Arbor Grace Wellness Center
Inspection Findings
F-Tag F0740
F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
be included in the residents' care plan so staff would be aware of what works for the residents when they become agitated or aggressive. In an observation and interview on 12/22/2025 at 11:30 AM, Resident #1 was in the dining room, she was clean and dressed for the day, she appeared calm, walking around in the dining room. Resident #1 did not verbalize any concerns related to her care. In an interview on 12/22/2025 at 1:30 PM, MDS Coord. stated he was responsible for updating the resident's care plan and if he was unavailable, the responsibility would fall to Administration. The MDS Coord. stated Resident #1's care plan was missing her diagnoses, her behavioral diagnosis with the medication management, her aggression and her refusal of care. The MDS Coordinator also stated he missed revising the documentation related to her Depression and the discontinued medication Lexapro. The MDS Coord stated that he did not feel the nursing staff used the care plans to check the status of a resident, it was more for when State would come into the building. The MDS Coordinator, however, said the care plan should reflect the current status of a resident. The MDS Coord. stated the facility does not do morning meetings every morning to relay this information. In an interview on 12/22/25 at 2:45 PM, LVN A stated she was not aware of any specific behavioral interventions for Resident #1 other than redirecting. LVN A stated Resident #1 could be aggressive toward staff or if she wanted something staff had, such as food or a drink, she would grab it from staff. LVN A stated if interventions were not addressed per specific behavior, then a possible negative outcome would be that the behavior could possibly get worse. LVN A stated the MDS Coordinator was responsible for ensuring care plans reflected the resident's status. In an interview on 12/22/2025 at 2:51 PM, the DON stated there were interventions in place for Resident #1, such as medication management and redirection. The DON said the AD was also working with Resident #1 in activities. The DON did not mention walking around the building as an intervention. The DON stated the resident's care plan should reflect the resident's diagnoses, medications and refusal of care and any interventions related to resident's behavior The DON stated the MDS Coordinator was responsible to update care plans with interventions or changes, but she was responsible to ensure it was completed. The DON was not sure what was in the care plan related to interventions related to Resident #1's behaviors. The DON further stated not including information in the care plan could result in a lapse in care for the resident. In an interview on 12/22/2025 at 3:00 PM, the AD said she had not been instructed to work specifically with Resident #1 related to behavioral interventions. The AD, however, said the resident does attend activities with the group. The AD stated that although the resident can be difficult to understand, she felt Resident #1 wanted to be heard, and she had made a point to sit with the resident to listen to her and felt doing that helped the resident. In
an interview on 12/22/2025 at 3:45 PM during the exit conference, the ADM confirmed the care plan should reflect the resident's' status related to her behaviors and interventions and stated their approach was not where it should be with Resident #1. Record review of the facility's policy Behavioral Health Services dated February 2019 reflected the following:The facility will provide, and residents will receive behavioral health services as need to attain or maintain the highest practicable physical, mental and psychosocial wellbeing
in accordance with eh comprehensive assessment and plan of care. Staff training regarding behavioral health services includes, but is not limited to:Recognizing changes in behavior and indicate psychological distress.Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs.Monitoring care plan interventions and reporting changes in condition.
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ARBOR GRACE WELLNESS CENTER in LITTLEFIELD, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LITTLEFIELD, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ARBOR GRACE WELLNESS CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.