Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Arbors At Gallipolis during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and behavioral symptoms became involved in a physical altercation with another resident and was then taken to the nurses’ station, where three CNAs forcefully seated him in a chair, held his arms down, and one CNA straddled his leg while others pulled up on his sweatpants. Video showed the resident being repeatedly pushed back into the chair and physically restrained by multiple CNAs, while cognitively intact residents and a CNA witness reported that staff were laughing, teasing him, and making demeaning comments as he tried to get up and walk away. The resident was later found to have a bruise and skin tear of unknown origin on his arm, exhibited increased agitation, and was placed on Depakote for behavioral management for two days before it was discontinued. The facility’s investigation, including review of video and witness statements, substantiated that the CNAs’ actions constituted physical abuse and a violation of the resident’s rights.
A resident with dementia, psychosis, and a history of aggressive behaviors had a care plan calling for calm approaches, redirection, re-approach after de-escalation, non-judgmental support, and other non-pharmacological interventions. During a behavioral episode in which the resident entered another resident’s room and both began hitting each other, staff separated them and physically controlled the resident by "arm to arming" him to a chair near the nurses’ station, repeating this when he tried to get up and became argumentative. Documentation did not describe specific de-escalation or non-pharmacological measures used, and staff reported limited, mostly computer-based training on managing aggressive behaviors. The physician later indicated the resident’s behaviors were instigated by staff and that forceful handling could provoke retaliatory responses, while the facility’s behavior management policy required individualized, non-pharmacological strategies before or alongside psychotropic medication use. This resulted in a deficiency for not providing appropriate behavioral interventions consistent with the resident’s care plan.
Opened multi-dose vials of Tuberculin Purified Protein were found in two medication room refrigerators without being dated when first accessed. This was confirmed by a registered nurse and an LPN, indicating that the facility did not follow proper labeling protocols for these medications.
A resident with a recent left below-knee amputation and hemiplegia was not provided with necessary interventions such as stump elevation or regular repositioning to off-load pressure, despite being at risk for skin breakdown and requiring staff assistance for bed mobility. Staff observations and interviews confirmed the absence of these interventions, and the resident's surgical wound subsequently worsened.
A resident with multiple medical conditions, including a recent amputation and hemiplegia, was ordered to wear a knee immobilizer and required assistance with turning and repositioning. Despite care plans and physician orders, staff did not consistently turn or reposition the resident, and there was no documentation of refusal. Physical therapy identified skin breakdown, but nursing staff delayed assessment and treatment. The resident developed facility-acquired pressure injuries due to lack of timely intervention and adherence to prevention protocols.
Two residents with significant cognitive and physical impairments did not receive physician-ordered fall prevention interventions, such as non-skid strips, dycem, and visible reminder signs. Observations and staff interviews confirmed that these measures were not in place as required by the care plans and facility policy.
A resident with multiple medical conditions, including COPD, was administered oxygen therapy without a physician's order and without an oxygen warning sign posted on the door, as required by facility policy. Observations and staff interviews confirmed the absence of both the order and the warning sign while the resident was using an oxygen concentrator.
A resident with a documented diagnosis of PTSD was not properly assessed or provided with a comprehensive care plan addressing their trauma-related needs. Despite medical records and psychiatric notes confirming PTSD, social service assessments failed to recognize the diagnosis, and no trauma-informed interventions or care planning were implemented as required by facility policy.
Two residents with intact cognition either did not understand or did not recall signing binding arbitration agreements, with one stating she did not watch the explanatory video and another noting the signature on the agreement was not hers. Staff confirmed the video was available, but there was no evidence it was viewed or that the agreements were explained in a way the residents understood, contrary to facility policy.
Abusive Physical Restraint and Humiliation of Cognitively Impaired Resident by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident with vascular dementia and other psychiatric and neurologic diagnoses from physical and psychosocial abuse by three CNAs. The resident had severely impaired cognition, intermittent ability to make himself understood, and a history of some physical and verbal behaviors, but was not known to reject care and typically required only supervision or touching assistance for transfers and ambulation. On the evening in question, a nurse heard yelling and arguing from another resident’s room and found this resident standing by a female resident’s bed, with both residents hitting and smacking each other as he yelled at her to get out of his bed. After staff separated the residents, a CNA took the resident to the nurses’ station, where he continued to be described as physically abusive and verbally aggressive toward staff. Subsequently, multiple CNAs physically controlled and restrained the resident in a manner that was later substantiated by the facility as physical abuse. Video footage showed two CNAs each holding one of the resident’s arms as they directed him down the hall toward the nurses’ station and sat him in a chair. When the resident became agitated and attempted to stand, a third CNA joined them; the two original CNAs grabbed his arms while the third CNA grabbed the back of his sweatpants, pulling them up and back as he was forcefully placed back into the chair. The two CNAs then held his arms down against the chair armrests with closed hands over his wrists and lower forearms, and one CNA straddled his leg. At various points, different CNAs took turns holding his arms or hands while he was kept in the chair for several minutes before being allowed to get up and return to his room. Witness accounts from cognitively intact residents and staff further described the abusive nature of the interaction. One resident reported seeing two female staff hold the resident down in a chair while he only wanted to go to his room, stating he was not fighting and that staff were teasing him; another resident reported staff laughing and teasing the resident, telling him they were holding him down and that he should not move, including calling him “stupid.” A CNA witness stated she did not like how the staff handled the situation and, when asked if she would consider it abuse if it were her family member, she answered yes. The physician later documented that the resident’s behaviors were being instigated by staff and that he was responding to how staff intervened, describing him as being in a protective mode. Following the incident, the resident was noted to have a skin tear and bruise of unknown origin on his arm, increased agitation, and was started on Depakote for behavioral management for two days before it was discontinued. The facility’s own investigation, initiated after reviewing video footage while following up on the earlier resident-to-resident altercation, concluded that physical abuse had occurred. The three CNAs involved were identified as the perpetrators, and their personnel files documented termination for violating residents’ rights, including abuse and failure to report to a supervisor. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and specified that willful meant acting deliberately, not necessarily intending harm. The actions of the CNAs in forcefully seating the resident, holding his arms down, straddling his leg, and teasing and laughing at him were determined by the facility to meet this definition of abuse, resulting in actual harm to the resident, including bruising, a skin tear, increased agitation, and the need for additional psychotropic medication for behavioral control immediately following the incident.
Failure to Implement Care-Planned Behavioral Interventions for Dementia-Related Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate, necessary, and effective interventions for a resident with dementia and behavioral symptoms, as outlined in his care plan. The resident was admitted with vascular dementia, unspecified psychosis, depression, seizure disorder, cognitive communication deficit, unsteadiness on feet, and muscle weakness, and had a care plan addressing behaviors such as restlessness, anxiety, physical aggression, hallucinations, delusions, exit seeking, verbal aggression, and wandering. The care plan interventions included approaching the resident calmly, re-approaching later if he became agitated, attempting redirection, communicating care before tasks, providing non-judgmental support, keeping him safe during behavioral episodes, documenting behaviors, notifying the physician when behaviors persisted, and using non-pharmacological interventions and activities of interest to keep him engaged. On the evening of the incident, during a medication pass, an RN heard yelling and arguing from another resident’s room and found the cognitively impaired resident standing by a female resident’s bed while both residents were hitting and smacking each other. The resident was yelling at the female resident to get out of his bed. The RN attempted to separate the residents and diffuse the situation, and an unidentified CNA took the resident to the nurses’ station, where he continued to be physically abusive and verbally aggressive toward staff. The physician was notified and new orders were obtained for Haldol and Depakote, and the resident’s son consented to the new medications. The resident was later taken to bed and fell asleep, and the as-needed Haldol was not administered, but Depakote was started as a daily medication. The nursing progress note did not document specific details on how staff attempted to diffuse the situation or what non-pharmacological interventions were used in response to this behavioral episode. Subsequent documentation indicated that the resident had been reported to the physician as having increased agitation and aggressive behaviors with psychotic issues, and that Depakote had been started in response to the incident. The physician later documented that the resident was being treated inappropriately and that his behaviors were instigated by staff, describing the resident as being in a protective mode and stating that he had been told a CNA grabbed the resident. The physician stated that staff should have tried redirection without force, removal from the provoking area, and other calming strategies, and that holding down a cognitively impaired resident could elicit a retaliatory response. CNAs interviewed about the incident reported that they “arm to armed” the resident by wrapping their arms around his arms to move him from the other resident’s room to a chair near the nurses’ station, and that when he stood up and became argumentative or went toward a CNA, they again “arm to armed” him back into the chair. One CNA reported that additional staff from another floor came up and that this likely worsened the resident’s agitation and was overwhelming for him. Multiple CNAs stated they did not feel properly trained to deal with aggressive behaviors, reporting only limited or computer-based training and describing that management’s guidance was mainly to offer food or snacks during behaviors, which contrasted with the more comprehensive behavioral management approach described in the facility’s behavior management policy and the resident’s care plan. The facility’s behavior management policy required that residents exhibiting behaviors negatively affecting themselves or others be reviewed by a behavior management team, that root causes and target behaviors be identified, and that individualized plans of care and non-pharmacological interventions be used to minimize the need for medications or allow for the lowest possible dose. In this case, the record and interviews did not show that the non-pharmacological, de-escalation, and redirection strategies specified in the resident’s care plan and the facility’s policy were effectively implemented or documented during and after the behavioral episode. Instead, staff used physical control techniques (“arm to armed”) and obtained new psychotropic medication orders without clear evidence of prior, thorough use of individualized, non-pharmacological interventions as outlined in the care plan and policy. This failure to follow the resident’s behavior care plan and the facility’s behavior management program requirements led to the cited deficiency for not ensuring the resident received appropriate treatment and services for dementia-related behaviors.
Failure to Date Opened Multi-Dose TB Vials
Penalty
Summary
Surveyors observed that opened multi-dose vials of Tuberculin Purified Protein (TB) were not dated when first accessed in two separate medication room refrigerators within the facility. On the third floor, a vial of TB solution was found opened and undated, which was confirmed by a registered nurse present at the time. Similarly, on the second floor, another opened and undated vial of TB solution was identified, with a licensed practical nurse verifying the lack of dating. These findings indicate that the facility did not ensure that opened multi-dose TB vials were labeled with the date of first use, as required by professional standards for drug labeling and storage.
Failure to Implement Pressure Relief Interventions for Surgical Wound
Penalty
Summary
A deficiency occurred when the facility failed to implement adequate and effective interventions to promote healing and prevent deterioration of a left below-the-knee surgical site with staples for a resident upon admission. The resident, who had a history of left below-knee amputation, hemiplegia affecting the left side, dementia, and other significant comorbidities, required staff assistance for bed mobility and was at risk for skin breakdown as indicated by a Braden Scale score of 17. Despite these risks, the care plan and physician orders did not initially include interventions to elevate or float the left stump, nor was there documentation of regular turning and repositioning or resident refusal of such care. Multiple observations over several days revealed the resident was consistently found lying on the left side with the left stump not floated or elevated, and no interventions in place to off-load pressure or promote healing of the surgical wound. Interviews with nursing staff and CNAs confirmed that the resident required assistance to turn in bed and did not refuse care, yet staff did not recall or document providing necessary interventions such as floating the stump or using pillows or wedges. The resident himself reported needing help to move in bed and did not refuse staff assistance when offered. The lack of appropriate interventions and documentation led to a decline and worsening of the surgical wound, as evidenced by wound assessments showing deterioration. The facility's own policy required a plan of care for prevention and/or treatment to include a turning schedule and off-loading, which was not implemented for this resident until after the wound had worsened.
Failure to Implement Pressure Ulcer Prevention for Resident with Knee Immobilizer
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to promote skin integrity for a resident who was ordered to wear a knee immobilizer at all times. The resident, who had multiple complex medical conditions including a recent left below-knee amputation, hemiplegia, dementia, and was at risk for skin breakdown as indicated by a Braden Scale score of 17, required assistance with bed mobility and turning. Despite physician orders and care plans specifying frequent turning and repositioning to prevent skin breakdown, there was no documentation that the resident refused to be turned, and observations repeatedly found the resident lying on the same side in bed. Physical therapy staff identified skin breakdown under the knee immobilizer and alerted nursing staff, but no immediate assessment or treatment was implemented on the day the wound was discovered. The wound, later assessed as a deep tissue injury (DTI) to the front left thigh, was not measured or treated until the following day, in accordance with the facility's routine wound measurement schedule. Additional documentation revealed the development of an unstageable wound in the left popliteal fossa. Throughout the period in question, there was minimal documentation of the resident refusing repositioning, and staff interviews confirmed the resident did not refuse care and required assistance to be turned. Facility policy required a turning schedule and offloading care for residents at risk of pressure ulcers, but the plan of care and physician orders were not consistently followed. The lack of timely intervention and documentation regarding turning, repositioning, and wound assessment contributed to the development of facility-acquired pressure injuries for this resident.
Failure to Implement Physician-Ordered Fall Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement physician-ordered fall prevention interventions for two residents with known fall risks. For one resident with diagnoses including Alzheimer's disease, dementia, and severe cognitive impairment, the care plan and physician orders required specific fall interventions such as non-skid strips to the left side of the bed, non-skid strips in front of the recliner, and dycem to the recliner seat. Observations revealed that these interventions were not in place, and this was confirmed by staff interviews. Another resident, with a history of dementia, seizures, Parkinsonism, and other significant medical conditions, also had physician orders for fall prevention measures. These included dycem to the wheelchair seat, non-skid strips in front of the toilet, and a sign reminding the resident to use the call light. Observations showed that the dycem was missing from the wheelchair, non-skid strips were not present in front of the toilet, and the reminder sign was not visible to the resident. Staff confirmed that these interventions were not implemented as ordered. The facility's policy required that residents be assessed for fall risk and receive care and services according to their risk level. Despite this, the required fall prevention interventions were not consistently provided for residents identified as being at risk for falls, as evidenced by direct observation and staff verification.
Failure to Obtain Physician Order and Post Oxygen Warning Sign for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy and did not post an oxygen warning sign for a resident who required respiratory care. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, cerebral infarction, and atherosclerosis, and was assessed as needing substantial assistance with daily activities. The care plan indicated that oxygen should be provided as needed when the resident exhibited signs of difficulty breathing, but there was no active physician order for oxygen therapy in the resident's medical record. Observations on two separate days revealed that the resident was using an oxygen concentrator set to 2 liters, with a nasal cannula either on the bed or in use, but there was no oxygen in use sign displayed on the resident's door. Interviews with nursing staff confirmed the absence of both the required physician order and the oxygen warning sign. Review of the facility's policy on oxygen administration indicated that both a physician's order and an oxygen warning sign are required when oxygen is in use.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and develop a care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite the resident's medical record and psychiatric progress notes indicating a diagnosis of chronic and controlled PTSD, the initial and subsequent social service histories did not document PTSD, and the resident was not assessed for trauma-related needs. The quarterly MDS assessment did indicate PTSD as a current diagnosis, along with other psychiatric and medical conditions, but this information was not incorporated into the resident's care planning. There was no care plan in place to address the resident's PTSD triggers or to provide trauma-informed care as required by facility policy. The policy mandates screening for trauma history upon admission, obtaining physician orders for mental health evaluation if trauma is identified, and developing individualized care plans to mitigate triggers. An interview with the Regional Registered Nurse confirmed that the resident was not assessed for PTSD and that a comprehensive plan of care was not developed to address this diagnosis.
Failure to Ensure Residents Understood Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the binding arbitration agreements they were asked to sign, as required by facility policy. For one resident with intact cognition, review of records showed she signed the agreement, but during interview, she stated she did not watch the explanatory video and did not understand what she was signing. For another resident, also with intact cognition, review of the signed agreement revealed a signature that did not match her usual signature style, as it lacked her middle initial, which she consistently used on other documents. This resident did not recall signing the agreement and stated she would not have signed it if she had understood its contents. Staff interviews confirmed that the explanatory video was available, but there was no evidence that the residents had viewed it or that the agreement was explained in a manner they understood. Additionally, the Admissions Director who signed one of the agreements was no longer employed at the facility, and the facility policy required that the arbitration agreement be explained to residents or their representatives in a form and manner they understand. These findings affected two of three residents reviewed for arbitration agreements.
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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 Gallipolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abbyshire Place Health And Rehabilitation Center L | 0.4 mi | ★★★★★ | 2 | 0 |
| Holzer Senior Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Healthcare Center | 7.9 mi | ★★★★★ | 3 | 0 |
| Majestic Care Of Lakin | 12.2 mi | ★★★★★ | 0 | 0 |
| Overbrook Center | 14.9 mi | ★★★★★ | 11 | 0 |
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