Arbor Grace Wellness Center

During observation with the ADM there was no sign posted at the front door area and no survey binder available in the receptionist office. He stated his expectations were for proper signage to be always posted and survey binder available. He stated the potential negative outcome would be violation of resident rights. On 02/26/2026 at 11:44 a.m. surveyor requested policy related to posting and availability of State Agency (SA) survey inspection results such as (surveys, certifications, and complaint/incident investigations).

During an interview on 2/26/26 at 4:00 p.m. the ADM stated they followed the Federal Regulations requirements for any policies not provided.

Findings included: Interviews during an undisclosed date and time, 11 confidential residents stated they did not have access to the Grievance form, they did not know they could file a grievance anonymously, the grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the grievance procedure in prominent locations.

The confidential Residents also said they did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed.

Record review of the facility Grievance policy revised date 12/2023; revealed the facility's grievance information should be posted in designated locations throughout the facility.

Observation of prominent postings on 02/25/2026 at 03:20 p.m., observed the front door area, area around the nurses' station, area down halls A, B, C and D, no observation of grievance information found. No observed grievance forms were available, and there was no access to submit grievances anonymously.

During an interview on 02/25/2026 at 03:30 p.m. with AD, she stated the SW keeps grievance forms in her office.

She stated SW was not at the facility full-time.

She stated the residents would let her know if they have a grievance and they would write them for them.

She stated the residents do not have access to blank grievance forms.

During an interview on 02/26/2026 at 09:32 a.m. with ADM, he stated the SW was responsible for grievance forms. He stated the SW resigned on 02/23/2026. He stated he was not aware there were no forms available for residents to file a grievance anonymously. He stated his expectations were for forms to be available to residents. He stated staff have been trained in grievance forms. He stated the potential negative outcome could be violation of resident rights.

Record Review Grievance Policy revised date 12/2023 revealed the following: Policy Statement:It is the policy of the facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agencies/entity without fear of discrimination or reprisal.

Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay.

The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have.Procedure: .2.

Information is made available to the resident and/or representative and posted in designated locations throughout the facility.

Information includes:Resident/resident representative have the right to file grievance orally, in writing and/or anonymously.

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339

During an interview on 02/26/26 at 12:53 PM, the ADM stated he was not aware that Resident #46 had significant weight loss until annual survey. He stated nursing staff and nursing administration were responsible for ensuring weights are monitored and timely notifications of significant weight changes are made to physicians and the RD.

The ADM stated his expectation of staff was to monitor resident weight and make timely notification of changes to physicians because it can really affect a resident.

The ADM stated a potential negative outcome for failure to monitor resident weight and make timely interventions for significant changes would depend on the diagnosis, but it could cause medical issues.

Record review of the facility's undated policy titled, Policy/Procedure - Nursing Clinical reflected the following: Section: Care and Treatment Subject: Nutrition: Weight Management Policy: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible.

Purpose: To provide care and services including: Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status.

Implementation of orders as written by the Doctor Clinical Evaluation: 1.

Nutritional assessment may include: Weighing and weight changes 2.

The Nurse will notify physician, family, and/or resident of weight loss/gain with interventions.

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339

Based on observation, interview and record review, the facility failed to ensure all drugs and

medication cart (Hall D medication cart) reviewed for storage of drugs.The Facility failed to provide change direction labels for Resident #15's medication package of hydroxyzine (hydroxyzine is an antihistamine that reduces symptoms caused by allergies) which had medication order change from as needed every 6 hours to 10 mg twice a day.

This failure could place residents at risk of medication misuse and diversion.The findings were:

Record review of Resident #15's physician orders, dated 02/26/2026, revealed an order for hydroxyzine 10 mg give 1 tab by mouth twice a day with a start date of 01/29/2026 and no end date.

Observation on 02/25/2026 at 08:32 a.m. revealed a package in the Hall D medication cart contained medication for Resident #15 with a label for 10 mg of hydroxyzine, and instructions to give 1 tab by mouth every 6 hours as needed. MA administered 10 mg of hydroxyzine to Resident #15.

During an interview on 02/26/2026 at 09:08 a.m. the MA B stated she was aware Resident #15 hydroxyzine medication was changed from as needed to twice a day.

She stated the process when medication order change was to place a label change sticker on the top of the medication blister pack until the new medication blister pack was received from pharmacy.

She stated she was not sure why the sticker was not put on the blister pack.

She stated she had been trained in medication changes.

She stated the potential negative outcome could be resident not getting the medication as ordered.

During an interview on 02/26/2026 at 09:10 a.m. LVN A stated when medication orders were changed, they notify the MA and remind them to place a medication change sticker on the medication blister pack.

She stated she had been trained in medication order changes.

She stated the potential negative outcome could be the resident getting the wrong medication dose.

During an interview on 02/26/2026 at 09:23 a.m. the DON stated the process for medication order changes was there should be a sticker on blister pack and notifying the pharmacy.

She stated all staff have been trained in medication order changes.

She stated all nurses and MA were responsible for making sure a sticker was placed on the medication blister pack when the medication order has changed.

She stated her expectations would be that once they have a new medication order, they address it with MA so the sticker can be placed on blister pack at that time.

She stated the potential negative outcome could be over dosage or under dosage.

During an interview on 02/26/2026 at 09:32 a.m. the ADM stated he was not aware Resident #15 medication label was wrong. He stated he was not sure what the process was and would have to talk with his DON. He stated his expectation was for the nurses to be following the facility policy and keeping the residents safe. He stated the DON, ADON and pharmacy consultant were responsible for monitoring medication order changes. He stated the potential negative outcome were lots of variables. On 02/26/2026 at 11:44 a.m. surveyor requested policy related to medication order changes and medication label changes from ADM.

During an interview on 2/26/26 at 4:00 p.m. the ADM stated they followed the Federal Regulations requirements for any policies not provided.

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339

Based on a facility's reasonable efforts, menus should reflect the religious, cultural, and ethnic needs of the population served, as well as input received from individuals and groups.

Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. 6.

Temporary changes in the menu will be noted on the menu substitution sheets and posted so that facility staff is aware of changes.

The Registered Dietician Nutritionist or designee will approve all permanent menu changes.

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339

During an interview on 2/26/26 at 2:28 PM, the ADM stated he was not aware the refrigerators were not cooling to the appropriate temperature as he was recently hired and had not had a chance to go into the kitchen and inspect it for any concerns. He stated the DS also just started working at the facility last week. He stated he was not aware of any issues going on in the kitchen.

He stated he would provide resources for staff and monitor issues in the kitchen more closely. He stated the kitchen staff had not been in-serviced on kitchen related topics the kitchen since he started employment. He stated the DS would be responsible to ensure kitchen staff were trained. He stated he would meet with the DS and staff to see where they are and provide them with proper training because he was not aware if they were trained properly. He stated cold food temperature issues could have caused sickness. He stated clean dishes should have been stored face down because they could have standing water that could grow bacteria.

During an interview on 2/26/26 at 4:00 PM, the ADM stated they followed the Federal Regulations requirements for any policies not provided.

Record review of the facility's policy titled Dietary Services, Subject: Food Sanitary Conditions for, undated, revealed in part: Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by Federal, State, and/or local authorities.

Procedures:1.

The facility will store, prepare, distribute, and serve food under sanitary conditions.2.

Hot foods will leave the kitchen (or steam table) above 135 F and cold foods at or below41 F.5.

Refrigerator temperatures should be at 41 F or below.7.

Toxic items (i.e., insecticides, detergent, and polishes) will be properly stored, labeled, and used separately from the food.

Record review of the facility's policy titled Dietary, undated, revealed in part: Policy Statement: The facility shall ensure that all food service operations comply with applicable state and federal regulations, including those set forth by Texas Health and Human Services Commission (HHSC) and Centers for Medicare & Medicaid Services (CMS), to protect residents from foodborne illness and ensure nutritional adequacy.

Scope: This policy applies to all dietary, nursing, and supervisory staff involved in food handling, preparation, service, and storage.

Procedures1.

Dish and Utensil StoragePolicy: All clean dishes, utensils, and food-contact equipment shall be stored in a sanitary manner to prevent contamination.Procedure:-Store clean dishes and utensils covered or inverted in designated clean storage areas.-Keep storage shelves at least 6 inches off the floor.-Separate clean items from soiled items at all times.-Air-dry dishes; do not towel-dry.-Inspect storage areas daily for cleanliness, dust, pests, or moisture.-Remove chipped, cracked, or damaged dishes from service immediately.2.

Expired Food ControlPolicy: The facility shall not store, prepare, or serve expired, spoiled, or unsafe food.Procedure:All food items must be clearly labeled with:-Date received or prepared-Use-by or expiration dateImmediately discard:-Expired food-Food with signs of spoilage (odor, mold, discoloration)-Food from compromised packaging (swollen cans, broken seals).

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339

Findings included:

Record review of the admission record for Resident #52 undated, revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: sepsis (infection which can result in widespread inflammation and damage to vital organs), epilepsy (seizure disorder), diabetes (high blood sugar) and quadriplegia (partial or complete loss of function in all four limbs and torso).

During an observation on 0/24/2026 at 04:46p.m., LVN C was preparing G-Tube medications for Resident #52 at the medication cart located in the hallway outside of the resident's door.

Observation of the PPE cart located beside Resident #52's door revealed an EBP sign above the cart. LVN C put on PPE (gown and gloves), gathered supplies off top of cart and entered Resident #52's room. LVN C put supplies and medications on the bedside table. LVNC determined she was missing a medication and she picked up medications off bedside table, removed PPE and exited Resident #52's room. LVN C did not wash her hands after removing PPE.

During an interview on 02/24/2026 at 05:18 p.m., LVN C stated she was aware she did not wash her hand or use ABHR after removing PPE.

She stated she should have washed her hands after removing PPE but she forgot.

She stated she had been trained on proper hand hygiene and to wash hands after removing PPE.

She stated the potential negative outcome could be spreading infection.

During an interview on 02/26/2026 at 09:23 a.m., the DON stated staff should wash their hands after removing PPE.

She stated all staff were responsible for following proper hand hygiene.

She stated all staff have been trained in proper hand hygiene and PPE.

She stated she expects all staff to wash hands or use ABHR after removing gloves.

She stated the potential negative outcome could be spread of infection and cross contamination.

During an interview on 02/26/2026 at 09:32 a.m., the ADM stated he was not aware staff were not washing hands or using ABHR after removing gloves. He stated all staff had been trained on proper hand hygiene. He stated staff should be washing hands or using ABHR after removing gloves. He stated the potential negative outcome could be possible cross contamination and infection control.

Record review of the facility policy titled, Handwashing/Hand Hygiene, with a revised date of 10/2022 reflected the following: Policy Statement: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards.

Purpose:Hand hygiene is one of the most effective measures to prevent the spread of infection.Procedure: .2.

Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m.

After removing gloves; .

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339

During an interview on 2/26/26 at 10:13 AM, the ADM stated there was no one to his knowledge that

regarding the new smoking policy that was implemented when the new company took over the facility.

During an interview on 2/26/26 at 12:45 PM, the Driver stated she supervised the 2:00 PM smoking breaks for residents.

The Driver stated Resident #29 kept his smoking materials including cigarettes and lighters in his room.

She stated Resident #29 kept his cigarettes and lighter in an empty deodorant container on his person when he brought them outside to smoke.

She stated Resident #29 was able to light his own cigarette and smoke independently.

She stated she previously was told by a nurse that no one was supposed to have smoking materials in their room.

She stated she had gotten another resident to voluntarily hand over their lighter recently.

She stated she had not asked Resident #29 for his smoking materials because he had always smoked on his own.

The Driver stated she told some nurses that Resident #29 had smoking materials in their room after the new policy was implemented when the new company took over the facility.

The Driver stated she could not recall what nurses she told.

She stated she was not given any additional instructions after reporting the information to the nurses.

She stated Resident #29 could be difficult at times.

The Driver stated she had not received training on the new smoking policy since the switch over to the new company.

The Driver stated Resident #29's family buys his smoking materials.

She stated other residents' smoking materials were locked in the medication room.

The Driver stated a potential negative outcome was that someone could accidentally set a fire, burn the facility down, an oxygen tank could explode, or a resident could get burned.

The Driver stated someone else could get ahold of the smoking materials and have an accident.

During an interview on 2/26/26 at 2:47 PM, the ADM stated residents were not allowed to keep smoking materials including lighters in their rooms and that all smoking materials must be kept at the nurse's station.

The ADM stated the current smoking policy was implemented on 2/1/26 when the new company took over the facility.

The ADM stated all residents that smoked reviewed the new policy and signed the agreement.

The ADM stated he was not aware there were residents who kept smoking materials in their rooms.

The ADM stated he would continue to educate residents about how smoking materials were safety hazards and fire hazards however he could not confiscate the smoking materials against their will due to resident rights.

The ADM stated all staff had been in-serviced on the new smoking policy during morning meetings.

The ADM stated he expected staff to tell him or the DON if they were to become aware of any residents that kept smoking materials in their rooms so they could educate the residents.

The ADM stated potential negative outcome was that it was a fire hazard.

Record review of the facility' policy titled Smoking and Safety Measures, original date March 2008 reflected the following in part: Safety Measures: .

• All smoking materials, charging devices and charging of electronic cigarettes will be secured at the

nurse's station when not in use during designated smoking times.

675978 02/26/2026

Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339