The Atrium of Bellmead

Inspectors wroteBased on observation, interview, and record review, the facility failed to consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (R#1) of 5 residents. The facility failed to ensure staff notified R#1's Physician, Hospice Physician and NP when R#1 fell during a 1-person transfer without a gait belt on 7/14/26, 7/19/26, and 7/20/26. R#1 cried, said her buttocks was hurting, and complained of right hip pain after the fall on 7/19/26. R#1 also cried and said her right hand was hurting and she hit her leg after the fall on 7/20/26. This failure could place residents at risk of falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise 1 (R#1) of 5 residents' care plans. The facility failed to review and revise R#1's care plan to reflect she required a gait belt and 2-person assistance with transfers after she fell during a 1-person transfer without a gait belt on 7/14/26, 7/19/26, and 7/20/26. This failure could place residents at risk of not having their care and service needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (R#1) of 5 residents received adequate supervision and assistance devices to prevent accidents.1. The facility failed to ensure staff used a gait belt and 2-person assistance when transferring R#1 on 7/14/26, 7/19/26 and 7/20/26. R#1 fell on 7/14/26, 7/19/26, and 7/20/26. R#1 cried, said her buttocks was hurting, and complained of right hip pain after the fall on 7/19/26. R#1 also cried and said her right hand was hurting and she hit her leg after the fall on 7/20/26. 2. The facility failed to ensure staff used a gait belt when transferring R#1 on 7/21/26. This failure could place residents at risk of falls, injuries, and change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (R#1) of 5 residents were provided with pain management. The facility failed to accurately assess R#1's pain after her falls on 7/19/26 and 7/20/26. R#1 cried, said her buttocks was hurting, and complained of right hip pain after the fall on 7/19/26. R#1 also cried and said her right hand was hurting and she hit her leg after the fall on 7/20/26. This failure could place residents at risk of not having pain treated and change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (R#3) of 5 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to follow hospital discharge orders and ensure R#3's physician followed up with her within a week after she returned from the hospital with an acute kidney injury on 7/10/26. This failure could place residents at risk of falls, injuries, and change in condition.

Inspectors wroteBased on interview, and record review, the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 8 of 8 resident. The facility failed to provide continued care for 8 of 8 residents (Resident #1, Resident # 2, Resident # 3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8) after being treated by podiatry. This failure resulted in Resident #1 developing Gangrene which lead to toe amputation. An Immediate Jeopardy (IJ) was identified on 06/17/2026 at 5:14PM. The initial IJ template was provided to the facility on [DATE] at 5:14PM. While the IJ was removed on 06/18/2026 at 7:42PM, the facility remained out of compliance at the scope of pattern and severity of no actual harm due to the facility's need to train all staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #64) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #64's PRN prescription of Ativan (a medication used to treat the symptoms of anxiety) was discontinued after 14 days. The facility did not document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services that assures the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 5 residents reviewed for pharmacy services, in that: The facility failed to ensure Resident #1's narcotic medications were recorded in the EMR, showing they had been administered on 10/3/2025, 10/5/2025, 10/6/2025, and 10/8/2025. This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization.

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 in 1 of 1 kitchen reviewed for dietary services in that: 1) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 2) Dietary staff failed to effectively label items in in freezer. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 6 residents (Resident #144) reviewed for resident rights. The facility failed to ensure Resident #144's call light was within reach on 11/04/24. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to ensure 3 expired Central Line Dressing Change Kits, 3 expired I.V. Start Kits and 1 Pack of 30 expired syringes of Ativan/Benadryl 1-25mg/ml medications were removed from the medication storage room located near Nurse's Station 2. There were no active orders for the medication. These failures could place residents who needed intravenous medications at risk to have contaminated dressings or contaminated I.V. lines started. This would put them at risk of infection. The failure to removed expired medications could put residents at risk of receiving ineffective medications. [...]

Inspectors wroteBased on interview, and record review the facility failed to keep residents free from physical and verbal abuse for 1 (Resident # 1) of 4 residents reviewed for abuse. The facility did not ensure Resident # 1 was free from abuse, as a result Resident # 1 was physically assaulted by Resident # 2 and was injured. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.