Arbor Grace Guest Care Center

Penalties

• Apr 29, 2026 — Fine ($187,096)

Inspection findings

1. Jun 17, 2026 Health · 12 findings
   • Not serious Scope/severity D Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Jun 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity B

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

2. Apr 29, 2026 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 1, 2026 · CMS health inspection

3. Apr 2, 2025 Health · 8 findings
   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 23, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Apr 23, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Apr 23, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 23, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 23, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 23, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 23, 2025 · CMS fire safety

4. Mar 20, 2024 Health · 8 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 10, 2024 · CMS fire safety

   • Not serious Scope/severity B

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 10, 2024 · CMS fire safety

   • Not serious Scope/severity B

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

5. Feb 29, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 1, 2024 · CMS health inspection

6. Feb 23, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Feb 24, 2024 · CMS health inspection

7. Nov 20, 2023 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Nov 21, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Nov 21, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0809 Nutrition and Dietary Deficiencies

     Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

     Corrected Nov 21, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• GAMBLE, DENNY — operational/managerial control, NOT APPLICABLE, since 06/01/2023
• HOOPER, GRADY — corporate officer, NOT APPLICABLE, since 06/01/2023
• KEGARISE, BRANDON — operational/managerial control, NOT APPLICABLE, since 02/27/2023
• KEGARISE, BRANDON — adp of the snf, NOT APPLICABLE, since 02/27/2023
• MACHEN, MATT — operational/managerial control, NOT APPLICABLE, since 06/01/2023
• SHEN, HONG-I — operational/managerial control, NOT APPLICABLE, since 06/01/2023
• SHEN, HONG-I — adp of the snf, NOT APPLICABLE, since 06/01/2023
• GAMVEST TEXAS LLC — adp of the snf, NOT APPLICABLE, since 06/01/2023
• K-J-K VENTURE, LLC — adp of the snf, NOT APPLICABLE, since 06/01/2023
• MACHEN HEALTH MANAGEMENT LLC — adp of the snf, NOT APPLICABLE, since 06/01/2023
• MPD ACQUISITION OF KILGORE, LLC — adp of the snf, NOT APPLICABLE, since 06/01/2023
• MPD ACQUISITION OF KILGORE, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 06/01/2023
• MPD TEXAS RESOURCES OF KILGORE LLC — operational/managerial control, NOT APPLICABLE, since 06/01/2023
• MPD TEXAS RESOURCES OF KILGORE LLC — adp of the snf, NOT APPLICABLE, since 04/29/2025