Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
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.
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 | ★★★★★ | 4 | 1 |
| St. Catherine Center | 1.3 mi | ★★★★★ | 6 | 0 |
| Ivy Creek Wellness & Rehabilitation | 2.4 mi | ★★★★★ | 1 | 0 |
| Crestview Healthcare Residence | 2.5 mi | ★★★★★ | 1 | 0 |
| Lakeshore Village Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.