Health inspection·February 28, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made for 1 of 5 residents (Resident #1) reviewed for abuse. ADM failed to report an allegation of abuse with Resident #1 to the appropriate State Agency. This failure can result in continued or escalation of abuse, mental anguish, and/or physical harm. Findings Include: Record review of Resident #1's face sheet, dated 2/28/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses include but were not limited to chronic obstructive pulmonary disease (COPD- chronic inflammatory lung disease that obstructs airflow from the lungs), major depressive disorder (persistent feeling of sadness and loss of interest), polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body), and morbid (severe) obesity (BMI of 40 or more). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 15 indicating intact cognitive response. Resident is maximum assist or dependent on activities of daily living including bathing, toileting, personal hygiene, oral care, and all mobiliity measures including rolling, sitting, and transfers. MDS stated resident does require the use of a mechanical lift. Record review of grievance resolution form, dated 12/29/23, revealed ADON received a grievance from Resident #1 regarding CNA A and CNA B being rough with her during a transfer. Resident #1 reported she verbalized CNA A and CNA B was hurting her when CNA A stated, you're just trippin. Record stated the actions upset the resident to the point of crying. Record review of TULIP on 2/27/24 reflected no report made of the incident that occurred on 12/29/24 involving Resident #1. In an interview on 2/27/24 at 4:50 PM, ADM stated there was not a provider investigation report and she did not report the allegation. ADM stated it was reported as being rough and it could be considered abuse. ADM stated the facility could get cited and there could have been some negative outcomes. In an interview on 2/27/24 at 4:50 PM, Resident #1 stated she told a nurse about the incident, and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675978 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)