Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Grace Guest Care Center during CMS and state inspections, most recent first.
The facility failed to ensure psychotropic meds were reviewed for GDRs and that PRN psychotropic orders were limited to 14 days unless a rationale was documented. A resident with COPD had a PRN Ativan order extended beyond the limit without rationale, while other residents with schizophrenia, schizoaffective disorder, dementia, and anxiety had pharmacist-recommended dose reductions for meds such as buspirone, Ambien, Seroquel, and lorazepam that were not supported with documented clinical rationale. Staff, including the DON and ADM, acknowledged the missing rationales and the need for proper review of these orders.
Food storage and kitchen sanitation standards were not maintained in the facility’s kitchen. A broken flour container with a hole and crack was found in dry storage with flour still inside, the fryer had food crumbs and grease buildup, and the ice machine had a pink substance above the ice. The Dietary Manager and Administrator both acknowledged these conditions should not have been present.
A resident with dementia, severe cognitive impairment, and multiple chronic conditions had her debit card stolen and $1,600 withdrawn from her account by a contracted CNA. Records showed repeated ATM withdrawals and a store purchase while the resident was hospitalized, and the police investigator later reported the CNA admitted making the transactions. The resident said she wanted the perpetrator to go to jail and felt hurt that someone had stolen from her.
A resident admitted with ischemic stroke and dementia did not have the admission MDS completed within the required 14-day timeframe. Several MDS sections remained incomplete, and the assessment was still unsigned and unfinished when reviewed. The MDS Nurse acknowledged the assessment was not done by the deadline, while the Administrator and DON stated they expected MDS assessments to be completed accurately and timely.
A resident with dementia, aphasia, Alzheimer’s disease, and bilateral hand contractures had an annual MDS coded as having no upper-extremity ROM limitation even though both hands were contracted. The ADON confirmed the resident could not move either hand, and the MDS nurse acknowledged the item was marked incorrectly.
A resident with dementia, aphasia, Alzheimer’s disease, and bilateral hand contractures did not receive consistent contracture management. The care plan addressed hand contractures, but the MAR/TAR showed no treatment, and repeated observations found both hands contracted with no hand rolls in place. Staff gave conflicting accounts about whether hand rolls were needed or who was responsible for using them, and the DON and DOR stated therapy had determined they were not needed because the contractures had not changed.
A CNA provided catheter and incontinent care to a resident with urinary retention, an indwelling catheter, bowel incontinence, and moderate cognitive impairment, but removed dirty gloves and put on clean gloves without sanitizing her hands before continuing care. RN observed the missed hand hygiene step, and the CNA acknowledged she forgot to clean her hands between glove changes. Facility leadership stated staff were expected to sanitize hands when moving from dirty to clean, and the hand hygiene policy requires hand hygiene after glove removal.
Antibiotic Stewardship Not Followed for Prophylactic Bactrim Use: A resident with Alzheimer’s disease and MS was ordered Bactrim 800-160 mg daily indefinitely for UTI prophylaxis. The ADON said the medication was being used as a UTI preventative, but there was no documented criteria, written provider rationale, or documentation of other interventions tried; the DON said the resident met McGeer’s criteria for a prophylactic antibiotic.
A resident with hemiplegia, severe cognitive impairment, and total dependence for ADLs fell from bed during incontinent care when a CNA turned her to the side and then released her to pick up supplies, allowing her to roll off the bed. Video showed the CNA first attempting to lift the resident by her arms and then, with two LVNs, manually lifting her from the floor by shoulders and knees back into bed, despite a care plan requiring a Hoyer lift with two staff for transfers and without a thorough on-floor injury assessment. Nursing documentation reported no injuries initially, but photos and video over subsequent days showed progressive swelling and discoloration of the right lower leg and foot, while hospice notes and staff conversations reflected pain behaviors that were not consistently reported or acted upon. A later nursing assessment documented edema, warmth, and discoloration, leading to hospice notification, an x-ray order, and diagnosis of tibia and fibula fractures about a week after the fall. Facility policies required comprehensive post-fall assessment, monitoring for delayed complications, and CNA reporting of subtle changes, but interviews and records showed incomplete assessments, missed or unreported skin and pain changes, and failure to follow the resident’s transfer and bed mobility care plan, forming the basis of the cited deficiency.
Multiple staff failed to follow infection prevention protocols during direct care, including not changing gloves or performing hand hygiene between dirty and clean procedures, not donning gowns or PPE when required for residents on enhanced barrier precautions, and touching clean items with contaminated gloves. These lapses occurred during wound care, catheter care, PEG tube medication administration, and incontinent care for residents with complex medical needs.
A resident with cognitive and vision impairments, requiring maximal assistance, was found with a bottle of isopropyl rubbing alcohol on his bedside table on multiple occasions. Staff interviews confirmed that such items are prohibited in resident rooms due to safety risks, and facility policy restricts access to hazardous chemicals. The presence of the rubbing alcohol indicated a failure to ensure a hazard-free environment and adequate supervision.
A resident with a suprapubic catheter and moderate cognitive impairment did not have a required catheter securement device in place, despite medical orders and care plan interventions specifying its use. Nursing staff and facility leadership confirmed the expectation for the device to be present at all times to prevent catheter movement and infection, but it was not observed during care, constituting a deficiency in catheter management.
A resident's insulin was found improperly stored in a cabinet instead of a refrigerator, with one bottle expired and used, and two unopened. Staff confirmed the insulin, brought from home, should have been refrigerated, disposed of, or returned to the family if not used. Facility policy requires proper storage and disposal, which was not followed in this instance.
Psychotropic Medication Review and PRN Order Deficiencies
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had gradual dose reductions attempted when indicated and that behavioral interventions were used unless clinically contraindicated. The report identified six residents affected by these issues, including residents receiving lorazepam, buspirone, Ambien, Seroquel, and Zyprexa. Facility staff and leadership acknowledged during interviews that psychotropic medications should have appropriate review, that PRN psychotropic medications should have 14-day limits, and that rationales should be documented when a gradual dose reduction was not attempted or when a PRN order was extended. For one resident with COPD and moderate cognitive impairment, the record showed an Ativan 0.5 mg PRN order for anxiety written for 30 days, and the medication had not been administered during the reviewed month. The facility’s policy stated PRN psychotropic medications are limited to 14 days unless the prescriber documents a rationale for extending use and includes the duration. The record did not contain a documented rationale for extending the PRN lorazepam order beyond 14 days. For another resident with paranoid schizophrenia, major depressive disorder, anxiety disorder, and PTSD, the consultant pharmacist recommended gradual dose reductions for buspirone and Ambien, but the physician marked the recommendations as disagree and did not provide a rationale. For a resident with schizoaffective disorder and severe cognitive impairment, the pharmacist recommended reducing Seroquel, but the physician again disagreed and documented only that the resident was stable. The report also identified a resident with severe cognitive impairment and dementia who had a PRN lorazepam order written as indefinite per Hospice, with no 14-day end date, and another resident with Alzheimer’s disease, psychosis, and agitation whose Seroquel order lacked a documented rationale and response for recommendations related to the diagnosis and gradual dose reduction review.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety requirements. During an observation of the kitchen, a flour container in the dry storage room was broken with a hole approximately the size of a golf ball and a crack in the side while flour remained inside. The fryer was covered with aluminum foil, and when uncovered it had food crumbs all over it, grease buildup on the baskets, and grease buildup on the back of the fryer. The ice machine also had a pink colored substance on the inside at the top directly above the ice. During interview, the Dietary Manager stated the ice machine should have been cleaned and should not have had pink residue, the fryer should not have had food particles or grease buildup, and the flour container should not have had a hole in it. She said the fryer had been used on Sunday night and she did not expect the evening shift to clean it after use. She also stated someone should have noticed the pink residue in the ice machine and someone should have replaced the flour container. The Administrator later stated there should not have been a pink substance in the ice maker, food particles or grease buildup on the fryer, or a hole in the flour container.
Misappropriation of Resident Debit Card by Contracted CNA
Penalty
Summary
The facility failed to ensure Resident #4 was free from misappropriation of resident property when CNA J stole the resident’s debit card and withdrew money from her account. Resident #4 was a female with diagnoses including COPD, Type II diabetes, severe protein-calorie malnutrition, dementia, cognitive communication disorder, and hypertension. Her quarterly MDS indicated a BIMS score of 7, severe cognitive impairment, and that she was usually understood and understood others. Her care plan noted paranoid and suspicious behavior related to cognitive impairment, that she often reported items stolen but later located them, and that she kept her debit card with her and would not allow staff to keep it in a safe. Record review showed multiple debit card transactions and ATM withdrawals totaling $1,600, along with withdrawal fees and a convenience store purchase. The facility’s investigation report stated the ADM asked the Social Worker to obtain the resident’s bank card code number to get cigarettes, and that the resident’s card was later not found in the lockbox. The report also stated the resident had been hospitalized during part of the period when purchases occurred, and the RP reported not making purchases for the resident and not visiting her during those months. The police investigator met privately with the resident, who did not know what happened to her card. During the investigation, the police investigator reviewed footage from a convenience store and identified the alleged perpetrator as contracted employee CNA J. The investigator later stated CNA J admitted making the transactions with the resident’s debit card. The resident told the investigator she wanted the perpetrator to go to jail and said she felt hurt that someone had stolen from her. Interviews with facility staff showed they were aware of the missing debit card and that the ADM, DON, SW, and other staff discussed the incident, while the facility policy stated residents have the right to be free from misappropriation of property and that the facility must protect residents from misappropriation by staff, contractors, visitors, family members, and others.
Late and Incomplete Admission MDS Assessment
Penalty
Summary
The facility failed to complete Resident #21’s admission MDS assessment within 14 days of admission. Resident #21 was admitted with diagnoses including cerebral infarction due to embolism of another cerebral artery and unspecified dementia. Her comprehensive MDS assessment had an ARD of 6/8/26 and was identified as an admission assessment required by day 14, but several sections remained incomplete, including A0310, A1005, A1010, A1110, A1805, J2000, O0110, and V0200. Section Z0500 was not signed and the assessment was still incomplete on 6/17/26, indicating it was completed late. During interview, the MDS Nurse stated she completed the MDS assessments and acknowledged she was not finished with Resident #21’s MDS. She stated she had 14 days from the admission date to complete the assessments and that her goal was to finish them that day, noting that the prior day was the 14th day and the assessments had not been completed. The Administrator and DON both stated they expected MDS assessments to be completed accurately and timely, and identified the MDS Nurse as responsible for them. The facility policy stated the resident assessment coordinator is responsible for ensuring an MDS assessment has been completed for each resident and that each assessment is coordinated and certified as complete by the resident assessment coordinator.
MDS Range of Motion Item Coded Incorrectly for Resident with Bilateral Hand Contractures
Penalty
Summary
Resident #27’s annual MDS assessment dated 3/20/26 was coded inaccurately for Section GG0115, Functional Limitations in Range of Motion. The assessment indicated no functional limitation in the resident’s upper extremities, including the hands, even though the resident had bilateral hand contractures documented in the record and noted in the care plan. The resident’s diagnoses included dementia, aphasia, and Alzheimer’s disease, and the MDS also reflected short-term and long-term memory problems and dependence on staff for eating, toileting, dressing, and personal hygiene. During observation on 6/15/26, Resident #27 was found in bed with both hands contracted. An interview with the ADON confirmed the resident could not move either hand and stated the MDS should have been coded as a 2 for impairment on both sides. The MDS nurse acknowledged she marked the item as 0, meaning no impairment, despite knowing the resident had bilateral hand contractures, and stated she would complete an MDS correction. The DON and ADM stated their expectations were for MDS assessments to be completed accurately and timely, and the DON identified the MDS Coordinator as responsible for the assessments.
Failure to Provide Contracture Management for Resident with Bilateral Hand Contractures
Penalty
Summary
The facility failed to ensure Resident #27 received appropriate treatment and services to prevent further decrease in ROM when bilateral hand contracture prevention devices were not in place. Resident #27 was an older female with diagnoses including unspecified dementia, aphasia, Alzheimer’s disease, and gastrostomy status. The record showed she had cognitive impairment and was dependent on staff for eating, toileting, dressing, and personal hygiene. Her care plan identified bilateral hand contractures and stated she was at risk for skin breakdown, increased pain from affected areas, injuries, and mobility impairment related to functional limitation in ROM. The care plan included interventions to apply splints as ordered and encourage use of mobility devices if needed, but the MAR/TAR for May and June 2026 did not show any treatment for her bilateral hand contractures. The annual MDS dated 3/20/26 indicated no functional limitation in ROM in the upper extremities, even though the care plan continued to address bilateral hand contractures. Multidisciplinary Screening Forms dated 3/9/26 and 6/12/26 documented therapy reviews stating there was no change in the contractures and that the resident was not appropriate for therapy services. During observations on 6/15/26, 6/16/26, and 6/17/26, Resident #27 was found in bed with both hands contracted and no hand rolls in either hand. Staff interviews showed inconsistent understanding of who was responsible for placing hand rolls and whether they were needed. An OTA stated the resident currently used rolled wash cloths in her hands for contracture management, while a CNA said she had never seen hand rolls in the resident’s hands and was not responsible for them. An LVN said she sometimes placed hand rolls in the resident’s hands but did not document when she did so, and said it had probably been about a week since she last did it. The DON and DOR stated therapy had determined hand rolls were not needed because the contractures had not changed, and the DON said no one was supposed to be putting hand rolls in the resident’s hands. Later, an ADON assessed the resident’s hands and stated she should have hand rolls because her hands were closed all the way and there was a risk of the contractures getting worse and of wounds if her fingernails dug into her skin.
Missed Hand Hygiene During Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA B did not sanitize her hands after removing dirty gloves and before applying clean gloves while providing catheter care and incontinent care for Resident #7. During the observation, CNA B performed catheter and incontinent care, removed her dirty gloves, and then put on clean gloves without sanitizing her hands before continuing care and applying a clean brief and pants. RN A observed the task and noted the hand hygiene step was missed before the next step began. Resident #7 was a female with diagnoses including chronic diastolic heart failure, urinary retention, and chronic kidney disease stage 3B. Her MDS reflected that she was understood and understood others, had a BIMS score of 10, was dependent on staff for ADLs, was always incontinent of bowel, and had a catheter for urinary continence. Her care plan reflected that she required assistance with ADLs, had enhanced barrier precautions related to an indwelling catheter and wound, and required catheter care per physician order. During interview, CNA B stated she knew she forgot to sanitize her hands between glove changes and acknowledged that hand hygiene was required when going from dirty to clean. RN A stated she expected CNAs to change gloves and sanitize their hands when going from dirty to clean during catheter and incontinent care, and she observed the missed hand hygiene step. The DON, ADON, and Administrator each stated staff were expected to sanitize hands between glove changes and when moving from dirty to clean, and the facility policy stated hand hygiene is indicated after glove removal.
Antibiotic Stewardship Not Followed for Prophylactic Bactrim Use
Penalty
Summary
The facility failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy and by providing a written rationale from the provider when an antibiotic was used despite criteria to determine appropriate use. For Resident #32, a female with Alzheimer’s disease and multiple sclerosis and a BIMS score of 09 indicating moderate cognitive impairment, the record showed an order for Bactrim 800-160 mg, 1 tablet by mouth daily for prophylactic use indefinitely, with a start date of 03/12/26 and no end date. During interview, the ADON stated the medication was being given as a UTI preventative because the resident had recurrent UTIs and had been placed on IV antibiotics to treat them, but she also stated there were no documented criteria followed, no documented rationale for the antibiotic, and no documentation of other interventions tried. The DON stated the resident had recurrent UTIs and met McGeer’s criteria for a prophylactic antibiotic. The facility policy on Antibiotic Stewardship - Orders for Antibiotics stated appropriate indications for antibiotics include criteria met for clinical definition of active infection or suspected sepsis, and pathogen susceptibility based on culture and sensitivity, or therapy begun while culture is pending.
Failure to Perform Adequate Post-Fall Assessment and Safe Transfer, Resulting in Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards of practice for one resident following a fall from bed during incontinent care. The resident was an elderly female with hemiplegia, severe cognitive impairment (BIMS score of 03), COPD, and convulsions, who was totally dependent on staff for transfers, bed mobility, and hygiene, and care planned to require a Hoyer lift with two staff for transfers. On the day of the incident, a CNA turned the resident onto her right side for incontinent care, then let go of the resident to pick up supplies from the floor. Video footage showed that, after the CNA released her, the resident rolled off the bed and onto the floor. The CNA then climbed across the bed and attempted to lift the resident by her arms to put her back in bed, was unable to do so, and lowered her back to the floor before calling for a nurse. Video footage and staff interviews showed that when two LVNs entered the room, the resident was still on the floor. One LVN placed a pillow under the resident’s head, and when the third nurse (the LVN who later documented the incident) arrived, the two LVNs and the CNA lifted the resident from the floor by her shoulders and knees and placed her back in bed, despite the resident being care planned for Hoyer lift transfers. The video showed that this was done without a proper assessment for injury while the resident was still on the floor. The documenting LVN’s progress note stated that the resident was checked for injuries and none were noted except blanchable redness on the right arm, and that the resident was assisted back to bed by two staff. However, the video evidence and subsequent interviews indicated that the assessment was cursory, that the resident was manually lifted contrary to her care plan, and that the nurse later acknowledged her assessment was not appropriate and that a Hoyer lift should have been used. In the days following the fall, multiple opportunities to identify and respond to signs of injury were missed. Hospice notes on two separate visits documented mild pain using the PAINAD scale, and the resident was noted to be at high risk for falls. A skin assessment completed several days after the fall documented no alterations in skin integrity, despite later photographic and video evidence showing progressive swelling and discoloration of the right lower leg and foot beginning shortly after the fall. Pictures and video from the resident’s room over several days showed swelling and yellow discoloration of the right lower leg and foot, and staff were heard discussing the resident’s facial grimacing as a sign of pain. CNAs later reported that they either did not notice or did not report the swelling, discoloration, or bruising, and one CNA acknowledged seeing bruising on the resident’s upper arm but not reporting it. Nursing notes eventually documented edema, warmth, discoloration, and pain responses in the right lower extremity, leading to hospice notification, an x-ray order, and the discovery of minimally displaced fractures of the distal tibia and mid fibula approximately one week after the fall. The facility’s own falls and acute change policies required thorough post-fall assessment, monitoring for delayed complications such as late fractures, and CNA reporting of subtle changes, but interviews and records showed that these assessments and communications were not consistently carried out for this resident. The deficiency also included failures related to care planning and communication of the resident’s care needs for bed mobility and incontinent care. The resident’s care plan identified total assistance needs for ADLs and the requirement for a Hoyer lift with two staff for transfers, but the actual care provided during and after the fall did not follow these directives. The CNA performed incontinent care without ensuring the resident was safely positioned in the middle of the bed and with supplies within reach, then left the resident unsupported on her side, resulting in the fall. After the fall, staff manually lifted the resident from the floor to the bed instead of using a Hoyer lift, despite being aware of her transfer status. Several staff, including the DON and Medical Director, acknowledged in interviews that they had not fully reviewed or acted upon video evidence or early signs of injury, and the Medical Director stated he had not been notified of increased pain, swelling, or discoloration in time to order earlier diagnostic testing. These combined actions and inactions led surveyors to identify an Immediate Jeopardy situation related to failure to assess for injury after the fall, failure to address bed mobility and incontinent care needs, and failure to transfer the resident back to bed using the required Hoyer lift. The facility’s own policies on falls and acute condition changes required nurses to assess vital signs, musculoskeletal function, neurological status, cognition, and pain after a fall, and to monitor for delayed complications such as late fractures and major bruising. Policies also required that direct care staff be trained to recognize and report subtle but significant changes, such as changes in skin color or condition. Despite these policies, the record and interviews showed that the resident’s post-fall assessments were incomplete, that weekly and ongoing skin assessments did not capture obvious swelling and discoloration documented in photos and video, and that CNAs did not consistently report observed or suspected pain, bruising, or changes in the resident’s condition to nursing staff. The combination of improper handling during and after the fall, failure to follow the resident’s care plan for transfers and bed mobility, and failure to recognize and act on evolving signs of injury over several days formed the basis of the cited deficiency. Additionally, the report documents that video evidence of the fall and subsequent handling was available to certain staff members but was not promptly escalated to facility leadership. A family member stated that video footage of the fall was sent to the documenting LVN on the day of the incident, and that she believed there was no other incident that could have caused the fractures. The ADON reported seeing only a brief portion of the video days later and stated that, had she seen all of it, she would have terminated the CNA at that time. The hospice RN reported showing the video to the DON several days after the fall, and the DON acknowledged reviewing the video but not reporting what she saw to the Administrator. The Administrator and Medical Director both stated they had not seen the videos until they were reviewed with the surveyor. This failure to fully review and act upon available video evidence contributed to delays in recognizing the severity of the incident and in addressing the resident’s injuries and care needs. The surveyors concluded that the facility failed in three key areas for this resident: assessing for injury following the fall from bed during incontinent care, addressing care needs for bed mobility and incontinent care in accordance with the care plan, and transferring the resident back to bed using a Hoyer lift as required. These failures were supported by video footage, interviews, and record review, including documentation of delayed recognition of swelling, discoloration, and pain in the right lower extremity, and the eventual diagnosis of tibia and fibula fractures one week after the fall. The Immediate Jeopardy was identified based on these findings, and although it was later removed, the facility remained out of compliance at a lower scope and severity because not all staff had been trained on key assessment and reporting processes at the time of the survey. The nursing home is disputing this citation, and the Medical Director stated he could not determine how the fractures occurred. However, the family member who reviewed all video footage from the date of the fall through the date of diagnosis reported that there was no other incident that would have caused the fractures. The survey findings relied on the combination of video evidence, staff statements, medical records, and facility policies to support the conclusion that the resident did not receive care and services in accordance with professional standards of practice in the areas of post-fall assessment, adherence to transfer and mobility care plans, and recognition and reporting of changes in condition following the fall.
Infection Control Lapses During Resident Care Activities
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for four residents, as observed during direct care activities. In one instance, a treatment nurse did not change gloves or perform hand hygiene appropriately while providing wound care to a male resident with a stage 4 pressure ulcer, diabetes, and heart failure. The nurse touched clean supplies, the resident’s brief, blanket, and bed controls with contaminated gloves, and did not sanitize her hands after glove removal. Interviews with the nurse and facility leadership confirmed that glove changes and hand hygiene were required between dirty and clean procedures, and that these steps were not followed during the observed care. Another deficiency was observed when an LVN provided catheter care to a female resident with a suprapubic catheter and Alzheimer’s disease, who was on enhanced barrier precautions. The LVN did not don a gown before performing the procedure, despite signage and care plan instructions indicating the need for enhanced barrier precautions. The LVN and facility leadership acknowledged that a gown should have been worn to protect the resident from infection, especially given the presence of a medical device. Additional lapses included an LVN failing to apply PPE while administering medications via a PEG tube to a female resident on enhanced barrier precautions, and a CNA not changing gloves or sanitizing hands after performing incontinent care before applying a clean brief to a female resident with dementia and chronic conditions. Both staff members admitted to missing required infection control steps, and interviews with other staff and leadership confirmed that proper PPE use and hand hygiene were expected during these care activities. Facility policies reviewed supported the need for these infection control measures.
Failure to Prevent Access to Prohibited Hazardous Item
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including Amyotrophic Lateral Sclerosis, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes, was found to have a bottle of isopropyl rubbing alcohol on his bedside table during two separate observations. The resident had mild cognitive impairment, required maximal assistance for all activities of daily living, and had moderately impaired vision. Despite these vulnerabilities, the prohibited item remained in the resident's room, accessible and unsecured. Interviews with facility staff, including an LVN, the Director of Nurses, and the Administrator, confirmed that rubbing alcohol is a prohibited item in resident rooms due to the risk of ingestion and potential harm. Facility policy also prohibits access to toxic chemicals and hazardous items in resident environments. The presence of the isopropyl alcohol in the resident's room demonstrated a failure by staff to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Ensure Catheter Securement Device for Resident with Suprapubic Catheter
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and Alzheimer's disease, who had an indwelling suprapubic catheter, did not have a catheter securement device in place as required. The resident's medical orders and care plan specified the use of a catheter securement device to be checked and maintained every shift to prevent complications, including urinary tract infections. During an observation, it was noted that the resident did not have the securement device in place prior to catheter care being provided by an LVN. Interviews with nursing staff, the ADON, DON, and the Administrator confirmed that the securement device was expected to be in place at all times to prevent catheter movement, pulling, and potential infection. The facility's policy also required the catheter to be secured with a device to reduce friction and movement at the insertion site. The failure to ensure the securement device was in place represented a lapse in following physician orders, care plan interventions, and facility policy for catheter care.
Improper Storage and Disposal of Insulin
Penalty
Summary
The facility failed to ensure proper storage and disposal of insulin for one resident with type 2 diabetes mellitus, muscle weakness, severe protein calorie malnutrition, and chronic kidney disease. During an observation, three bottles of insulin labeled for the resident were found in a cabinet, with one bottle showing an expired date and evidence of use. Two of the bottles were unopened, and none were stored in the refrigerator as required for unused insulin. Staff interviews confirmed that insulin should be refrigerated until opened and that improper storage could render the medication ineffective. The insulin in question was brought from the resident's home and was used by the facility until pharmacy-supplied medication arrived. Staff acknowledged that the insulin should have been either refrigerated, disposed of, or returned to the family if not used. The facility's policy requires all medications to be stored in locked compartments under proper temperature controls, with medications requiring refrigeration to be kept in a designated refrigerator. The improper storage and failure to dispose of expired insulin were confirmed through staff interviews and review of facility policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 225 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kilgore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Rehab & Nursing | 0.7 mi | ★★★★★ | 7 | 0 |
| Avir At Overton | 8.2 mi | ★★★★★ | 19 | 1 |
| Pine Tree Lodge Nursing Center | 12.4 mi | ★★★★★ | 20 | 2 |
| Highland Pines Nursing Home | 12.8 mi | ★★★★★ | 10 | 0 |
| Truman W Smith Children's Care Center | 13.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Arbor Grace Guest Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.