Arbor Grace Wellness Center
ARBOR GRACE WELLNESS CENTER in LITTLEFIELD, TX — inspection on December 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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