Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0732
Post nurse staffing information every day.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to post the facility Daily Staffing Report
daily and, in an area, visible to all residents and visitors. This failure has the potential to affect all 58
residents residing in the facility.
Residents Affected - Many
Findings include:
The facility's Midnight Census report, dated 11/6/24, documents there are currently 58 residents residing in
the facility.
On 11/6/24 at 8:35 am, the facility's Nurse Staffing posting was located near the Receptionist desk, on the
wall, behind a portable stand that held instructions for visitors to sign in on the facility's visitor log. This
posting is not easily visible to staff, residents, or visitors. This Nurse Staffing posting was last completed on
10/29/24.
On 11/8/24 at 10:20 am, 10:22 am, 10:24 am, and 10:25 am, R2, R9, R10, and R12 respectively stated
they do not know where the Nursing Staff posting is located.
On 11/6/24 at 9:12 am, V2 DON (Director of Nursing) walked with this writer to the Receptionist desk and
confirmed the location of the Nurse Staffing posting on the wall behind a portable stand and confirmed it
had not been completed since 10/29/24 and should have been. V2 DON stated V13 CNA Scheduler usually
fills it out. V2 DON did not move the portable sign to enable visibility of the staff posting.
On 11/7/24 at 3:20 pm, V1 Interim Administrator accompanied writer to the Receptionist desk and
confirmed the Nurse Staff posting is not easily visible to residents, visitors, or staff due to being on the wall
behind a portable sign and stated should be completed or updated daily.
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:
145319
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
145319
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arc at El Paso
555 East Clay
El Paso, IL 61738
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)
F 0851
Level of Harm - Minimal harm
or potential for actual harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on observation, interview, and record review the facility failed to accurately report the PBJ (pay-roll
based journal) staffing information. This failure affects all 58 residing in the facility.
Residents Affected - Many
Findings include:
The facility's PBJ (pay-roll based journal) Staffing Data Report, fiscal year Quarter 3 2024, dated April 1
through June 30, 2024, documents Excessively Low Weekend Staffing was triggered due to facility
submission of excessively low staffing worked on the weekends.
The facility's Midnight Census report, dated 11/6/24, documents there are currently 58 residents residing in
the facility.
On 11/6/24 and 11/7/24 at 7:30 am through 4:00 pm, there were six CNAs (Certified Nursing Assistants),
two RNs (Registered Nurses) and one LPN (Licensed Practical Nurse) working on the day shift.
On 11/6/24 at 11:05 am and 11:21 am, and on 11/7/24 at 7:45 am and 9:40 am R2, R10, R6 and R9
respectively stated the facility has two to three CNAs and a Nurse for each hallway in the facility and their
needs are being met.
On 11/8/24 at 8:30 am, R12 stated she is the President of Resident Council, and no one has complained
about the staff or the staffing during the meetings.
On 11/6/24 at 8:05 am, 8:16 am, 8:30 am, and 11:05 am, V10, V11, V12, V13 and V17 CNAs respectively
stated the facility is staffed with six CNAs on the day and evening shifts and four on the midnight shift. V10
through V13 and V17 CNAs stated they feel there is enough staff and can complete their work assignments
daily and Nurses help when needed.
On 11/6/24 at 11:00 am, V6 RN and V8 LPN respectively stated there are three Nurses and five to six
CNAs on the day shift, two Nurses and six CNAs on evening shift, and one Nurse and four CNAs on the
midnight shift. V6 RN and V8 LPN stated the staff can get their work done daily and that everyone helps
when needed.
On 11/7/24 at 9:10 am, and 9:30 am, V4 SSD and V5 Activity Director respectively stated the facility has
adequate staffing and they assist when needed.
On 11/7/24 at 3:15 pm, V1 Interim Administrator stated the facility census is at 58 and normally stays
consistent between 55 to 60. The staffing is based on the facility census and acuity of care. The staffing
hours are submitted to the RDO (Regional Director of Operations), RDO uses a calculator, and we adjust
the staffing accordingly.
On 11/7/24 at 3:00 pm, V3 VP (Vice President) of Clinical Operations and V1 Interim Administrator provided
staff timecard reports for April through June 2024 and stated the facility reports show there was adequate
staffing on the weekends during the third quarter. V3 VP of Clinical Operations stated she did some
investigating regarding the facility's PBJ staffing numbers, compared the staff timecard reports to the daily
schedules, and can only concluded she believes V24 Former Administrator did
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145319
If continuation sheet
Page 2 of 3
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
145319
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arc at El Paso
555 East Clay
El Paso, IL 61738
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)
F 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
not report the use of the Agency Nurses and CNAs during that quarter. V3 also stated the management
staff are salary, but when they cover a shift or work other than their job, they are to punch the time clock
which would post their hours for the PBJ reporting and the management staff have not been doing this, so
their hours worked are not being counted.
On 11/8/24 at 11:00 am, V3 VP of Clinical Operations provided facility timecard reports and Agency staff
hours worked for the weekends of 10/12/24, 10/13/24, 10/19/24, and 10/20/24 and stated V24 Former
Administrator was not including the Agency Nurses and CNAs in the total hours when submitting the hours
for the PBJ staffing information. V3 VP of Clinical Operations reviewed hours with this writer and stated the
facility had greater totals of staff than what was reported. V3 stated the staffing hours will be reported
correctly from here on out and the next quarter will reflect accurate information for the facility's PBJ report.
Event ID:
Facility ID:
145319
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
FAQ · About this visit
Common questions about this visit
What happened during the November 8, 2024 survey of ARC AT EL PASO?
This was a inspection survey of ARC AT EL PASO on November 8, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARC AT EL PASO on November 8, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Post nurse staffing information every day."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.