Beltline Healthcare Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags in the dry storage pantry and refrigerator areas.3. The facility failed to ensure that expired items in the dry storage pantry were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area were separated from the other canned food.5. The facility failed to ensure that foods brought into the facility by visitors was not stored in the facility's refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the 4 medications reviewed on 2 of 2 medication carts. The facility failed to ensure proper storage and disposal of Resident# 25's tramadol 50 hcl mg (controlled medication) by taping a narcotic medicationThe facility failed to ensure proper storage and disposal Resident# 38's tramadol 50 hcl mg (controlled medication) by taping a narcotic medication The facility failed to ensure that Resident#51's opened Lantus insulin was dated after opening. The facility failed to ensure that unopened vial of insulin aspart 100unit/1ml was properly stored in the refrigerator. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews and record reviews, the facility to provide necessary care and services for three (Residents #1, #2 and #3) of three residents reviewed for quality of care. 1. The facility failed to monitor and assess Resident #1 who had a seizure disorder, after she had a seizure on 09/15/25. The facility did not complete any neurochecks, assessment or lab monitoring. The resident was sent out to the ER by family request later that day due to concerns for a change in condition.2. The facility failed to complete and document neurological checks following Resident #2's fall with a head strike and injury when she returned from the ER on [DATE].3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received and was provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to include but not limited to, the prevention and treatment of mental and substance use disorders for one (Resident #3) of three residents reviewed for behavioral health care. The facility failed to assess, monitor and implement appropriate behavioral health interventions for Resident #3, who lived with bipolar disorder and dementia and repeatedly refused prescribed psychotropic medications. The facility failed to ensure Resident #3's care plan was revised or initiated timely psychological or psychiatric services in response to the refusals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one of three residents (Resident #3) reviewed for dementia care. The facility failed to ensure Resident #3 received the appropriate treatment and services for her dementia diagnoses. Resident #3's behavior escalation resulted in a physical aggression incident on 09/19/25 towards another resident and subsequent transfer to an inpatient psychiatric hospital for further evaluation. An Immediate Jeopardy (IJ) situation was identified on 09/21/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician and responsible party of a significant change in condition for one (Resident #1) of three residents reviewed for notification of changes. The facility failed to notify Resident #1's physician and responsible party of a witnessed seizure on 09/15/25. Facility staff did not initiate neurological checks, perform an assessment or obtain labs following the event and the physician was not informed to direct further care. Resident #1 remained without clinical intervention until later that day, when the family requested a hospital transfer due to unaddressed changed in condition. On 09/18/25 an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure required physician visits were completed at least once every 30 days during the first 90 days of admission, as required, for three (Resident #1 and Resident #3 ) of five residents reviewed for physician services. The facility failed to ensure Resident #1 and Resident #3 were seen by a physician at least once every 30 days during the first 90 days following their admission, as required. During this time frame, Resident #1 sustained a seizure and Resident #3 had behavioral decompensation requiring in-patient psychiatric hospitalization. The failure placed residents at risk of not receiving timely medical oversight and increased the risk that changes in condition could go unrecognized or untreated.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two of five residents (Resident #1 and Resident #4) reviewed for medication administration.1. The facility failed to ensure Resident #1's blood pressure was obtained and documented prior to the administration of physician-ordered antihypertensive medications with parameters in July 2025 on 12 occasions. 2. The facility failed to ensure Resident #4's blood pressure was obtained and documented prior to the administration of physician-ordered antihypertensive medications with parameters 12 times in August 2025 and seven times in September 2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility's governing body failed to provide effective oversight and ensure systems were in place and operational to protect resident health and safety for three (Residents #1, #2 and #3) of three residents reviewed for administration. The facility's governing body failed to ensure that administrative oversight and monitoring systems were maintained during a period in which the facility operated without and assigned administrator (09/12/25-09/17/25). During this time, three Immediate Jeopardy situations occurred, including failure to notify the physician/responsible party following a seizure for Resident #1, failure to complete neurological checks after a fall with a head strike and injury for Resident #2, and failure to address repeated psychotropic medication refusals for Resident #3 who had dementia and bipolar disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for one (Resident #2) of five residents reviewed for hospitalizations. 1. The facility failed to complete an incident report after Resident #2 fell, struck her head and had to be sent to the ER due to excessive bleeding. 2. The facility failed to ensure Resident #2's clinical record included hospital documentation following a return to the facility from the ER after a fall with head strike and sutures. These failures placed residents at risk for unmet medical needs, delayed treatment, poor clinical decision-making, and placed them at risk for decline, injury or other adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of X residents (Resident #1's) reviewed for drug diversion. The facility failed to prevent an employee with access to controlled medications from diverting 44 Tablets of Hydrocodone-Acetaminophen 10-325 MG tablets (a schedule II-controlled substance opiate used to treat pain) belonging to Resident #1 from a medication cart. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for unrelieved pain due to his medication not being readily available.

Inspectors wroteBased on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 4 of 4 areas (1 storage room and 2 shower rooms and 1 activity room), reviewed for accidents and hazards. 1. The facility failed to ensure that the mechanical lift (Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) in the Activity Room was locked and secured when not in use. 2. The facility failed to ensure that the sit-to-stand lift (a device that helps move a resident from a seated position to a standing position) in the Activity Room was locked and secured when not in use. 3. The facility failed to ensure that the Shower Room door on Station 1 was locked and secured. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. 2. The facility failed to ensure that 2 dented cans were removed and separated from the other canned food. 3. The facility failed to seal open items in plastic bags in the dry storage pantry. 4. The facility failed to ensure that expired items in the dry storage pantry and refrigerator were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 (#85, #5,#24, & #8) of 8 residents observed for infection control. - The facility failed to ensure RN B cleaned the glucometer in between each resident's use. - The facility failed to ensure LVN C disinfected the blood pressure cuff in between each resident's blood pressure checks. These failures could place residents at risk for infection and cross contamination of pathogens and illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 1(Residents #5) of 6 residents reviewed for activities. The facility failed to provide individualized and group activities for Resident #5. The facility failed to ensure Resident #5 had an individualized activity care plan. These failures could place resident at risk for decline in quality of life, social and mental psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of one resident (Resident #5) reviewed for feeding tubes. 1. The facility failed to ensure LVN B flushed Resident #5's G-Tube with 30 cc of water prior to the medication administration per physician's orders. 2. The facility failed to ensure LVN B flushed Resident #5's G-Tube with 10 cc of water in between each medication. 3. The facility failed to ensure LVN B checked Resident #5's G-Tube placement and residual (the process of aspirating (drawing out) a small amount of fluid from the stomach through the feeding tube to measure the volume of liquid remaining in the stomach) during medication administration. These failures could affect residents by placing them at risk of abdominal discomfort and obstruction of the G-tube.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 residents (Resident #11) reviewed for hospice services. The facility did not update Resident #11's care plan to reflect that she was on hospice. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs.

Inspectors wroteBased on interviews and record review, the facility failed to complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter), for 1 (Resident #1) of 1 resident reviewed for discharge planning. The facility failed to complete a reconciliation of Resident #1's medications when she discharged home. This failure placed residents at risk of a lack of continuity of care and adequate medication administration after they are discharged home.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of the resident's admission for one of eight residents (Residents #177) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Residents #177 within 48 hours of admission which included the minimum required healthcare information which included physician orders, dietary orders, therapy services and social services. This failure could place residents at risk of not receiving effective and person-centered care.

Inspectors wroteResident #177 Care Planning See Surveyor Khadija Jaddour's notes; citation for Baseline Care Planning.