Health inspection·August 23, 2024

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 were maintained on each resident that were complete and accurately documented for 2 (Resident #6 and Resident #11) of 11 residents reviewed for administration. -The facility failed to document in Resident #6's medical records the resident's desire to transfer from the facility. -The facility failed to ensure Resident #11's Care Plan intervention tasks regarding falls, was free of error. These failures could place residents at risk of not receiving needed services or errors in treatment based on incorrect information. Findings included: Resident #6: Review of Resident #6's Face Sheet dated 08/22/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged [DATE]. Resident #6 diagnoses included unilateral primary osteoarthritis of left knee (a type of arthritis that affects one side of a joint, resulting from a previous traumatic injury), and depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities). Review of Resident #6's MDS assessment dated [DATE], revealed resident had a BIMS score of 15 indicating that the person was intact cognitively. Review of Resident #6's progress notes from 08/01/2024 to 08/20/2024, revealed no documentation regarding Resident #6 request to transfer to another facility. During an interview on 08/22/2024 at 10:59 a.m., Resident #6 said after the second day of being at the facility, she requested to be transferred to another facility that was closer to her home Resident #6 said she spoke with the RP from the other facility, and they informed Resident #6 that they had room for her to transfer. Resident #6 said she spoke with the DON and the DON said her transfer would be fine. Resident #6 said that a video meeting between the RPs from both facilities was supposed to take place at a scheduled date and time, although did not remember the exact date and time. Resident #6 said the facility's BOM that she was admitted to was supposed to be the RP for the meeting Page 1 of 5 676283 676283 08/23/2024 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 from her understanding. Resident #6 said when that date and time came, the BOM did not call in to the meeting. Resident #6 said she called her insurance who were aware of the meeting, and they informed Resident #6 that since no one called in from the facility, her transfer request was denied. Resident #6 said she was upset but since she was only staying at the facility a short time for skilled services, she just wanted to complete her time and dropped the transfer request. Residents Affected - Few During an interview on 08/22/2024 at 2:50 p.m., the BOM said she had not had any involvements with resident discharges or transfers but since the facility did not have a Social Worker (SW), administration asked if she could send over the clinical records to the other facility that Resident #6 requested to transfer to. The BOM said she could not remember the date of the requested transfer. The BOM said she did not document the requested transfer anywhere in the resident's clinical records. The BOM said the DON was handling most of the transfer actions and was the person who would have documented in the clinical records. The BOM said she emailed Resident #6's clinical records to the admission Coordinator at the other facility and had no further involvement. The BOM said this was a task that the SW would have handled and was outside her scope of responsibility. The BOM said she did not receive any notification regarding any peer-to-peer meetings with the other facility. During an interview on 08/22/2024 at 2:57 p.m., the DON said Resident #6 verbalized to her that she would like to be transferred to another facility. The DON said she did not remember the date of the request. The DON said she told Resident #6 yes of course we can initiate that and reach out to (the other facility) and get order to release information. The DON said the BOM helped her put the packet together and send the information to the other facility. The DON said she did not hear anything back from the other facility. The DON said when she visited with Resident #6, she told the DON that the BOM was supposed to be on a call for the insurance to accept the transfer. The DON asked the BOM to speak with Resident #6 about the matter and Resident #6 dismissed the BOM and said to leave it alone and that she was going to stay at the facility and be done with treatment. The DON said the resident's request for a transfer should have been documented in the progress notes of Resident #6. The DON said the facility did not have a SW and she would have documented the transfer request. The DON reviewed the resident's progress notes and said that she did not document the request for transfer in the resident's clinical notes. The DON said she did not document the request anywhere else. The DON said she overlooked documenting the information that was her responsibility. The DON said all the residents' documentation should accurately reflect the residents' progress and details such as request for transfers. The DON said the risk of failing to document could be missing information, or misleading/inaccurate information affecting resident care. Review of facility provided Discharge Planning policy dated 06/09/2023, reads in part when the interdisciplinary team determines .the resident expresses a desire for discharge, Social Services staff addresses the following information utilizing the Discharge Summary or discharge plan/instructions from which is contained in the resident's medical record. Documentation in the resident medical record should include the following: F. The resident's desire to transfer or discharge from the facility should be documented in the resident medical records. Resident #11: Review of Resident #11's Face Sheet, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11's diagnoses included impulse disorders, anxiety disorder, unsteadiness on feet, muscle weakness, and abnormalities of gait and mobility. Review of Resident #11's MDS dated [DATE], revealed in Section B - Hearing, Speech, and Vision that 676283 Page 2 of 5 676283 08/23/2024 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 resident had adequate ability to see in adequate light. Resident #11 did not use corrective lenses. Section C - Cognitive Patterns revealed resident had a BIMS score of 02 indicating severe cognitive impairment. Review of Resident #11's Care Plan dated 08/23/2024, read in part Resident has history of falling. Part of the interventions with start date of 08/16/2024, read in part Approach: assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair. Review of Resident #11's Orders dated 08/23/2024, reads that resident does not wear glasses. Observation and interview on 8/23/2024 at 9:06 a.m., revealed Resident #11 seated on wheelchair in hallway. Resident #11 did not have eyeglasses on. Resident #11 said she did not know about having any eyeglasses. During an interview on 08/23/2024 at 9:10 a.m., LVN K said Resident #11 did not use eyeglasses. LVN K reviewed Resident #11's care plan and said the intervention about eyeglasses on the care plan was a mistake. LVN K said she was the person who documented the intervention and made the mistake on the care plan. LVN K said she had been trained on writing care plans. LVN K said she did not know why she documented the inaccurate information on the care plan. LVN K said inaccurate information could be misleading and that she would correct her mistake. During an interview on 08/23/2024 at 10:00 a.m., the DON said that nurses could modify the care plan based on resident needs or change of condition. The DON said all nurses had been trained on documentation and how to manage the system including the care plan itself. The DON said the plan of care was specific on type of care residents were receiving. The DON said the plan had to be accurate and any failure could result in residents not receiving appropriate care. During an interview on 08/23/2024 at 12:50 p.m., the Administrator said the expectation was that facility staff documented according to policy and documented accurately. The Administrator said failure to accurately document in the clinical records could result in a gap of information missing. The Administrator said the purpose of the care plan was to make sure there is proper guidance to care for the residents. The Administrator said the risk inaccurate documentation was the resident may not receive the appropriate care. Review of facility provided Documentation Guidelines policy dated 05/05/2023, reads in part Documentation guidelines to good clinical record practice will be followed by all individuals who document in the medical record. Make all entries in chronological order .Entries are factual and objective .Do not document an action that did not take place. 676283 Page 3 of 5 676283 08/23/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for administration. Residents Affected - Many -The facility, which was licensed for 124 beds, failed to employ a qualified social worker on a full-time basis since on 08/05/2024 This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included: Record review of the facility's summary report dated 08/21/2024, revealed the facility was licensed for 124 beds. During an interview on 8/21/2024 at 9:57 a.m., Resident #1's FM said the facility did not have a Social Worker for three weeks. The FM said he found out because he had a grievance that he wanted to file with the SW and found out the following day that the SW had quit. The FM said he gave the grievance to the Administrator. The FM said no harm came to Resident #1. The FM said he learned that the DON was handling SW duties and felt the DON was not qualified or had the time to complete the SW duties. During an interview on 08/21/2024 at 10:59 a.m., Resident #6 said she had requested to transfer to another facility a few days after being admitted to the facility on [DATE]. Resident #6 said there was no SW available to speak with about her request and she ended up speaking with the DON about her desire to transfer. Resident #6 said her requested transfer did not occur because facility staff did not follow up with the other facility to make it happen and her insurance denied the transfer. Resident #6 said she just decided to stay at the facility until her treatment was done and discharged from the facility on 08/20/2024. During an interview on 08/21/2024 at 1:15 p.m., the DON said there was no SW at the facility since the first week of August when the previous SW resigned. The DON said the previous SW's last day was 08/02/2024. The DON said the facility was in the process of looking to hire a SW. The DON said the SW handled grievances by bringing it to the attention of the administration and they would all work on resolving the grievances. The DON said since the SW resigned, she was taking care of the referrals and resident discharges. The DON said SW duties were split up amongst management. The DON said the SW would have taken care of transfers and discharges and ensured the tasks were documented. The DON said Resident #6 had requested to transfer from the facility to another one. The DON said she failed to document when this request took place and knew that the transfer did not occur because a meeting with the other facility was not done. The DON said the SW would have taken care of those specific tasks regarding requests for transfers. The DON said the fact that the facility did not have a SW meant the workload for each manager increased on top current responsibilities. During an interview on 08/22/2024 at 11:30 a.m., the Administrator said he was hired at the facility on 07/29/2024. The Administrator said the SW's last day at the facility was 08/02/2024. The Administrator said they were in recruiting process. The Administrator said the DON was assisting with discharge planning. The Administrator said he was handling the grievances and said any person can report 676283 Page 4 of 5 676283 08/23/2024 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0850 Level of Harm - Potential for minimal harm Residents Affected - Many a grievance to any staff member and this reported information was then brought up in morning meetings or throughout the day as he followed-up with the process. The Administrator said he had not received any grievances from anyone regarding discharges or transfers. The Administrator said the SW position had been posted since 07/08/2024 on an online job search site. The Administrator said the challenge of not having a SW was they are not there for family and residents. The Administrator said he had a potential candidate for the position scheduled for an interview on 08/26/2024. Review of the facility's provided Social Worker job description, read in part, The Social Worker is responsible for assisting in planning, organizing, implementing, evaluating, and directing of the Social Services Department in accordance with current existing federal, state and local standards, as well as established policies and procedures to ensure that the medically related emotional and social needs of patient/resident are met/maintained on an individual basis. Part of essential duties and responsibilities included: Participates in patient/resident assessments, development, and implementation of social care plans and discharge planning. Reviews complaints and grievances and makes necessary oral/written reports to the department manager. 676283 Page 5 of 5