Health inspection·May 22, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #7) of 5 residents reviewed for accidents hazards. -The facility failed to ensure that Resident #7's fall mat was positioned bedside while resident was lying in bed. This failure could place residents at risk of falls and/or injuries. Findings included: Review of Resident #7's face sheet dated 05/22/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity (blood clot forms in one or more of the deep veins in the body, usually in the legs), hypotension (low blood pressure which can cause fainting or dizziness because the brains does not receive enough blood), dementia (group of thinking and social symptoms that interferes with daily functioning), anxiety (feeling or worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), insomnia (persistent problems falling and staying asleep), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of Resident #7's quarterly MDS dated [DATE], revealed Resident #7 had a BIMS score of 08 indicating moderate cognitive impairment. Section J - Health Conditions revealed resident had falls in the last month, last 2-6 months and since admission with no injury. Review of Resident #7's Care Plan dated 03/22/2024, revealed category of Falls with goal reading Patient will be free of injuries; and approach instructions reading fall mattress to reduce the severity of injuries if resident falls from the bed. Record review of Resident #7's Morse Fall Scale assessment dated [DATE], revealed resident was high risk for falls. Record review of Resident #7's progress notes dated 05/11/2024, reads that nurse heard resident calling out and upon entering the room the resident was found lying half on the floor mat and half on the floor. No visual injuries noted, and resident denied any pain or hitting head. Neuro checks were initiated. Page 1 of 5 676283 676283 05/22/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and observation on 05/22/2024 at 11:15 a.m., Resident #7 was observed lying in bed in the lowest position. There was a floor mat that was folded and leaning against an unoccupied bed in the room. Resident #7 said he had fallen a couple of times while at the facility. Resident #7 said that the falls occurred while he was outside picking up branches. Resident #7 said he did not remember when the falls occurred or where exactly the falls happened. Resident #7 said he does not remember having any falls in the facility building. Resident #7 said he was not sure of any other details. During an interview and observation on 05/22/2024 at 11:22 a.m., LVN I entered Resident #7's bedroom and said that Resident #7 had history of being confused and poor historian. LVN I said Resident #7 was a high risk for falls. LVN I was observed grabbing the folded mat that was leaning against the unoccupied bed in the room and placing the mat on the floor next to Resident #7. LVN I said that floor mat needs placed on the floor next to Resident #7's bed anytime he was in bed. LVN I said the mat was used to reduce the risk of serious injury should Resident #7 have a fall from bed. LVN I said she did not know why the floor mat was leaning against the other bed and not in position on the floor next to Resident #7's bed. LVN I said anyone who checks on the resident was responsible to ensure the floor mat was in place. LVN I said she did not know when the resident was last checked. During an interview on 05/22/2024 at 11:35 a.m., the DON said Resident #7 was a high risk fall patient as shown on fall risk assessment conducted on 12/2/2023 Morse fall scale which showed high risk of falls. The DON said Resident #7 should have floor mat in place anytime he was in bed. The DON said the fall mat was in place to prevent any major injury and the risk was Resident #7 having a major injury from a fall. The DON said staff members who check on the residents were responsible to ensure fall prevention steps were taken and in place to include the use of fall mats. Review of facility policy titled Fall Management dated 05/05/2023, read in part, The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. The care plan reflects individualized interventions that are reassessed and revised as needed. 676283 Page 2 of 5 676283 05/22/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #8) of 3 residents observed for oxygen management. Residents Affected - Few -The facility failed to ensure Resident #8 had an oxygen sign posted outside of her bedroom. This failure could place residents on oxygen therapy at risk exposure to a fire hazard if staff and visitors are not aware of oxygen present. Findings included: Review of Resident #8's face sheet dated 05/22/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body). Review of Resident #8's quarterly MDS dated [DATE], revealed Resident #8 had a BIMS score of 02 indicating severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #8 on intermittent oxygen therapy. Review of Resident #8's care plan dated 05/22/2024, revealed resident receiving respiratory therapy with treatment of following physician orders. Review of Resident #8's orders dated 05/22/2024, revealed an order for oxygen at 2 liters per minute via nasal cannula as needed to maintain oxygen sats above 90% every shift. During an observation on 05/22/2024 at 10:39 a.m., noted Resident #8 in her assigned bedroom. Resident #8 was lying in bed with nasal cannula on and oxygen concentrator running at 2 liters. There was no oxygen sign posted outside of Resident #8's room. During an interview on 05/22/2024 at 10:43 a.m., RN H said Resident #8 used oxygen. RN H said residents who uses oxygen should have a sign by the entrance of the room that reads no smoking, oxygen in use. RN H was asked about Resident #8's room and said she had not noticed that there was no sign posted and there should be one. RN H said she would immediately get a sign put in place. During an interview on 05/22/2024 at 3:08 p.m., the DON said that residents on oxygen require an oxygen sign posted outside of the resident's room. The DON said this let's everyone know that oxygen was in use in the room. The DON said the facility was a non-smoking facility making the risk very low. The DON said regardless they want to make sure that everyone who works or visits the facility knows that oxygen was in use. The DON said the Charge Nurse of the hall was responsible for ensuring the sign was posted. Review of facility policy regarding Oxygen Administration undated reads in part, If the patient care area isn't already clearly labeled and your facility requires it, place an OXYGEN PRECAUTIONS sign on the door to the patient's room. 676283 Page 3 of 5 676283 05/22/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #7) of 6 residents reviewed for medical records. -The facility failed to ensure nursing documentation was accurate for Resident #7. This failure could lead to errors in treatment based on incorrect information. Findings included: Review of Resident #7's face sheet dated 05/22/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity (blood clot forms in one or more of the deep veins in the body, usually in the legs), hypotension (low blood pressure which can cause fainting or dizziness because the brains does not receive enough blood), dementia (group of thinking and social symptoms that interferes with daily functioning), anxiety (feeling or worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), insomnia (persistent problems falling and staying asleep), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of Resident #7's quarterly MDS dated [DATE], revealed Resident #7 had a BIMS score of 08 indicating moderate cognitive impairment. Section J - Health Conditions revealed resident had falls in the last month, last 2-6 months and since admission with no injury. Review of Resident #7's Care Plan dated 03/22/2024, revealed care plan category of Falls with goal reading Patient will be free of injuries. Record review of Resident #7's Morse Fall Scale assessment dated [DATE], revealed resident was high risk for falls. Review of Resident #7's Morse Fall Scale assessment dated [DATE], completed by RN K due to post fall, reads in part that resident did not have a history of falls. The assessment also reads that Resident #7 was low risk for falls. During an interview on 5/22/2024 at 11:35 a.m., the DON said Resident #7 was and is a high risk fall patient. The DON said the fall risk assessment was conducted on 12/2/2023 showing resident was high risk of falls. The DON said Resident #7 has had falls in the facility since that time and remains a high risk of falls. The DON reviewed the fall assessment completed on 5/11/2024 showing Resident #7 was a low fall risk with no history of falls. The DON said the assessment was not correct and does not know why the nurse assessed the resident as low risk of falls. The DON said the risk of inaccurate documentation could affect how the resident was treated. The DON said Resident #7 has a care plan for high fall risk in place. The DON said she was going to find out what happened and address the issue with staff. Review of facility policy titled Fall Management dated 05/05/2023, reads in part, The facility will 676283 Page 4 of 5 676283 05/22/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0842 Level of Harm - Minimal harm or potential for actual harm identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Qualified staff evaluates all patient/resident for fall risk at a minimum upon admission, quarterly, with significant change, and post fall. The fall risk evaluation assists in identifying the appropriate preventative interventions that will be recorded on the patient/resident's care plan. Residents Affected - Few 676283 Page 5 of 5