Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Atrium Of Bellmead during CMS and state inspections, most recent first.
A resident with dementia, weakness, and high fall risk had repeated falls during transfers while staff used improper transfer techniques and, in several instances, no gait belt. The resident cried and reported pain after some of the falls, but the physician, hospice physician, and NP were not consistently notified of the incidents. Interviews and video showed staff confusion about the resident’s transfer status and repeated transfers without the required assistance.
A resident with dementia, muscle weakness, and other chronic conditions had a care plan that still reflected 1-person transfer assistance after repeated falls during transfers. Video and staff statements showed CNAs transferred her without a gait belt and, at times, without the required 2-person assist, while leadership and nursing staff acknowledged she needed more assistance and a gait belt for transfers.
A resident with dementia, weakness, poor coordination, and high fall risk was transferred without the required gait belt and 2-person assist, leading to repeated falls during transfers. Video showed CNAs pulling and pivoting the resident without proper support, and the resident cried and reported buttocks, hip, hand, and leg pain after some of the falls. Staff interviews showed inconsistent knowledge of the resident’s transfer needs and that several staff were not aware of the required transfer interventions.
A resident with dementia and Alzheimer’s disease, dependent on staff for transfers, had two transfer-related falls in which she cried out and reported pain to her buttocks, right hip, right hand, and leg. Video showed staff transferring her without the required gait belt and, in one instance, without the required 2-person assist. The charting and staff interviews showed inconsistent pain assessment practices, including use of a numerical scale instead of the Pain Ad scale for a nonverbal resident, and the resident’s pain was not accurately assessed after the falls.
A resident with Parkinson’s disease, cognitive decline, and CHF returned from the hospital after AKI, pneumonia, dehydration, and SOB, but the facility did not ensure the physician or NP followed the discharge order for follow-up within one week. The record showed no physician progress note after the return, and interviews with the physician, NP, resident, and staff confirmed the follow-up did not occur as expected.
Failure to Follow Podiatry Orders and Provide Foot Care: Staff did not properly receive, verify, or carry out podiatry orders for multiple residents after a provider visit. A resident with diabetes and circulation problems developed a black toe and later required amputation after a tight dressing was left in place and the ordered follow-up care was not implemented. Other residents with conditions such as DM, PVD, ESRD, malnutrition, and stroke sequelae also had foot-care orders that were not promptly routed to nursing staff or documented in the skin assessments.
PRN Ativan Order Lacked Required Stop Date: A resident with Lewy body neurocognitive disorder, hallucinations, and moderate cognitive impairment had a PRN Ativan order for anxiety/agitation/restlessness that was not limited to 14 days. The ADON and DON stated PRN psychotropics were supposed to have a 14-day stop date unless the prescriber documented an extension, but the order was missed and no rationale for continued use was documented.
A resident with multiple chronic conditions received several doses of Hydrocodone-Acetaminophen that were documented on the narcotic count sheet but not in the electronic MAR. Interviews with the DON and two LVNs revealed that the omissions occurred due to distractions and high workload, despite facility policy requiring documentation in both records.
The facility's dietary staff failed to properly reseal, label, and date food items in the walk-in refrigerator and freezer, as observed during a survey. Cabbage was found in an open bag without a label or date, and croissants were in a bag without a label. Interviews with the Dietary Manager and Assistant Dietary Manager confirmed the importance of sealing, labeling, and dating food to prevent spoilage and cross-contamination, in line with the facility's policies.
A resident's call light was found on the floor and out of reach, preventing the resident from calling for assistance. Despite staff training on call light accessibility, there was no formal policy, leading to a risk of unmet needs for the resident.
The facility failed to remove expired medical supplies and medications from the medication storage room, including Central Line Dressing Change Kits, I.V. Start Kits, and syringes of Ativan/Benadryl. Despite staff being in-serviced on the policy for handling expired items, these were not destroyed as required, indicating a lapse in pharmaceutical services.
A resident with mild cognitive impairment was physically assaulted by her roommate, who had a history of behavioral disturbances, in an LTC facility. The incident resulted in a skin tear on the assaulted resident's leg. Despite the aggressor's known potential for physical behaviors, the facility failed to prevent the altercation, leading to a deficiency in ensuring resident safety.
Failure to Notify Physicians After Resident Falls During Transfers
Penalty
Summary
The facility failed to notify the resident’s physician, hospice physician, and nurse practitioner after multiple falls that occurred during transfers. The resident had diagnoses including late onset Alzheimer’s disease, dementia, muscle wasting and atrophy, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders. Her care plan identified her as a fall risk and required 1-person assistance with transfers, and her fall risk assessment classified her as a high fall risk. On one occasion, a CNA attempted to move the resident from her recliner to her bed, the chair moved, and she fell onto her buttocks. On another occasion, a CNA attempted to transfer her into her recliner using a walker, her legs gave out, and she was assisted to the floor. On a third occasion, while transferring from her wheelchair to her recliner, the resident slid to the floor after her knee started to hurt. Video footage showed staff transferring her without a gait belt and using improper handling during the transfers. During the falls, the resident cried and reported pain, including buttocks pain, right hip pain, right hand pain, and leg pain. The record and interviews showed the resident’s physician was notified after the 7/19/26 fall, but the physician stated he was not notified about the 7/14/26 or 7/20/26 falls. The hospice physician and nurse practitioner also stated they were not notified of the resident’s falls on 7/14/26, 7/19/26, and 7/20/26. Staff interviews reflected inconsistent understanding of the resident’s transfer status and use of a gait belt, and several staff stated they had transferred the resident without a gait belt or without the required assistance. The facility’s incident log documented only the 7/14/26 fall, and the physician-notification policy stated the nurse should notify the physician immediately with significant change in status.
Care Plan Not Updated After Repeated Transfer Falls
Penalty
Summary
The facility failed to review and revise one resident’s care plan after repeated falls during transfers. The resident had diagnoses including late onset Alzheimer’s disease, dementia, muscle wasting and atrophy, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders. Her quarterly MDS reflected she was dependent on staff for transfers, and her care plan identified her as a fall risk with 1-person assistance for transfers, but it was not updated to reflect the need for 2-person assistance and a gait belt after subsequent falls. The resident fell during transfer on 7/14/26, 7/19/26, and 7/20/26. The 7/14/26 note described a CNA attempting to move her from a recliner to the bed without a gait belt, after which she fell to the floor. The 7/19/26 note reflected a CNA attempted to transfer her into a recliner using a walker, her legs gave out, and she was assisted to the floor. Video footage from 7/19/26 showed the CNA pulling the resident forward toward the recliner, with the gait belt hanging on the walker and not used, and the resident fell forward over the walker and landed on her knees. Video footage from 7/20/26 showed another CNA transferring her without a gait belt, pulling her up toward a walker, and the resident fell backward, hit her arm and back, and landed on her buttocks. Interviews showed staff and leadership knew the resident required more assistance with transfers, and multiple staff stated she required 2-person assistance and a gait belt. The ADON said the resident needed 2-person assistance with a gait belt because her legs would buckle, and the DON said the resident required a gait belt and expected 2-person assistance. The MDS Coordinator said care plans were usually revised the morning of a fall, but she was not at the facility on 7/20/26 and 7/21/26, and the care plan was not revised in a timely manner. The resident’s representative also stated she had asked staff to ensure the resident used her walker and received 2-person assistance with a gait belt when transferring her.
Failure to Use Required Transfer Assistance and Gait Belt
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were used for a resident with dementia, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders. The resident’s admission record reflected she was dependent on staff assistance with transfers and was identified as a high fall risk. Her care plan, revised before the events, required 1-person assistance with transfers, and there were no revised interventions in place before the resident’s falls to require 2-person assistance and a gait belt. The resident fell during transfers on multiple occasions. On one occasion, a CNA attempted to move her from a recliner to a bed, the chair moved, and she fell onto her buttocks. On another occasion, a CNA attempted to transfer her into a recliner using a walker, her legs gave out, and she was assisted to the floor. On a later occasion, while transferring from a wheelchair to a recliner, her knee started to hurt, she missed the seat, and slid to the floor. After the later falls, the resident cried and reported pain, including buttocks pain, right hip pain, right hand pain, and pain in her leg. Video footage showed staff transferring the resident without the required gait belt and without the required 2-person assistance. On one video, a CNA tried to pull the resident forward toward a recliner while the gait belt hung on the walker, and the resident fell forward over the walker and landed on her knees. On another video, a CNA held the resident by the arm, pulled her toward a walker, pivoted her toward a recliner, and the resident fell backward, hit her right arm on the window sill and back on the wall, then slid to the floor. Interviews with staff showed inconsistent understanding of the resident’s transfer needs, and several staff stated they had not been in-serviced before the events or did not know the resident required 2-person assistance and a gait belt. The physician also stated he expected staff to use a Hoyer lift, or a gait belt could be used, and that he was not notified of all of the falls.
Inadequate Pain Assessment After Transfer-Related Falls
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for one resident who had dementia, late onset Alzheimer’s disease, muscle weakness, lack of coordination, psychotic disorder with hallucinations, and bone density and structure disorders. The resident was dependent on staff for transfers and had a care plan identifying her as a fall risk, with staff required to use 1-person assistance for transfers before the events described in the report. The resident’s pain documentation showed that staff had previously used a Pain Ad scale, but the most recent documented pain entry was several months before the falls. After a fall during a transfer into a recliner, the resident cried and told staff to look at her buttocks because it was hurting a little bit. The fall event note stated she denied pain and did not appear to be in pain, but the video footage showed the resident being pulled forward with a walker and falling to the floor. The report also states there were no interventions in place prior to the fall, and the only intervention initiated afterward was education of the CNA on transferring the resident with 2-person assistance. After a second transfer-related fall the next day, the resident cried, said her right hand was hurting, and said she hit her leg. The fall note stated she appeared and stated she was in pain to her right knee, but there were no interventions in place prior to the fall and no new interventions initiated in response to it. Video footage showed the resident being transferred without a gait belt, falling backward, hitting her right arm on the window sill and her back on the wall, sliding down, landing on her buttocks, and crying out in pain. Interviews with staff showed inconsistent understanding of how to assess the resident’s pain, including whether to use a numerical scale or a Pain Ad scale, and the physician stated he would not have expected the resident to be sent to the emergency room unless she experienced pain.
Failure to Follow Hospital Discharge Orders and Physician Follow-Up
Penalty
Summary
The facility failed to ensure that one resident with Parkinson’s disease, age-related cognitive decline, and chronic congestive heart failure received treatment and care in accordance with hospital discharge orders, the comprehensive care plan, and the resident’s choices. The resident was admitted to the facility, later sent to the hospital after showing a change in condition with respiratory issues and shortness of breath, and returned to the facility after being diagnosed with pneumonia, dehydration, and an acute kidney injury. The care plan identified a potential fluid deficit and required staff to obtain and monitor ordered lab and diagnostic work and report results to the MD with follow-up as indicated. After the resident returned from the hospital, the record showed nursing notes documenting the return and that hospital instructions and follow-up appointments were noted, but there were no physician progress notes after the resident came back from the hospital. The hospital discharge orders required follow-up with the physician within one week. During interviews, the physician and NP stated they had not seen the resident after the hospital return and could not confirm follow-up. The resident also stated the physician did not visit her after she returned from the hospital. Facility staff described expectations that discharge orders be reviewed, entered into the EHR, and communicated to the physician or NP, but the record and interviews showed this did not occur for the resident’s post-hospital follow-up. The ADM stated the hospital discharge summary follow-up instruction was generic and not an instruction, while the DON stated staff were expected to enter orders in the EHR and the readmission nurse relayed notifications to the physician at the time. The facility’s physician progress notes policy stated physician visits must occur on a required timeline and be timely if completed no later than ten days after the date the visit is required.
Failure to Follow Podiatry Orders and Provide Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care and follow-through on podiatry treatment orders for 8 of 8 residents who were seen by podiatry. After the podiatry visit, orders were left with non-clinical staff rather than being received and implemented by licensed nursing staff. The record and interviews showed that staff did not recognize the paperwork as physician orders, did not enter the orders into the resident record in a timely manner, and did not ensure the ordered dressing changes and follow-up care were carried out. For one resident with a history of gangrene and acquired absence of a toe, the podiatrist performed an incision and drainage with toenail removal and ordered the dressing removed after 24 hours, followed by ointment and bandaging. Facility staff did not identify the orders when they were left at the business office, and a nurse later observed and reapplied the dressing without checking the orders. When the dressing was eventually removed, the toe was black and appeared smaller at the tip, and the resident was sent to the hospital. Hospital records showed necrosis and gangrene that resulted in toe amputation. The same breakdown affected the other residents seen by podiatry, including residents with diagnoses such as diabetes, end-stage renal disease, peripheral vascular disease, malnutrition, stroke sequelae, unsteadiness on feet, and muscle wasting. Their podiatry orders included removing dressings within 24 to 48 hours, applying ointment and bandages for several days, using ketoconazole lotion, and notifying the PCP about edema and DVT risk. The facility’s skin assessment policy stated that open areas were to be treated according to physician orders and documented, but the record showed that the resident with the toe injury had a skin check with no issues noted despite the bandage being present, and the orders were not followed as intended.
PRN Ativan Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure that a PRN order for Ativan, a psychotropic anti-anxiety medication, was limited to 14 days for one resident. Resident #64 had diagnoses including neurocognitive disorder with Lewy bodies, psychotic disorder with hallucinations, muscle wasting, and difficulty walking, and her MDS reflected a BIMS score of 9 indicating moderate cognitive impairment. Her care plan stated that she used anti-anxiety medication for anxiety and included monitoring for side effects and effectiveness. The active physician order report showed an order for Ativan 0.5 mg by mouth every 8 hours as needed for anxiety, agitation, or restlessness dated 01/25/2026. The resident’s February 2026 MAR showed no administration of Ativan. During interview, the ADON stated that PRN psychoactive medications usually had a 14-day stop date and that the order for this resident must have been missed; she also stated the risk of not having a stop date could be oversedation. The DON stated PRN psychotropic medications were to have a 14-day stop date unless the physician provided an extended letter, and that if a PRN medication without a stop date was found, the facility would contact the doctor for clarification. The facility policy stated PRN antidepressant, hypnotic, and antianxiety drugs are limited to 14 days unless the prescriber documents a rationale and duration for extension.
Failure to Document Narcotic Administration in MAR
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic medication administration for one resident, as required by their policies and procedures. Specifically, multiple doses of Hydrocodone-Acetaminophen administered to a resident were recorded on the narcotic count sheet but were not documented in the electronic Medication Administration Record (MAR) on several occasions. This discrepancy was identified through review of the narcotic count sheet and the MAR, which showed missing entries for the administration of the medication on specific dates and times. Interviews with staff involved in the administration of these medications revealed that the omissions were due to distractions, high workload, and failure to follow the established process of documenting in both the MAR and the narcotic count sheet. The DON, who administered one of the doses, acknowledged forgetting to document in the MAR after being pulled away to assist another resident. Similarly, two LVNs admitted to administering the medication and signing the narcotic count sheet but failing to document in the MAR due to being busy, distracted, or overwhelmed by their workload. The resident involved had multiple significant diagnoses, including acute respiratory failure, COPD, atrial fibrillation, congestive heart failure, and hypertension, and was assessed as having no cognitive impairment. The facility's policy required that all medication administrations be documented in the MAR and, for controlled substances, also on the narcotic count sheet. The failure to document in the MAR was confirmed by staff interviews and review of facility policy.
Failure to Properly Store and Label Food in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed during a survey. Specifically, the dietary staff did not properly reseal, label, and date food items in the walk-in refrigerator and freezer. During an initial tour of the kitchen, it was noted that cabbage was stored in an open plastic bag without a label or date in the walk-in refrigerator, and croissants were found in the freezer in a clear plastic bag without a label. These practices were not in compliance with the facility's policies, which require all opened food packages to be stored in closed containers or sealed bags and labeled with the date they were opened. Interviews with the Dietary Manager (DM) and Assistant Dietary Manager (ADM) confirmed that all items in the refrigerators and freezers should be sealed, labeled, and dated to prevent spoilage and cross-contamination. Both managers acknowledged that improperly sealed or unlabeled food could lead to safety and identification issues. The facility's policies, dated 2012, emphasize maintaining storage areas in an orderly manner and ensuring food is covered and labeled when stored. The failure to follow these procedures could potentially place residents at risk for food contamination and foodborne illness.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs and preferences. On two separate observations, the call light for a resident was found lying on the floor, out of reach, while the resident was in bed. The resident expressed that he could not reach the call light and would not attempt to do so to avoid falling, indicating a risk of unmet needs due to the inability to call for assistance. Interviews with staff, including a CNA and the DON, confirmed that call lights should always be within residents' reach, and all staff had been trained on this requirement. However, there was no formal policy in place regarding call light placement. The ADM also acknowledged the expectation for call lights to be accessible and answered promptly, yet the lack of a policy may have contributed to the oversight in ensuring the resident's call light was within reach.
Expired Medications and Supplies Not Removed from Storage
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not removing expired medical supplies and medications from the medication storage room near Nurse's Station 2. Specifically, three expired Central Line Dressing Change Kits, three expired I.V. Start Kits, and a pack of 30 expired syringes of Ativan/Benadryl were found. These items had expired between July and October 2024, and there were no active orders for the medications. The presence of these expired items in the medication room indicates a lapse in the facility's procedures for acquiring, receiving, dispensing, and administering drugs and biologicals. Interviews with the Director of Nursing (DON), the Administrator (ADM), a Licensed Vocational Nurse (LVN-A), and a Medication Aide (MA-B) revealed that the facility's policy required expired items to be destroyed and placed in a designated bin. However, the responsibility for this task was not effectively executed, despite staff having been in-serviced on the policy. The failure to adhere to these procedures could lead to the use of ineffective medications and compromised supplies, posing a risk of infection and harm to residents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, resulting in an incident where one resident was physically assaulted by another. The assaulted resident, a female with a history of dementia, hypertension, and other medical conditions, was admitted to the facility with a mild cognitive impairment. She was assessed to have no behaviors or refusal of care. The incident occurred when the resident was verbally abused and physically kicked by her roommate, leading to a skin tear on her leg. The aggressor, another female resident with moderate cognitive impairment and a history of dementia with behavioral disturbances, was known to have potential for physical behaviors. Despite this, the facility did not prevent the altercation. The aggressor expressed frustration with her roommate's need for assistance with activities of daily living, which led to the physical assault. The facility's care plan for the aggressor included monitoring for changes in cognitive function and intervening in case of physical behaviors, but these measures were not effectively implemented to prevent the incident. The incident was documented by a Licensed Vocational Nurse who witnessed the verbal abuse and assessed the physical injury. The facility's social worker later assessed both residents, finding that neither felt afraid or distressed after the incident. However, the failure to prevent the altercation and protect the resident from abuse constitutes a deficiency in the facility's duty to ensure resident safety and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bellmead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Springs Nursing Center | 0.6 mi | ★★★★★ | 10 | 1 |
| Ivy Creek Wellness & Rehabilitation | 2.4 mi | ★★★★★ | 4 | 0 |
| Crestview Healthcare Residence | 2.5 mi | ★★★★★ | 0 | 0 |
| Lakeshore Village Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 6 | 0 |
| Avir At Jeffrey Place | 4.7 mi | ★★★★★ | 4 | 0 |
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