Health inspection·December 30, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. - The facility failed to ensure the NP's order on 12/17/25 for a UA was completed for Resident #1, after the resident's RP expressed concerns for a UTI. This failure placed residents at risk of a delay in medical evaluation and treatment, which could result in worsening of condition or serious harm.Findings included: Record review of Resident #1's face sheet, dated 12/30/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses that included: dementia (brain disorder that affects memory, thinking, and behavior), congestive heart failure, chronic kidney disease, hx cerebral infarction (stroke), and hx malignant neoplasm of breast (cancer of the breast). Record review of Resident 1's quarterly MDS assessment, dated 10/26/25, reflected the resident's BIMs score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Status (self-care), reflected Resident # 1 required substantial assistance with most ADLs. The MDS Assessment under Section H-Urinary Toileting Program, reflected Resident #1 was always incontinent. Record review of Resident 1's care plan, dated 11/14/25, reflected the resident had an ADL self-care performance deficit with interventions that included a 2-person assist with toileting. The document also reflected Resident #1 had bladder incontinence with interventions that included: incontinent care at least every 2 hours with application of barrier cream after every episode, monitoring and documenting s/sx of UTI (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating pattern), and monitoring, documenting and reporting s/sx to the MD. Record review of Resident #1's progress notes, dated 12/17/25 at 11:25 AM by the ADON, reflected the following: [Resident #1's] family requested that UA to be done on [Resident #1] that she is feeling discomfort, notified DON and sent a message to [MD], awaiting his response at these [sic] time. [Family] also brought a pressure pad for [Resident #1] whenever they get her up these [sic] morning that they should spread it on [Resident #1's] bed, DON to look at it first before usage. Record review of a facility document titled 24-Hour Nurse Report, dated 12/28/25, reflected in part the following: [Resident #1] - [Family] wants to rule [sic] UTI. [MD] notified Record review of a facility document titled 24-Hour Nurse Report, dated 12/29/25, reflected in part the following: [Resident #1] - [Family] requesting [MD] to rule out UTI. [MD] notified, no order received. No complain [sic] Record review of Resident #1's EHR reflected there was no order entered for a UA or one completed on or after 12/17/25. In an interview and observation on 12/30/25 at 10:30 AM, Resident #1 was lying awake in bed and visiting with family. Resident #1 was alert, but her thoughts were slightly scattered, and she was not a good historian. When asked how she was doing, Residents Affected - Few Page 1 of 3 675822 675822 12/30/2025 Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 stated I guess I'm okay. Observation of Resident #1 revealed she was clean with no odors or visible marks or bruises. Resident #1's family stated the charge nurse never followed up on concerns they had regarding Resident #1's health and proceeded to call another family member on the phone to provide further details. The family stated Resident #1 complained that it hurt when she urinated and that she felt discomfort. The family stated Resident #1 was confused sometimes due to her dementia, so they asked her on multiple occasions, and she consistently complained about the discomfort, so it was reported to the charge nurse. The family was unable to provide the name of the charge nurse; however, she informed the family that the MD would be notified so a UA could be completed. The family stated that it happened weeks ago, and no one had followed up with any results. The family stated someone visited Resident #1 daily and the nurses could never give an answer about whether the UA was completed, and they could never speak with the MD. In an interview on 12/30/25 at 12:20 PM, the MD stated the expectation was for the nurses to notify him of any changes in a resident's condition and they were typically good about doing so. The MD stated he could not recall being notified that Resident #1's family had concerns that the resident might have a UTI, but his NP might have received the notification. The MD stated some s/x of a UTI included an altered mental status, chills, nausea, and continued discomfort and he had not been informed that Resident #1 was experiencing any of those symptoms. The MD checked the messaging system and found a note from the NP on 12/17/25 approving an order to collect a UA from Resident #1. The MD stated he was not sure why the UA was not collected and followed up on. The MD stated a delayed UA to test for a UTI could place the resident at risk of the infection spreading to her bloodstream. In an interview on 12/30/25 at 1:08 PM, the DON stated she received notification anytime there was communication in the messaging system with the NP or MD, and she would normally check the messages so she would be aware of any changes in a resident's condition and/or new orders for them to follow up on. The DON stated she somehow missed the message regarding the order to UA Resident #1, and it was overlooked. The DON stated the ADON was the person who notified the NP on 12/17/25 and received the new order, and she should have put it in the system and ensured that it was completed. The DON stated Resident #1 was non-compliant with care and it would be difficult to collect a UA; however, it was still the facility's responsibility to the get family and MD involved to figure out the best solution. The DON stated some s/sx of UTI include a change in behavior, increased confusion, and change in appetite. The DON stated no one had reported Resident #1 exhibiting any s/sx of a UTI. The DON stated not following orders to complete a UA could place the resident at risk of an infection that could cause those symptoms. An attempted interview on 12/30/25 at 1:32 AM with the ADON was unsuccessful due to no response to call. In an interview on 12/30/25 at 2:01 PM, CNA B stated she worked at the facility since 11/2025. She stated some s/sx of a UTI included a change in smell and look of urine. She stated she worked with Resident #1 about a week ago and noticed the resident's urine smelled stronger than usual like she just needed more water, but not like there was an infection. CNA B stated she reported it to the charge nurse and was told to let them know if the smell got any stronger. CNA B stated there were no other changes in Resident #1's condition or signs of a UTI. In an interview on 12/30/25 at 2:11 PM, RN A stated she only worked PRN at the facility. RN A stated she worked with Resident #1 about 3 times within the past 2 weeks and the nurses had not reported any changes in the resident's condition. RN A stated she had not noticed any changes in Resident #1 and the resident had not expressed any discomfort to her. However, RN A recalled at the end of her shift one night, Resident #1's family reported that the resident needed to be checked for a UTI. RN A stated she documented it on the 24-hour report but was not sure if anyone followed up on it because she did not return to work until about a week later. RN A stated 675822 Page 2 of 3 675822 12/30/2025 Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anything documented on the 24-hour report was supposed to be discussed during morning stand-up meetings, so she assumed it was addressed while she was off. In a further interview on 12/30/25 at 2:47 PM, the DON stated any significant concerns from the 24-hour reports were addressed daily during morning meetings; however, she relied on the nurses to inform her of the concerns, and she did not always look at the 24-hour reports herself. The DON stated concerns for Resident #1 having a UTI had not been mentioned during the morning meetings although it was recently documented on 24-hour reports. The DON stated moving forward she would be sure to look over the 24-hour reports during the meetings. Review of the facility's policy titled Resident Rights, undated, reflected in part the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. Planning and implementing care - The resident has the right to be informed of, and participate in, his or her treatment, including:. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:.d. The right to receive the services and/or items included in the plan of care. The surveyor requested a policy regarding following physician orders on 12/30/25 at 1:35 PM from the Administrator and it was not provided prior to exit. 675822 Page 3 of 3