Arbor Grace Guest Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; and the resident's drug regimen was free from unnecessary psychotropic drugs and PRN orders for psychotropic drugs were limited to 14 days for 6 of 12 residents reviewed for unnecessary psychotropic drugs (Resident #3, Resident #5, Resident #53, Resident #10, Resident #25, and Resident #64). 1. The facility failed to ensure a rationale was documented in Resident #3's medical record for extending the PRN lorazepam 0.5mg (a prescription medication used to treat anxiety disorders: feelings of fear, dread, and uneasiness) order duration beyond 14 days. 2. [...]

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 the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure the flour container in the dry storage room was in good repair and did not have a hole in it. 2. The facility failed to ensure the fryer was clean and free of grease buildup and food particles. 3. The facility failed to ensure the ice machine did not have a pink substance on the inside of the machine above the ice. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 2 residents reviewed for misappropriation of resident property. (Resident #4) The facility failed to prevent CNA J from stealing Resident #4's debit card and withdrawing $1600 dollars from her account. These failures could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 4 residents (Resident #21) reviewed for comprehensive assessments and timing. The facility did not ensure Resident #21's admission MDS assessment was completed within 14 days of admission. Resident #21 was admitted to the facility on [DATE] and her comprehensive care plan was not completed until 6/17/26. This failure could place residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 21 residents reviewed for assessments. (Resident #27) The facility failed to ensure the MDS was appropriately coded for functional limitations in ROM for Resident #27. Resident #27 had bilateral hand contractures. This failure could place residents at risk for decreased quality of care due to inaccuracy of assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease in ROM for 1 of 21 residents reviewed for rmobility. (Resident #27) The facility failed to ensure Resident #27 had contracture prevention devices in place for treatment of her right-hand and left-hand contractures. These failures could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. Record review of the face sheet dated 6/16/26 indicated Resident #27 was an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of the physician's orders, dated 6/16/26, indicated Resident #27 had diagnoses that included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents (Resident #7) reviewed for infection control. The facility failed to ensure CNA B sanitized her hands after removing dirty gloves and applying clean gloves while providing catheter care and incontinent care for Resident #7 on 6/16/26. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider when an antibiotic was used despite criteria, to determine the the appropriate use of an antibiotic for 1 of 5 residents reviewed for antibiotic use (Resident #32). The facility failed to ensure Resident #32 did not receive Bactrim 800-160mg (an antibiotic used to treat a variety of bacterial infections) for prophylactic antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for quality of care.1. The facility failed to ensure Resident #1 was assessed for injury following a fall from bed on 4/12/2026 during incontinent care. Resident #1 was discovered to have a tibia/fibula fracture on 4/19/2026.2. The facility failed to ensure Resident #1's care needs were addressed for bed mobility and incontinent care.3. The facility failed to transfer Resident #1 back to bed with a Hoyer lift instead of grabbing her arms and legs and putting her back in bed. An IJ was identified on 4/27/2026. The IJ template was provided to the facility on 4/27/2026 at 4:26pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 18 residents reviewed for infection control practices (Resident #'s 56, 4, 7, 28). 1. The facility failed to ensure the treatment nurse changed her gloves and performed hand hygiene appropriately while providing wound care to Resident #56. 2. The facility failed to ensure LVN C donned a gown before performing catheter care on Resident #4. 3. The facility failed to ensure LVN F donned a gown when she gave Peg-tube medications to Resident #7. Resident #7 was on enhancement barrier precautions. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 20 residents (Resident #48) reviewed for adequate supervision. The facility failed to keep prohibited items, isopropyl rubbing alcohol, out of Resident #48's room. This failure could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #4) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). The facility failed to ensure Resident #4's indwelling suprapubic catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor the catheter to her leg. This failure could place residents at risk for urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored and disposed of properly, for 1 of 6 residents (Resident #56) reviewed for medication storage. 1. The facility failed to ensure Resident #56's humlin 70/30 insulin was properly stored in the refrigerator. 2. The facility failed to ensure Resident #56's humlin 70/30 insulin with an expired date was disposed of. This failure could place residents at risk of not receiving the therapeutic benefit of medications and adverse reactions to medications due to improper storage.

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 (Main Kitchen), in that: On 3/18/24 the facility failed to ensure food was discarded by the expiration date. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Three of six gas stove burners (front middle, right front, and right back) did not light automatically on 03/18/2024, when the knob was turned, the pilot light on the burners would not stay lit and both burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported to Texas Health and Human Services Commission immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #8) residents reviewed for abuse and neglect. The facility did not report an allegation of abuse that occurred between 3/8/24-3/10/24 when Resident #8 reported to LVN A that CNA B had been rough while providing care and had caused a bruise on her right thigh. This failure could place residents at risk of injuries, abuse, and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 12 residents reviewed for ADLs (Residents #48.) The facility did not clean or trim Resident #48's fingernails on 03/18/2023, 03/19/2024 and 03/20/2024. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 2 of 12 residents (Resident #35 and Resident #37) reviewed for respiratory care. The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #35 and Resident #37. These failures could place residents at risk for of respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 5 resident's reviewed for care plans. (Resident #1) The facility failed to ensure Resident #1's general surgeon (medical doctor) was informed of her care, as a follow-up appointment was missed and not rescheduled. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 residents reviewed for grievances. (Resident #1) The facility Administrator and DON failed to document, resolve, and follow up on grievances related to quality of care on behalf of Resident #1 on 01/26/2024 and 02/09/2024. These failures could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a dignified existence and were treated with respect and dignity that promoted or enhanced their quality of life for 1 of 5 residents reviewed for resident rights.(Resident #1) Resident #1 was not assisted with her meal or allowed to finish eating. The staff took Resident #1's Breakfast tray on 10/23/23 while she was still chewing without asking if she was finished. This negative finding caused resident to not have the right to a dignified existence.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice to prevent pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident #1) Resident #1 was noted with an area on her hip on [DATE]. However, skin assessment for the same date did not note the area. Resident #1 had staff reported areas of concern on her right hip prior to being notified by the family on [DATE] that she has a pressure ulcer. Resident #1 was identified by the family on [DATE] to have a stage 3 pressure ulcer to the right hip. These failures could cause residents to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was provided at least three meals daily for 1 of 5 residents reviewed for frequency of meals. (Resident #1) The facility neglected to provide a resident with a breakfast tray on 10/23/23. This negative finding could cause the resident to suffer physical harm and or emotional abuse.