Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Grace Guest Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia, severe cognitive impairment, and total dependence for ADLs fell from bed during incontinent care when a CNA turned her to the side and then released her to pick up supplies, allowing her to roll off the bed. Video showed the CNA first attempting to lift the resident by her arms and then, with two LVNs, manually lifting her from the floor by shoulders and knees back into bed, despite a care plan requiring a Hoyer lift with two staff for transfers and without a thorough on-floor injury assessment. Nursing documentation reported no injuries initially, but photos and video over subsequent days showed progressive swelling and discoloration of the right lower leg and foot, while hospice notes and staff conversations reflected pain behaviors that were not consistently reported or acted upon. A later nursing assessment documented edema, warmth, and discoloration, leading to hospice notification, an x-ray order, and diagnosis of tibia and fibula fractures about a week after the fall. Facility policies required comprehensive post-fall assessment, monitoring for delayed complications, and CNA reporting of subtle changes, but interviews and records showed incomplete assessments, missed or unreported skin and pain changes, and failure to follow the resident’s transfer and bed mobility care plan, forming the basis of the cited deficiency.
Multiple staff failed to follow infection prevention protocols during direct care, including not changing gloves or performing hand hygiene between dirty and clean procedures, not donning gowns or PPE when required for residents on enhanced barrier precautions, and touching clean items with contaminated gloves. These lapses occurred during wound care, catheter care, PEG tube medication administration, and incontinent care for residents with complex medical needs.
A resident with cognitive and vision impairments, requiring maximal assistance, was found with a bottle of isopropyl rubbing alcohol on his bedside table on multiple occasions. Staff interviews confirmed that such items are prohibited in resident rooms due to safety risks, and facility policy restricts access to hazardous chemicals. The presence of the rubbing alcohol indicated a failure to ensure a hazard-free environment and adequate supervision.
A resident with a suprapubic catheter and moderate cognitive impairment did not have a required catheter securement device in place, despite medical orders and care plan interventions specifying its use. Nursing staff and facility leadership confirmed the expectation for the device to be present at all times to prevent catheter movement and infection, but it was not observed during care, constituting a deficiency in catheter management.
A resident's insulin was found improperly stored in a cabinet instead of a refrigerator, with one bottle expired and used, and two unopened. Staff confirmed the insulin, brought from home, should have been refrigerated, disposed of, or returned to the family if not used. Facility policy requires proper storage and disposal, which was not followed in this instance.
Failure to Perform Adequate Post-Fall Assessment and Safe Transfer, Resulting in Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards of practice for one resident following a fall from bed during incontinent care. The resident was an elderly female with hemiplegia, severe cognitive impairment (BIMS score of 03), COPD, and convulsions, who was totally dependent on staff for transfers, bed mobility, and hygiene, and care planned to require a Hoyer lift with two staff for transfers. On the day of the incident, a CNA turned the resident onto her right side for incontinent care, then let go of the resident to pick up supplies from the floor. Video footage showed that, after the CNA released her, the resident rolled off the bed and onto the floor. The CNA then climbed across the bed and attempted to lift the resident by her arms to put her back in bed, was unable to do so, and lowered her back to the floor before calling for a nurse. Video footage and staff interviews showed that when two LVNs entered the room, the resident was still on the floor. One LVN placed a pillow under the resident’s head, and when the third nurse (the LVN who later documented the incident) arrived, the two LVNs and the CNA lifted the resident from the floor by her shoulders and knees and placed her back in bed, despite the resident being care planned for Hoyer lift transfers. The video showed that this was done without a proper assessment for injury while the resident was still on the floor. The documenting LVN’s progress note stated that the resident was checked for injuries and none were noted except blanchable redness on the right arm, and that the resident was assisted back to bed by two staff. However, the video evidence and subsequent interviews indicated that the assessment was cursory, that the resident was manually lifted contrary to her care plan, and that the nurse later acknowledged her assessment was not appropriate and that a Hoyer lift should have been used. In the days following the fall, multiple opportunities to identify and respond to signs of injury were missed. Hospice notes on two separate visits documented mild pain using the PAINAD scale, and the resident was noted to be at high risk for falls. A skin assessment completed several days after the fall documented no alterations in skin integrity, despite later photographic and video evidence showing progressive swelling and discoloration of the right lower leg and foot beginning shortly after the fall. Pictures and video from the resident’s room over several days showed swelling and yellow discoloration of the right lower leg and foot, and staff were heard discussing the resident’s facial grimacing as a sign of pain. CNAs later reported that they either did not notice or did not report the swelling, discoloration, or bruising, and one CNA acknowledged seeing bruising on the resident’s upper arm but not reporting it. Nursing notes eventually documented edema, warmth, discoloration, and pain responses in the right lower extremity, leading to hospice notification, an x-ray order, and the discovery of minimally displaced fractures of the distal tibia and mid fibula approximately one week after the fall. The facility’s own falls and acute change policies required thorough post-fall assessment, monitoring for delayed complications such as late fractures, and CNA reporting of subtle changes, but interviews and records showed that these assessments and communications were not consistently carried out for this resident. The deficiency also included failures related to care planning and communication of the resident’s care needs for bed mobility and incontinent care. The resident’s care plan identified total assistance needs for ADLs and the requirement for a Hoyer lift with two staff for transfers, but the actual care provided during and after the fall did not follow these directives. The CNA performed incontinent care without ensuring the resident was safely positioned in the middle of the bed and with supplies within reach, then left the resident unsupported on her side, resulting in the fall. After the fall, staff manually lifted the resident from the floor to the bed instead of using a Hoyer lift, despite being aware of her transfer status. Several staff, including the DON and Medical Director, acknowledged in interviews that they had not fully reviewed or acted upon video evidence or early signs of injury, and the Medical Director stated he had not been notified of increased pain, swelling, or discoloration in time to order earlier diagnostic testing. These combined actions and inactions led surveyors to identify an Immediate Jeopardy situation related to failure to assess for injury after the fall, failure to address bed mobility and incontinent care needs, and failure to transfer the resident back to bed using the required Hoyer lift. The facility’s own policies on falls and acute condition changes required nurses to assess vital signs, musculoskeletal function, neurological status, cognition, and pain after a fall, and to monitor for delayed complications such as late fractures and major bruising. Policies also required that direct care staff be trained to recognize and report subtle but significant changes, such as changes in skin color or condition. Despite these policies, the record and interviews showed that the resident’s post-fall assessments were incomplete, that weekly and ongoing skin assessments did not capture obvious swelling and discoloration documented in photos and video, and that CNAs did not consistently report observed or suspected pain, bruising, or changes in the resident’s condition to nursing staff. The combination of improper handling during and after the fall, failure to follow the resident’s care plan for transfers and bed mobility, and failure to recognize and act on evolving signs of injury over several days formed the basis of the cited deficiency. Additionally, the report documents that video evidence of the fall and subsequent handling was available to certain staff members but was not promptly escalated to facility leadership. A family member stated that video footage of the fall was sent to the documenting LVN on the day of the incident, and that she believed there was no other incident that could have caused the fractures. The ADON reported seeing only a brief portion of the video days later and stated that, had she seen all of it, she would have terminated the CNA at that time. The hospice RN reported showing the video to the DON several days after the fall, and the DON acknowledged reviewing the video but not reporting what she saw to the Administrator. The Administrator and Medical Director both stated they had not seen the videos until they were reviewed with the surveyor. This failure to fully review and act upon available video evidence contributed to delays in recognizing the severity of the incident and in addressing the resident’s injuries and care needs. The surveyors concluded that the facility failed in three key areas for this resident: assessing for injury following the fall from bed during incontinent care, addressing care needs for bed mobility and incontinent care in accordance with the care plan, and transferring the resident back to bed using a Hoyer lift as required. These failures were supported by video footage, interviews, and record review, including documentation of delayed recognition of swelling, discoloration, and pain in the right lower extremity, and the eventual diagnosis of tibia and fibula fractures one week after the fall. The Immediate Jeopardy was identified based on these findings, and although it was later removed, the facility remained out of compliance at a lower scope and severity because not all staff had been trained on key assessment and reporting processes at the time of the survey. The nursing home is disputing this citation, and the Medical Director stated he could not determine how the fractures occurred. However, the family member who reviewed all video footage from the date of the fall through the date of diagnosis reported that there was no other incident that would have caused the fractures. The survey findings relied on the combination of video evidence, staff statements, medical records, and facility policies to support the conclusion that the resident did not receive care and services in accordance with professional standards of practice in the areas of post-fall assessment, adherence to transfer and mobility care plans, and recognition and reporting of changes in condition following the fall.
Infection Control Lapses During Resident Care Activities
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for four residents, as observed during direct care activities. In one instance, a treatment nurse did not change gloves or perform hand hygiene appropriately while providing wound care to a male resident with a stage 4 pressure ulcer, diabetes, and heart failure. The nurse touched clean supplies, the resident’s brief, blanket, and bed controls with contaminated gloves, and did not sanitize her hands after glove removal. Interviews with the nurse and facility leadership confirmed that glove changes and hand hygiene were required between dirty and clean procedures, and that these steps were not followed during the observed care. Another deficiency was observed when an LVN provided catheter care to a female resident with a suprapubic catheter and Alzheimer’s disease, who was on enhanced barrier precautions. The LVN did not don a gown before performing the procedure, despite signage and care plan instructions indicating the need for enhanced barrier precautions. The LVN and facility leadership acknowledged that a gown should have been worn to protect the resident from infection, especially given the presence of a medical device. Additional lapses included an LVN failing to apply PPE while administering medications via a PEG tube to a female resident on enhanced barrier precautions, and a CNA not changing gloves or sanitizing hands after performing incontinent care before applying a clean brief to a female resident with dementia and chronic conditions. Both staff members admitted to missing required infection control steps, and interviews with other staff and leadership confirmed that proper PPE use and hand hygiene were expected during these care activities. Facility policies reviewed supported the need for these infection control measures.
Failure to Prevent Access to Prohibited Hazardous Item
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including Amyotrophic Lateral Sclerosis, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes, was found to have a bottle of isopropyl rubbing alcohol on his bedside table during two separate observations. The resident had mild cognitive impairment, required maximal assistance for all activities of daily living, and had moderately impaired vision. Despite these vulnerabilities, the prohibited item remained in the resident's room, accessible and unsecured. Interviews with facility staff, including an LVN, the Director of Nurses, and the Administrator, confirmed that rubbing alcohol is a prohibited item in resident rooms due to the risk of ingestion and potential harm. Facility policy also prohibits access to toxic chemicals and hazardous items in resident environments. The presence of the isopropyl alcohol in the resident's room demonstrated a failure by staff to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Ensure Catheter Securement Device for Resident with Suprapubic Catheter
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and Alzheimer's disease, who had an indwelling suprapubic catheter, did not have a catheter securement device in place as required. The resident's medical orders and care plan specified the use of a catheter securement device to be checked and maintained every shift to prevent complications, including urinary tract infections. During an observation, it was noted that the resident did not have the securement device in place prior to catheter care being provided by an LVN. Interviews with nursing staff, the ADON, DON, and the Administrator confirmed that the securement device was expected to be in place at all times to prevent catheter movement, pulling, and potential infection. The facility's policy also required the catheter to be secured with a device to reduce friction and movement at the insertion site. The failure to ensure the securement device was in place represented a lapse in following physician orders, care plan interventions, and facility policy for catheter care.
Improper Storage and Disposal of Insulin
Penalty
Summary
The facility failed to ensure proper storage and disposal of insulin for one resident with type 2 diabetes mellitus, muscle weakness, severe protein calorie malnutrition, and chronic kidney disease. During an observation, three bottles of insulin labeled for the resident were found in a cabinet, with one bottle showing an expired date and evidence of use. Two of the bottles were unopened, and none were stored in the refrigerator as required for unused insulin. Staff interviews confirmed that insulin should be refrigerated until opened and that improper storage could render the medication ineffective. The insulin in question was brought from the resident's home and was used by the facility until pharmacy-supplied medication arrived. Staff acknowledged that the insulin should have been either refrigerated, disposed of, or returned to the family if not used. The facility's policy requires all medications to be stored in locked compartments under proper temperature controls, with medications requiring refrigeration to be kept in a designated refrigerator. The improper storage and failure to dispose of expired insulin were confirmed through staff interviews and review of facility policy.
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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 Kilgore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Rehab & Nursing | 0.7 mi | — | 7 | 0 |
| Avir At Overton | 8.2 mi | — | 18 | 0 |
| Pine Tree Lodge Nursing Center | 12.4 mi | — | 17 | 2 |
| Highland Pines Nursing Home | 12.8 mi | — | 10 | 0 |
| Truman W Smith Children's Care Center | 13.6 mi | — | 5 | 0 |
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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 August 2026) and official state health department websites.