Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Grace Wellness Center during CMS and state inspections, most recent first.
Resident Mail Not Delivered on Weekends: A facility failed to ensure residents could promptly receive unopened mail on weekends. Eleven residents reported mail was not distributed on Saturday or Sunday and said they had never received weekend mail or been asked about it at monthly meetings. The AD and BOM stated they handled mail Monday through Friday and were unsure why weekend delivery was not occurring, while the ADM was unaware of the issue. The resident rights packet stated residents had the right to send and promptly receive unopened mail and other materials delivered to the facility.
Grievance Information Not Available to Residents: The facility failed to provide 11 confidential residents with access to grievance forms and information on how to file grievances anonymously. Residents stated they did not know where to get a form, who to submit it to, or what happens after filing, and they had not seen grievance information posted in prominent areas or discussed in Resident Council. Observation found no grievance postings or blank forms available, and the AD and ADM confirmed residents did not have access to blank grievance forms.
Failure to Monitor Significant Weight Loss: A resident with ESRD, cirrhosis, DM2, depression, and colon cancer had a 16.5% body weight loss, but the facility did not ensure ongoing weight monitoring or timely nutritional follow-up. The resident’s care plan and MD orders included supplements, snacks, and appetite stimulant therapy, yet weights were not continued after the loss was identified and meal intake was often 50% or less. The RD stated she was not contacted about the significant weight loss, and the DON acknowledged the resident should have been placed on weekly weights.
Facility dietary staff failed to follow approved menus and recipes for lunch meals and puree trays. A braised Swiss steak entrée was served as loose meat in liquid instead of the prepared patty-style recipe, portions were not served per recipe, and a substitute fruit item was used when cobbler ingredients were unavailable. Two puree trays were missing the wheat roll on one meal and cornbread on another, and a dietary staff member stated she did not puree the cornbread because she was running behind.
Kitchen A had multiple food safety failures, including refrigerators holding food above safe temps, expired or outdated food in dry storage, toxic hand sanitizer stored next to food, and clean plates and bowls stored face up. Staff observed milk, eggs, chicken, lettuce, deli ham, and supplements at unsafe temps, while the DS and CP noted the refrigerators were not maintaining proper cooling and that some food items were expired or should have been discarded.
A medication package on the Hall D cart for a resident had hydroxyzine directions that still read every 6 hours as needed even though the order had changed to 10 mg twice daily. Staff said the usual process was to place a change-direction sticker on the blister pack until a new pack arrived from the pharmacy, but the sticker was not on the package when surveyed. The MA, LVN, DON, and ADM each described staff responsibility for tracking medication order changes and keeping the label accurate.
Hand Hygiene Not Performed After PPE Removal: An LVN preparing G-tube meds for a resident with sepsis, epilepsy, diabetes, and quadriplegia put on PPE, entered the room, handled supplies and meds, then removed PPE and exited without washing hands or using ABHR. The LVN acknowledged the omission and stated she had been trained to perform hand hygiene after removing PPE; the DON and ADM stated staff are expected to wash hands or use ABHR after glove removal.
A resident with dementia, epilepsy, prior TIA/CVA, depression, and tobacco use was found keeping cigarettes and a lighter in his sweater pocket and lighting his own cigarette without staff assistance. His care plan required smoking materials to be kept at the nurse’s station, and the facility’s smoking policy stated all smoking materials must be secured there when not in use. The ADM stated residents were not allowed to keep smoking materials or lighters in their rooms, while the Driver reported the resident continued to keep them with him and smoke independently.
Survey Results Binder Not Accessible: The facility failed to make State Agency survey results, including surveys, certifications, and complaint/incident investigations, readily available and clearly posted for residents and visitors. Eleven residents said they did not know where to find the survey results and had never seen a labeled binder near the front door or receptionist desk. Surveyors observed no binder or notice in the front entrance area, receptionist desk area, nurses' station area, or administrative offices, and the ADM stated the binder should be posted and available but it was not found.
A resident with Alzheimer's disease and behavioral health diagnoses, including intermittent explosive disorder and anxiety, did not have her aggression, care refusal, or psychotropic medication management addressed in her care plan. Despite documented incidents of aggression and refusal, staff interviews revealed a lack of awareness and documentation of specific behavioral interventions, and the care plan was not updated to reflect the resident's current needs.
During a meal service, three staff members, including two CNAs and an LVN, failed to follow proper hand hygiene protocols while assisting residents with feeding. They did not sanitize their hands after tasks that could lead to contamination, such as moving wheelchairs and handling objects. Despite having received training on hand hygiene, the staff did not adhere to the facility's policy, risking the spread of infections.
The facility failed to label and date food items in the kitchen, as observed in both the refrigerator and freezer. Items such as lunch meat, sandwiches, fruit cocktail, cupcakes, and lemon bread were found without proper labeling or dating. Interviews with the DM and DA E confirmed that this oversight could lead to serving outdated food, posing a risk to residents' health. The facility's policy requires all stored foods to be labeled and dated, which was not adhered to.
A resident with severe cognitive impairment and quadriplegia was observed with an uncovered catheter bag, compromising his dignity and quality of life. Staff interviews confirmed the responsibility to cover catheter bags, aligning with the facility's policy on dignity. The resident expressed a preference for having the bag covered.
A resident with severe cognitive impairment and complete dependence on staff was not repositioned every two hours as required by their care plan. Observations and interviews revealed the resident remained in the same position for extended periods, and the facility's staff acknowledged the failure to adhere to the care plan. The facility's repositioning policy emphasizes the importance of regular repositioning to prevent skin breakdown and promote circulation.
The facility did not have an RN on duty for at least 8 hours on a specific day, as required. This was confirmed through interviews and record reviews, with staff acknowledging the oversight and potential negative outcomes. No policy for RN coverage was provided.
A facility failed to label and store Lantus insulin properly, as observed during a survey. An opened vial of insulin was found without an expiration date, contrary to professional principles. LVNs confirmed that insulin expires 28 days after opening, and the responsibility for labeling lies with the nurses. The ADON acknowledged the oversight and the need to include expiration dates, as per facility policy.
A resident with multiple health issues developed a Stage IV pressure injury that was not immediately reported to the physician or representative. The facility's CNAs lacked training in identifying skin issues, leading to a delay in detection. Miscommunication and documentation errors resulted in incorrect treatment until the resident was hospitalized.
A resident developed a Stage IV pressure ulcer with an exposed tendon due to inadequate skin assessments and lack of CNA training in a facility. The resident, with multiple health conditions, was not properly monitored for skin deterioration, leading to a severe infection and hospitalization. Facility staff failed to communicate effectively with the physician, delaying appropriate treatment.
A facility failed to implement a baseline care plan for a resident with quadriplegia, leading to improper transfer by a CNA without using the required Hoyer lift. The resident's care plan was incomplete, and staff inconsistencies in determining transfer methods were noted, posing a risk of injury.
A resident with severe cognitive impairment and multiple neurological conditions required a two-person assist for transfers, as indicated in their care plan. However, a CNA attempted to transfer the resident alone, resulting in the resident being lowered to the ground. The facility's policies require comprehensive care plans with measurable objectives, but the care plan was not adequately implemented, potentially placing the resident at risk.
Two residents in a LTC facility were not transferred according to their care plans, leading to deficiencies. A resident with quadriplegia was manually lifted by an agency CNA instead of using a Hoyer lift, while another resident with severe cognitive impairment was transferred alone despite requiring a two-person assist. These actions were against the care plans and posed potential risks of injury.
The facility failed to provide RN coverage for at least 8 consecutive hours on a weekend, as required. This deficiency was confirmed through interviews and record reviews, revealing no RN hours on the specified dates. Staff members had varying views on the impact of this absence, with some downplaying its significance. The ADM acknowledged the scheduling oversight, noting the importance of RNs in supervising staff and handling emergencies.
Resident Mail Not Delivered on Weekends
Penalty
Summary
The facility failed to ensure residents had reasonable access to communication methods by not delivering resident mail on the weekend. During a confidential group interview, 11 of 11 residents stated that mail was not being distributed on the weekend, that they were unsure why weekend staff did not deliver it, and that they had never received mail on the weekend or been asked about weekend mail delivery at monthly meetings. They stated they believed mail delivery on weekends was not a service offered by the facility. In interviews, the AD stated she distributed resident mail Monday through Friday and said the post office held mail on Saturday and delivered it on Monday, but she was not sure why mail was not delivered on Saturday. The BOM stated she received mail for the facility, including resident mail, worked Monday through Friday, and said the post office held the mail for Saturday and delivered it on Monday; she also stated she was not sure why this had been the practice since she started. The ADM stated he was not aware that mail was not being delivered on Saturday and was unsure whether mail was delivered to the facility on Saturday. Record review of the Federal Resident Rights document dated 02/24/2022 stated residents had the right to send and promptly receive unopened mail and other letters, packages, and materials delivered to the facility.
Grievance Information Not Available to Residents
Penalty
Summary
The facility failed to provide residents and their representatives with information about their rights related to filing grievances or concerns for 11 of 11 confidential residents. During interviews, the residents stated they did not have access to the grievance form, did not know they could file a grievance anonymously, had not discussed the grievance procedure in Resident Council, and had not seen the grievance procedure posted in prominent locations. They also stated they did not know where to obtain a grievance form, who to give it to, or what happens after a grievance is filed. Record review of the facility grievance policy, revised 12/2023, showed that grievance information should be posted in designated locations throughout the facility and that residents and/or representatives have the right to file grievances orally, in writing, and/or anonymously. Observation on 02/25/2026 found no grievance information posted in the front door area, around the nurses' station, or along halls A, B, C, and D, and no grievance forms were available for residents to use. During interview, the AD stated the SW kept grievance forms in her office, that the SW was not at the facility full-time, and that residents would let her know if they had a grievance and she would write it for them. The AD also stated residents did not have access to blank grievance forms. The ADM later stated the SW was responsible for grievance forms, that the SW resigned on 02/23/2026, and that he was not aware there were no forms available for residents to file a grievance anonymously.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to ensure that Resident #46 maintained acceptable nutritional status when the resident experienced a significant weight loss of 30.3 pounds, or 16.5% of body weight, between 01/02/26 and 02/03/26. Resident #46 was a male with diagnoses including end stage renal disease, alcoholic cirrhosis of the liver, Type II diabetes mellitus, major depressive disorder, and malignant neoplasm of the colon. The quarterly MDS dated 02/05/26 indicated severe cognitive impairment, independent eating with set-up and clean-up assistance, and dialysis while a resident. The resident’s care plan identified a nutritional risk and included interventions such as ordered diet, monitoring for decreased appetite and unexpected weight loss, and providing supplements including diabetic snacks, Med Pass 2.0, Prostat, and Megace. The physician’s orders reflected a low concentrated sweets diet, diabetic snack at bedtime, Med Pass 2.0 twice daily, Prostat three times daily, and Megace for weight loss. The weight record showed weekly weights in December 2025, one weight in January 2026, and one weight in February 2026, with no further facility weights found after the significant loss was identified on 02/03/26. Meal intake records for 02/02/26 through 02/25/26 showed the resident consumed 50% or less of meals on multiple days. The annual nutrition evaluation completed by the RD on 02/24/26 documented the most recent weight of 153.2 pounds and recommended using dry weights only for monitoring and adding house shakes daily for 30 days. During interviews, the RD stated she had not been contacted by the facility about the significant weight loss and expected weekly weights after such a change. The DON stated the resident should have been placed on weekly weights after the significant weight loss was identified and acknowledged that this did not occur. The facility policy stated that residents were to be assessed for nutritional status and that the nurse would notify the physician, family, and/or resident of weight loss or gain with interventions.
Menu and Recipe Noncompliance in Meal Preparation
Penalty
Summary
The facility failed to follow the prepared menu and approved recipes for lunch meals and pureed trays. On 2/24/26, the lunch menu called for braised Swiss steak, mashed potatoes, steamed broccoli, a wheat roll, margarine, fruit cobbler, and a beverage. During observation, the braised Swiss steak was prepared as a loose meat in a liquid soup texture rather than as a patty topped with gravy, and the portioning utensils used for the meal did not match the recipe directions. The facility also substituted mixed fruit for fruit cobbler because it did not have all of the ingredients for the cobbler. The same lunch meal on 2/24/26 also showed that two pureed trays did not include the wheat roll listed on the menu. The record review of the recipe for braised Swiss steak showed the dish was to be prepared as patties using specific ingredients and portioning steps, and the recipe for mashed potatoes listed a serving size of 1/2 cup. During observation, the hot food temperatures were checked before service, and the braised Swiss steak was noted to be in a loose, soupy form rather than the expected prepared item. Staff interviews confirmed that the steak had not thickened correctly, that too much tomato sauce had been used, and that the roll had not been pureed for the trays. On 2/25/26, the lunch menu called for baked ham, sweet potato, seasoned greens, cornbread, margarine, bread pudding, and a beverage. Two pureed trays observed during that meal did not include the cornbread listed on the menu. The dietary staff member stated she prepared only the starch and meat items and did not puree the cornbread because she was running behind, even though she acknowledged she had been trained to puree the bread items listed on the menu and was responsible for ensuring all items on the puree menu were prepared. The RD and DS stated staff should follow recipes and that pureed meals should include the same menu items as regular meals, with substitutions documented and approved when needed.
Kitchen food storage and temperature control failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in Kitchen A. During the initial kitchen observation, the external thermometer of Refrigerator B showed 45 F, and the refrigerator contained multiple food items including milk, cheese, chicken, eggs, soup, and produce. The external thermometer of the refrigerator named Victory also showed 45 F, while the internal thermometers showed 38 F on one side and 46 F on the other. The Dietary Supervisor stated the refrigerators should be at or below 35 F and said the facility was working on getting everything up to code and had purchased new refrigerators that were waiting to be delivered. The observation also showed toxic items and food stored together. A bottle of Premium Hand Sanitizer with Aloe was sitting on the bottom shelf of the preparation table next to bread, peanut butter dated 2/16, and opened grape jelly dated 8/5. The outside of the grape jelly was labeled to refrigerate after opening. In the dry pantry, five bags of corn tortilla chips dated 12/16, a tray of whole white onions dated 2/16 with a use-by date of 2/29, and an opened 37 lb. tub of multi-use lemon filling dated 8/19 were stored on shelves. The Dietary Supervisor stated the chips and lemon filling were probably expired and should have been thrown away. During the later observation, food temperatures in both refrigerators remained above safe levels. In Refrigerator B, a raw pasteurized egg measured 50.2 F, chick noodle soup measured 46 F, mechanical soft chicken measured 49 F, and chopped lettuce measured 48.7 F. In the refrigerator named Victory, deli ham measured 43.3 F, whole milk measured 41.5 F, a Mighty Shake measured 43.7 F, and milk poured from a gallon measured 45.1 F. The Dietary Supervisor stated the temperatures were above safe levels and contacted his boss. The Clinical Practitioner stated all food in the refrigerators was thrown away and a refrigerated truck was ordered for emergency refrigerated food storage. On a later kitchen tour, clean plates and bowls were observed stored facing upward. A staff member stated clean dishes were supposed to be stored face down to dry because sanitizer or water could sit in them if stored right side up.
Medication Label Did Not Match Updated Order
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles for one medication cart reviewed, the Hall D medication cart. During observation, a medication package for Resident #15 contained hydroxyzine labeled with instructions to give 1 tablet by mouth every 6 hours as needed, even though the physician order had been changed to hydroxyzine 10 mg by mouth twice a day with no end date. The medication package did not have the change-direction label that staff described as the process for reflecting an order change until a new blister pack was received from the pharmacy. Record review showed the updated physician order for hydroxyzine 10 mg twice daily. During interviews, the MA stated she knew the medication had been changed from as needed to twice daily and said the expected process was to place a label change sticker on the blister pack until the new medication was received. The LVN stated staff were supposed to notify the MA and remind them to place the sticker when medication orders changed. The DON stated all nurses and MAs were responsible for making sure a sticker was placed on the blister pack when the medication order changed, and the ADM stated he was not aware the label was wrong.
Hand Hygiene Not Performed After PPE Removal
Penalty
Summary
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 1 resident reviewed for infection control. During an observation, an LVN was preparing G-tube medications for a resident in the hallway outside the resident’s room. The LVN put on PPE, gathered supplies from the top of the PPE cart, and entered the resident’s room. She placed supplies and medications on the bedside table, then realized a medication was missing, picked up medications from the bedside table, removed her PPE, and exited the room without washing her hands. The resident involved was a [AGE]-year-old male admitted and readmitted with diagnoses including sepsis, epilepsy, diabetes, and quadriplegia. During interview, the LVN stated she was aware she did not wash her hands or use ABHR after removing PPE and said she should have washed her hands but forgot. She stated she had been trained on proper hand hygiene and to wash hands after removing PPE. The DON and ADM stated staff should wash hands or use ABHR after removing gloves and that all staff had been trained on proper hand hygiene and PPE. The facility policy titled Handwashing/Hand Hygiene stated hand hygiene is one of the most effective measures to prevent the spread of infection and directs staff to use alcohol-based hand rub or soap and water after removing gloves.
Smoking materials kept in resident room contrary to facility policy
Penalty
Summary
The facility failed to follow its smoking policy for one resident who used tobacco. The resident had diagnoses including acute respiratory failure with hypoxia, unspecified dementia with a BIMS score of 1, epilepsy, a history of TIA and cerebral infarction, major depressive disorder, and tobacco use. His care plan stated that he would adhere to the facility’s tobacco/smoking policies and that his smoking materials would be kept at the nurse’s station. His smoking evaluation documented that he was alert and oriented and able to light and hold his own cigarette. During observation, the resident was seen outside in the smoking area taking a container from his sweater pocket, removing a cigarette and lighter, and lighting the cigarette without staff assistance. On another observation and interview, he stated that he kept his cigarettes and lighter in his sweater pocket and had never been told they had to be kept at the nurse station. He also ended one interview after stating he had something else to do. The Driver observed him smoking independently and stated he went outside on his own to smoke because he could smoke independently. The facility’s smoking policy stated that all smoking materials and charging devices would be secured at the nurse’s station when not in use during designated smoking times. The ADM stated residents were not allowed to keep smoking materials or lighters in their rooms and that all smoking materials had to be kept at the nurse’s station. The ADM also stated there was no variance for any resident under the new smoking policy, and the Driver stated that Resident #29 kept his smoking materials in his room and that she had told nurses about it after the policy change.
Survey Results Binder Not Posted or Available
Penalty
Summary
The facility failed to ensure residents were aware of where to locate the State Agency survey inspection results, including surveys, certifications, and complaint/incident investigations, and failed to post them in a place readily accessible to residents, family members, and legal representatives. On 02/25/2026, the facility did not have a survey binder that was readily available and easily identified to residents or the public for viewing survey results. During a confidential group interview, 11 of 11 residents stated they did not know where or how to access survey results in the facility, and they reported they had never seen a binder labeled with that information near the front door or receptionist desk. An observation on 02/25/2026 at 10:45 a.m. of the front door area, receptionist desk, nurses' station area, and administrative office area showed no survey results binder or notice directing people where to locate it. On 02/26/2026 at 09:32 a.m., the ADM stated the binder was posted at the front door area and kept in the receptionist office, but during observation there was no sign at the front door and no survey binder available in the receptionist office. The ADM stated the expectation was for proper signage to always be posted and the survey binder to be available, and later stated the facility followed Federal Regulations requirements for any policies not provided.
Failure to Address Behavioral Health Needs in Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of aggression, refusal of care, and use of psychotropic medication for behavioral management. The resident, diagnosed with Alzheimer's disease, intermittent explosive disorder, major depressive disorder, and generalized anxiety disorder, had a comprehensive care plan that did not include goals or interventions addressing her behavioral diagnoses or medication management. Despite documented incidents of aggression and care refusal, these behaviors were not reflected in the care plan, and there was no documentation of behavioral monitoring related to her medication. Record reviews showed that the resident had active orders for Depakote for intermittent explosive disorder and had previously been prescribed Lexapro, which was discontinued. Behavioral monitoring records indicated multiple instances of care refusal and aggression over two months. Interviews with staff, including LVNs, the MDS Coordinator, the DON, and the AD, revealed a lack of awareness and implementation of specific behavioral interventions for the resident. Staff acknowledged that interventions such as redirection and medication management were used but were not documented in the care plan, and there was no consistent communication or morning meetings to relay this information. The facility's policy required staff to recognize behavioral changes, implement relevant care plan interventions, and monitor and report changes in condition. However, the MDS Coordinator admitted to missing updates in the care plan, and the DON was unsure of the care plan's contents regarding behavioral interventions. The absence of documented interventions and goals in the care plan for the resident's behavioral health needs constituted a failure to provide care in accordance with the comprehensive assessment and plan of care.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during a luncheon service. Three staff members, including two CNAs and an LVN, were observed feeding residents who required full assistance without sanitizing their hands after performing tasks that could lead to contamination. Specifically, one CNA moved a resident's wheelchair and touched her own hair before resuming feeding without hand sanitization. The LVN moved a dining room chair and began feeding a resident without re-sanitizing his hands. Another CNA handled a glass and pushed a resident's wheelchair before returning to feed another resident without sanitizing her hands. Interviews with the involved staff members revealed that they were aware of the importance of hand hygiene and recognized their lapses in practice, acknowledging the potential for spreading infections. The facility's Director of Nursing and Administrator confirmed that the staff had received in-service education on hand hygiene and universal precautions, and had demonstrated competency in these areas. The facility's policy on hand hygiene, which requires sanitizing hands before and after direct contact with residents and after handling objects in the resident's vicinity, was not adhered to during the observed incidents.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. Specifically, the facility did not ensure that items in the freezer and refrigerator were properly labeled and dated. During an inspection of the walk-in refrigerator, several items were found without labels or dates, including a partially used package of ham lunch meat, a package of lunch meat wrapped in saran wrap, a bucket of approximately 20 half sandwiches, a single half sandwich, two plastic containers of fruit cocktail, and a container with about 20 cupcakes. Similarly, in the freezer, two large packages of lemon bread were found without dates. Interviews with the Dietary Manager (DM) and Dietary Aide (DA E) revealed that the lack of labeling and dating could lead to serving outdated food, potentially causing residents to become ill. Both the DM and DA E acknowledged that all kitchen staff were responsible for ensuring food items were labeled and dated. The facility's policy on food safety and storage, dated July 2014, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated, which was not followed in this instance.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident's catheter drainage bag was covered, which compromised the resident's dignity and quality of life. The resident, a male with severe cognitive impairment and quadriplegia, was observed on multiple occasions with an uncovered catheter bag containing a small amount of amber liquid. This was noted during observations on two consecutive days, where the catheter bag was hanging from the left side of the resident's bed without a protective cover. Interviews with staff members, including CNAs and the ADON, confirmed that it was the responsibility of all staff to ensure catheter bags were covered to prevent embarrassment and maintain resident dignity. The facility's policy on dignity, dated August 2009, explicitly stated that urinary catheter bags should be covered to promote and enhance the quality of life and respect for residents. The resident himself expressed a preference for having his catheter bag covered, further highlighting the facility's failure to adhere to its own standards and policies regarding resident dignity.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to reposition a resident every two hours as specified in the resident's person-centered care plan. The resident, who is severely cognitively impaired and dependent on staff for all movements, was observed lying in the same position for extended periods, contrary to the care plan's directive for repositioning every two hours. Interviews with the resident and a family member confirmed that repositioning was not occurring as frequently as required, with the family member observing through a camera that the resident was not repositioned every two hours. The Assistant Director of Nursing (ADON) acknowledged that the repositioning was not being done as per the care plan, citing the resident's increased stiffness as a reason, but admitted that if it was documented in the care plan, it should have been followed. Licensed Vocational Nurse (LVN) A confirmed that Certified Nursing Assistants (CNAs) were responsible for repositioning residents and that charge nurses were responsible for ensuring it was done. The facility's repositioning policy, dated May 2013, outlines the importance of repositioning to prevent skin breakdown and promote circulation, which was not adhered to in this case.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, on September 6, 2024, there was no RN on duty, which was confirmed through interviews and record reviews. The absence of an RN on this day was acknowledged by the Assistant Director of Nursing (ADON), the Business Office Manager (BOM), and the Administrator (ADM), who all recognized the potential negative outcomes of not having an RN available. The BOM confirmed that the lack of RN coverage on the specified date was an oversight, and no policy for RN coverage was provided upon request.
Failure to Properly Label and Store Insulin
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to currently accepted professional principles. During an observation and interview, it was found that a vial of Lantus insulin in the treatment cart was opened and lacked an expiration date. Licensed Vocational Nurse (LVN) A confirmed that the insulin expires 28 days after opening, indicating that the vial was expired. LVN A acknowledged that the nurses are responsible for labeling medications with expiration dates and removed the expired insulin for destruction. Further interviews with LVN B and the Assistant Director of Nursing (ADON) revealed a lack of adherence to labeling protocols, as they admitted to not including expiration dates on insulin vials, only the opening dates. The facility's policy on 'Labeling of Medication Containers' and 'Storage of Medications' requires that expiration dates be included when applicable. The ADON noted that the pharmacy had recently reviewed the medication carts but did not address the missing expiration dates, highlighting a gap in the facility's medication management practices.
Failure to Notify Physician and Representative of Resident's Condition
Penalty
Summary
The facility failed to immediately inform a resident's physician and representative of a significant change in the resident's physical status, specifically regarding a facility-acquired Stage IV pressure injury. The resident, a male with multiple diagnoses including primary lateral sclerosis and Parkinson's disease, was admitted with no initial skin integrity issues. However, on a subsequent assessment, open sores with visible tissue deterioration were noted on the resident's inner elbows, but this was not properly documented or communicated to the physician or the resident's representative. The situation was exacerbated by the lack of proper training for CNAs in identifying and reporting skin integrity issues. The CNAs were not specifically trained to look for wounds during showers or rounds, leading to a delay in the detection and reporting of the resident's condition. The resident's protective sleeves, which were supposed to be removed during showers, were not adequately checked, resulting in the oversight of the developing wounds. The miscommunication and documentation errors further delayed appropriate treatment. The LVN responsible for the resident's care misreported the location and nature of the wounds, leading to incorrect treatment with antifungal medications instead of addressing the pressure injury. This miscommunication persisted until the resident was eventually transferred to a hospital for proper evaluation and treatment, revealing the severity of the wounds.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a pressure ulcer, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This deficiency was identified for a resident who developed a facility-acquired Stage IV pressure injury with an exposed tendon. The resident, a male with multiple diagnoses including primary lateral sclerosis and Parkinson's disease, was admitted to the facility with no noted pressure injuries. However, an open area was later discovered on the resident's left antecubital area, which was not initially documented or treated appropriately. Interviews with facility staff revealed that CNAs had not been formally trained to perform thorough skin checks during showers, which contributed to the oversight of the resident's skin condition. The Director of Nursing (DON) and Administrator acknowledged that CNAs were not specifically instructed to check for open wounds or skin deterioration, particularly in areas affected by contractures. This lack of training and oversight led to the failure to identify and address the resident's developing pressure ulcer in a timely manner. The resident's condition worsened, resulting in a hospital admission for cellulitis and treatment with IV antibiotics. The facility's documentation and communication with the resident's physician were inconsistent, leading to a delay in appropriate medical intervention. The physician was initially informed of a rash rather than an open wound, which further delayed the correct treatment. The facility's policies and procedures for pressure ulcer risk assessment and prevention were not effectively implemented, contributing to the resident's deteriorating condition.
Failure to Implement Baseline Care Plan and Proper Transfer Method
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident, which is necessary to provide effective and person-centered care. The resident, a male with quadriplegia and other conditions, was admitted without a completed care plan. The baseline care plan, which was supposed to be completed within 48 hours of admission, was not fully developed, lacking comprehensive instructions for care beyond diet, advance directive, and activities. The deficiency was further compounded when a CNA transferred the resident without using the required mechanical lift, as documented in the baseline care plan. The CNA, who was an agency staff member, lifted the resident manually, despite knowing that the resident required a Hoyer lift for transfers. This action was contrary to the care plan and posed a risk of injury to both the resident and the CNA. Interviews with various staff members revealed inconsistencies in how they determined the appropriate transfer method for residents. Some relied on verbal instructions from nurses, while others checked the care plan on electronic devices. The Director of Nursing and other staff acknowledged the potential for accidents if care plans were not followed, highlighting a lack of adherence to established protocols for resident transfers.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2, who was admitted with multiple diagnoses including primary lateral sclerosis, muscle weakness, and Parkinson's disease. The resident's care plan indicated a need for total assistance with transfers, specifically requiring a two-person assist. However, the care plan lacked measurable objectives and timeframes to meet the resident's needs, as identified in the comprehensive assessment. An incident occurred where CNA D attempted to transfer Resident #2 alone, despite knowing that the resident required a two-person assist. During the transfer, the resident began to slip, and CNA D lowered him to the ground gently. Assistance was then called, and with the help of LVN C and another staff member, Resident #2 was lifted from the floor to the shower chair. Interviews with various staff members, including CNAs and the Director of Nursing, confirmed that Resident #2 was known to require a two-person transfer, and the failure to adhere to this requirement could lead to accidents or injuries. The facility's policies on care plans and departmental supervision emphasize the need for comprehensive, person-centered care plans with measurable objectives and timetables. The Director of Nursing and other supervisory staff are responsible for ensuring that care plans are appropriate and followed. However, in this case, the care plan for Resident #2 was not adequately implemented, leading to a situation where the resident was not transferred according to the specified requirements, potentially placing him at risk of harm.
Failure to Follow Transfer Protocols for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to deficiencies in their care. Resident #1, a male with quadriplegia and other significant health issues, was not transferred using the necessary mechanical lift as required by his baseline care plan. Instead, CNA D, an agency CNA, manually lifted the resident, which was against the care plan instructions. This action was taken despite the resident's inability to get out of bed by himself and his reliance on a Hoyer lift for transfers. The resident expressed feeling unsafe during these transfers, although he did not communicate this to the staff. Resident #2, who has severe cognitive impairment and multiple neurological conditions, was also not transferred according to his care plan, which required a two-person assist. CNA D attempted to transfer Resident #2 alone, resulting in the resident being lowered to the ground when he began to slip. This incident occurred because the CNA was aware of the two-person requirement but proceeded alone due to staff being busy. The resident was later assisted by additional staff to be placed in a shower chair, and no injuries were reported. Interviews with various staff members, including CNAs and the Director of Nursing, revealed inconsistencies in how transfer requirements were communicated and understood. The facility's policies on care plans and departmental supervision were not adequately followed, leading to these deficiencies. The lack of adherence to the care plans posed potential risks of injury to both residents and staff, as acknowledged by the facility's administration.
Failure to Provide RN Coverage on Weekend
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, there was no RN coverage on the weekend of June 1st and June 2nd, 2024. This deficiency was identified through a combination of observation, interviews, and record reviews. The Business Office Manager (BOM) confirmed the absence of RN coverage after reviewing time sheets and finding no records of RN hours for those dates. The Director of Nursing (DON) acknowledged that the lack of RN presence could negatively impact residents, as RNs are responsible for supervising staff and handling issues that Licensed Vocational Nurses (LVNs) cannot manage. Interviews with staff members, including an LVN and the Assistant Director of Nursing (ADON), revealed differing opinions on the impact of not having an RN on duty. The LVN suggested that residents would be sent to the hospital if issues arose that LVNs could not handle, while the ADON downplayed the necessity of RN presence. The Administrator (ADM) admitted responsibility for scheduling and acknowledged the failure to secure RN coverage on the specified dates, noting that RNs have the authority to delegate tasks to LVNs during emergencies. The absence of RN coverage was further corroborated by a facility report showing no RN hours for the weekend in question.
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What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — including the 1 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.
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Nursing homes near Littlefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmonee House | 8.3 mi | ★★★★★ | 1 | 0 |
| Runningwater Draw Care Center Inc | 21.8 mi | ★★★★★ | 6 | 0 |
| Levelland Nursing & Rehabilitation Center | 22 mi | ★★★★★ | 10 | 1 |
| Park View Nursing Care Center | 31.7 mi | ★★★★★ | 24 | 2 |
| The Plaza At Lubbock | 31.9 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.