The Arbors Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 7 residents (Resident #1) reviewed for resident rights in that: Resident #1 was not offered water after he asked repeatedly for water. Resident #1 was left lying on the bed in only a brief with no blanket covering resident. This failure could place all residents at risk for poor hydration and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 7 residents reviewed for dietary services. Resident #1's dietary card was not brought to the kitchen staff in a timely manner causing Resident #1 to miss meal service. This failure could place all newly admitted residents at risk for poor nutrition/hydration and reduced quality of life.

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 1 of 6 residents (Resident #6) and 1 of 2 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes while performing incontinent care for Resident #6 on 4/6/26. This failure could place residents at risk of exposure to infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards in the facility's only kitchen reviewed for food service safety. The facility did not ensure foods in the freezer were labeled and dated when removed from their original packaging on 1/12/2025. These failures could place residents who received their meals from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the option he or she prefers for 1 of 6 residents (Resident #5) reviewed for the right to be informed. 1. The facility failed to ensure Resident #5 had a signed medication consent form for Haldol (antipsychotic medication) and lorazepam (antianxiety medication) when ordered on 12/18/2025. 2. The facility did not ensure the need for and benefits of the proposed treatment with antipsychotic or neuroleptic medication was filled out on the HHSC Form 3713 Consent for Antipsychotic or Neuroleptic Medication when ordered on 12/18/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who use psychotropic drugs received appropriate monitoring for 2 of 6 residents reviewed for unnecessary medications. (Residents #5 and #48)1. The facility did not have appropriate monitoring for psychotropic medications for Resident #5's Haldol (antipsychotic) and lorazepam (antianxiety) from 12/24/2025 to 1/11/2026.2. The facility did not have appropriate monitoring of psychotropic medications for Resident #48's Zoloft and venlafaxine (antidepressants), Quetiapine (antipsychotic), clonazepam (antianxiety) from 12/29/2025 to 1/11/2026. These failures could place residents at risk for unintended, harmful events attributed to the use of medications without the appropriate monitoring or indication for use.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents reviewed for accuracy of assessments. (Resident #5) The facility failed to accurately document Resident #5's hospice services and antiplatelet therapy on her Quarterly MDS assessment on 1/05/2026. Resident #5 had an order on 12/18/2025 to admit to hospice services. This failure could place residents at risk of not receiving needed care and services.

Inspectors wroteBased on interviews and record review, the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 6 residents (Resident #5) reviewed for baseline care plans. The facility failed to ensure Resident #5's baseline care plan was completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on interview and record review the facility failed to make sure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #5) reviewed for care plans. The facility failed to ensure Resident #5's comprehensive care plan was reviewed and revised when she was admitted to hospice services on 12/18/2025 This failure could place residents at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 5 (Resident #62) residents observed for incontinent care. CNA B did not provide proper incontinent care for Resident #62 and wiped from the anal area toward the urethral area (back to front) on 1/13/2026. This failure could place residents at risk for bacterial infections from improper incontinent care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents (Resident #62) reviewed for enteral feeding. The facility failed to ensure Resident #62's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. The failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway).

Inspectors wroteBased on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, for 1 of 6 (CNA B) reviewed for annual competency evaluations. The facility failed to complete a performance review of CNA B and conducted services based on the results of the review. This deficient practice could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Inspectors wroteBased on observations, interviews, 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 1 of 3 residents (Resident #41) reviewed for infection control. The facility failed to ensure LVN A followed enhanced barrier precautions guidelines when wound care was provided to Resident #41 on 01/13/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and records review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for Resident Rights. The facility failed to ensure Resident #1 was treated with respect and dignity on 9/22/25 from approximately 9:00 a.m. to 1:00 p.m. when there was a brown substance that looked and smelled like feces smeared on the floor in her bathroom. The facility failed to ensure Resident #1 was treated with respect and dignity on 9/21/25 at approximately 6:00 p.m. when staff failed to provide assistance with ADLs. These failures could place residents at risk of psychosocial harm, self-isolation, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide 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 for 1 of 7 residents reviewed for pharmacy services. (Resident #1) The facility failed to provide a physician ordered medication of Estrace (estradiol), which was ordered to help reduce the thinning of vaginal and pelvic tissues, to Resident #1 for 32 days. This failure could place residents at risk for exacerbation of diagnoses or increased complications.

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 and follow infection control policies and procedures for 1 of 7 residents reviewed for infection control. (Resident #1) The facility failed to follow infection control guidelines and procedures when CNA B and CNA C performed catheter care for Resident #1 without donning appropriate PPE. The facility failed to follow infection control guidelines and procedures when CNA B and CNA C removed Resident #1's brief and performed catheter care without changing gloves, washing, or sanitizing their hands. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and for 1 of 7 residents reviewed for physical environment. (Resident #3) The facility failed to ensure access to warm water for showering for Resident #3. This failure placed all residents in the facility at risk for discomfort, potential skin irritation, and a decline in the resident's quality of life.

Inspectors wroteBased on observations, interviews, 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 2 of 3 residents (Resident # 9 and Resident # 25) reviewed for quality of care. The facility failed to ensure Residents # 9 and Resident # 25's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to resident and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 10 residents (Resident #3 and Resident #18) reviewed for call lights. The facility failed to ensure the emergency call light in Resident #3's and #18's shared bathroom was accessible from the floor on 10/7/24. These failures could affect residents who used their call lights or desire to use the call lights and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on observations, interviews, 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 1 of 2 residents (Resident #15) reviewed for infection control. CNA D did not wash or sanitize her hands when changing gloves while performing foley catheter care for Resident #15. CNA D wiped down the catheter tubing and without changing the washcloth picked up the washcloth and started at the top of the catheter and wiped down again while performing catheter care for Resident #15. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 10/08/24 when an empty cigarette package and paper towels were observed in an ashtray in smoking area. These failures could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a PASSR Level II resident review upon a significant change of condition for 1 of 4 Residents (Resident #36) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The MDS Coordinator failed to refer Resident #36 for a resident review after being diagnosed with major depression, (05/23), bipolar disorder, (06/7/23) anxiety, (06/17/22), and schizoaffective disorder, (06/17/22). This deficient practice could place residents at risk of not receiving the needed PASRR services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 191) reviewed for accidents and hazards. The facility failed to ensure Resident # 191 had adequate supervision and was wearing appropriate footwear while in wheelchair to prevent a fall in room on 9/11/23. This deficient practice could place the residents at risk for harm, serious injury or death.

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 1 of 5 staff (ADON) reviewed for infection control. ADON failed to clean the scissors used to cut wound care dressings for Resident #38 and she stored the scissors in her pocket. ADON failed to place wound care supplies on a clean surface while performing wound care to Resident #38. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 8 residents (Resident # 25) reviewed for call lights. The facility failed to ensure Resident # 25's emergency call light in the bathroom would reach the floor. The call light cord for Resident # 25 was wrapped around the grab bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.