplinary team provided oversight and reviewed the implementation of the corrective actions. The R-AD was informed the Immediate 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 due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

held due to the vitals being out of parameters, the online charting system would not let the person administering it move forward in the MAR unless they entered the vitals such as the blood pressure. She stated the nurse or medication aide usually wrote the blood pressure down because it was quicker than entering it into the e-chart. She stated, We hit the button and know to do a skilled assessment later with the [blood pressure] numbers. But if they are not skilled, you just move on because it does not make you put in vitals if the med was skipped. LVN B stated if a resident's blood pressure reading was not taken or documented, it could make the blood pressure spike or fall, cause lethargy and the resident could have a stroke if their blood pressure ran high and they did not get the medication. An interview with LVN F on 09/21/25 at 2:36 PM revealed when a blood pressure medication had parameters to be taken prior to administration, the e-chart would not let the nurse or med aide proceed if they entered they held a medication on the e-chart, unless they entered in the blood pressure and pulse first. If that 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

amount of time. An interview with the R-AD on 09/18/25 at 3:25 PM revealed he arrived at the facility. He stated he was the area director over ten nursing facilities and a new administrator would be starting on 09/29/25 and he was helping cover until then. The R-AD stated the previous administrator had gave a 30-day notice. He stated the daily stand-up meetings were being done by the new DON and the BOM also helped, although she had been out sick a few days the past week. The R-AD stated the abuse/neglect coordinator presently was himself and the DON. He stated he did have any self-reported incidents for the facility since the previous administrator left. The R-AD also stated grievances were handled by SW C and

the DON was supposed to review them and let him know if she needed assistance. The R-AD stated he texted the DON on her first day of employment-Monday 09/15/25 and I notified her I am here to help her out. The R-AD stated the company had 30 days to hire an administrator and the facility did not have to have one on site every day. The R-AD stated, for example, if an administrator went on vacation for a week, the facility's DON would cover, so it was okay for the DON to be a stand in for some of the ADM's responsibilities until a new one started employment. An interview with CNA, on 09/19/25 at 1:35 PM revealed abuse/neglect and exploitation was currently supposed to be reported to the ADM, but since there was not one, she would report it to ADON D. An interview with CNA on 09/19/25 at 1:45 PM revealed she did not know who the current/interim administrator was for the facility until 09/18/25 when she was notified it 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beltline Healthcare Center

106 N Beltline Rd Garland, TX 75040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet