Health inspection·July 11, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 5/10/24. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's electronic face sheet, dated 7/11/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include depressive disorder, anxiety disorder, and aggressive behaviors. Review of Electronic communication via email dated 7/10/24 from the Ombudsman wrote: I checked my records and I have not received a monthly discharge list from the facility since 2021 when facilities started sending me the list. I did receive one today from the social worker. I have checked my records and I don't have any e-mail or contact from the facility regarding [Resident #1] letting me know he will not return to the facility. During a phone interview on 7/11/24 at 1:05pm, the ombudsman stated that he had not heard anything about Resident #1 or their discharge. He stated he did not even see the resident on the discharge list, which he had not received from the facility in a few months. He stated he expected the notification of discharges from the facility monthly. During an interview on 7/11/24 at 1:20 pm, the SW stated he started doing all discharges when he got hired in late May 2024, early June 2024. He stated he had no idea whose responsibility it was to send monthly report to the ombudsman. He stated he believed the DON did it or would start sending emails to the ombudsman. During an interview on 7/11/24 at 1:35 pm, the DON stated the monthly discharge reporting fell on the social worker. She stated she was going to reach out to the previous social worker to see if she had been contacting the ombudsman or not. She stated that she spoke with the previous social worker Page 1 of 2 676283 676283 07/11/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who stated she had not been sending the ombudsman discharge notice monthly. She stated from that point on, it would be on the new social worker to send the ombudsman the monthly discharge notice. During an interview on 7/11/24 at 1:45 pm, the Administrator stated that the social worker should be the employee that contacted the ombudsman. She stated by not sending the discharge list to the ombudsman every month, the continuity of care could be missed for the residents. She stated she was not sure why the discharge list had not been sent monthly but will make sure it was sent out from that point on by the social worker. Record review of the facility's policy dated March 2021 titled: Transfer or Discharge Notice revealed: 6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 676283 Page 2 of 2