Health inspection·August 22, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 8 residents (Resident #2) reviewed for self -determination. The facility failed to ensure that Resident #2 received incontinence care before or during mealtimes when requested. This failure could place residents at risk for avoidable discomfort, compromised dignity, and potential complications such as urinary tract infections and skin breakdownFindings included: Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 5/15/25 revealed diagnoses of Hemiplegia, affecting left non-dominant side (means there is paralysis (loss of movement) on the left side of the body. Since most people are right-handed, the left side is considered the non-dominant side.), Unspecified dementia (a condition that affects memory, thinking, and daily functioning. Unspecified means the exact type of dementia (like Alzheimer's or vascular dementia) has not been clearly identified), Unspecified abnormalities of gait and mobility (means the person has trouble walking or moving around normally, but the exact cause or type of walking problem hasn't been clearly described), and Muscle wasting and atrophy (refers to the muscles getting smaller, weaker, and thinner over time, often because they are not being used enough or due to a medical condition). Record review of Resident #2's annual MDS dated [DATE], revealed, an intact cognition with no impairment BIMS score of 15 to be able to recall or make daily decisions. ADLs for toileting was partial/moderate assistance (Staff does less than half the effort). Resident was always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 6/24/25 revealed a focus for requires assist to complete ADL tasks due to impaired cognition, impaired mobility and incontinence with goal of will maintain a sense of dignity by being clean, dry, odor free and well-groomed thru the next review date and interventions included toiletingpartial/moderate assistance. Record review of Resident #2's grievance dated 6/18/25 revealed it was written by Resident #2's RP and it was communicated to the DON, Administrator, and SW. The grievance was communicated verbally, and the concern was mistreatment. The concern in detail read patients not being changed in a timely manner and left soiled through lunch. Separate sheet with details. the Documentation investigation and post investigation follow up were left blank and it was only signed by Resident #2's RP. Record review of Resident #2's grievance typed report (which was referred to above as separate sheet with details) dated 6/18/25 written by Resident #2 RP revealed On 05/02/2025 Around 11:45 AM. I went to DON office to get assistance to have someone change [Resident #2] who was soiled, call light was on for about 20 minutes, no one was around the hall nor in the nurse's station. I asked DON if she can have someone change my [Resident #2], she then in turn tells me that they can't right now because it's lunch time and that state regulations or law prohibits them to do so during lunch because it's unsanitary. [Resident #2] sat Page 1 of 10 676283 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few through lunch soiled for almost an hour. I spoke to [Administrator] about what had transpired with DON, and he tells me pretty much the same thing agreeing with what DON told me. I replied, that if not changing [Resident #2] who was soiled is not sanitary during lunch, is it sanitary for the patients to sit through lunch soiled? Would any of them sit through lunch soiled? I also told him that I had asked before lunch not during lunch. 15, 20 minutes before lunch. [Administrator] said that he would talk to DON to see if they can come up with a solution. 06/09/2025 At 11:17 AM, [Resident #2] tells me she needs to be changed because she pooped, I press the call switch the light goes on. Shortly afterwards [SW] walks in and asked who needed assistance, I responded that [Resident #2] needed to be changed. She said she would get someone and left the room, shortly she returns saying in an apologetic manner that [Resident #2] could not be changed at the moment cause the food trays were going to be distributed to the residents. I feel that the patients are being neglected and the progress of the staff was making has faltered. I have reached out to [Ombudsman] about what the Administrator and DON said about the regulations or law about changing patients at lunch or before lunch. His response was I have sought out law or regulation about patients being changed during this information is baseless and suggested I file a grievance report. During an interview on 8/19/25 at 2:08 pm, the Ombudsman stated that Resident #2's RP called him and reported that staff were not taking care of her. The Ombudsman stated he had not seen any regulation that prevented residents from being changed, but the RP stated the facility told him that per state regulations residents were not to be changed prior to and during meals due to infection control concerns. The Ombudsman stated this was concerning because it involved residents remaining in soiled briefs before and during meals, having to wait until after meals to be changed. During an interview on 8/20/25 at 9:07 am, Resident #2 stated she needed help with toileting. She stated she wore briefs and was changed approximately every two-three hours. She stated that on one occasion she asked to be changed and was told she had to wait until after the meal. She stated she was told this was due to hygienic concerns with the meal being at bedside. She could not remember the CNA's name but stated her RP was present when this occurred. She stated she was eventually changed but could not recall how long after her request. She stated she felt very uncomfortable waiting in her soiled brief and that her RP reported the concern, but she did not know to whom. During an interview on 8/20/25 at 9:12 am, Resident #2 stated she needed assistance with toileting and wore briefs. She stated that if she was soiled, she had to ask in advance because if it was close to mealtime, she had to wait until after she finished eating. She stated she was not given a reason for this but was told it was just how the facility operated. She stated there were times she sat in soiled briefs during meals and that it was uncomfortable, embarrassing, and irritating. She stated she had not told anyone because she was informed by staff that she had to wait and assumed it was the norm at the facility. During an interview on 8/20/25 at 9:17 am, LVN F stated CNAs did not change residents' briefs during meal tray delivery. She stated CNAs were not to change residents' briefs per facility practice until after the meal. When asked about policy, she could not recall which policy it was. LVN F stated the reason provided was to prevent cross-contamination. When asked if CNAs were washing their hands before and after providing incontinence care, she stated yes. When asked how that would be considered cross-contamination, she stated, I don't know how to answer that. When asked if it was the residents' right to be changed, she stated that it was but could not explain why it was not being done and only reiterated that it was for cross-contamination prevention. LVN F stated she had not received complaints from residents about not being changed. LVN F stated the only complaint came from Resident #2 RP, who had requested Resident #2 to be changed. LVN F 676283 Page 2 of 10 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #2 was eventually changed, but it occurred after the meal. When asked why care was delayed until after the meal, she hesitated and stated again it was to prevent cross-contamination. When asked about resident rights, she could not answer directly. During an interview on 8/20/25 at 9:26 am, CNA I stated that residents were not changed if they became soiled before or during meals. CNA I stated that if a resident requested to be changed during that time, she would encourage the resident to wait until they were done eating. She stated the reason given to staff was to prevent cross-contamination. When asked if she washed her hands before and after providing incontinence care, she stated yes. When asked how cross-contamination would occur if staff followed hand hygiene and infection control practices, she stated she did not know how to answer that question. During an interview on 8/20/25 at 10:07 am, the ADON (who is also the Infection Prevention nurse) stated residents were changed before meal trays were passed out and after they were done eating, but not during meals. She stated she had spoken with the DON and reviewed documentation. She stated the practice was due to infection control best practice. When asked if staff washed their hands and followed standard infection control procedures, she stated they did. She then stated the concern was also about dignity, as it was inappropriate for a roommate to eat while another resident was being changed. She acknowledged dignity issues could include odor, irritation, risk of urinary tract infections, or skin breakdown. During an interview on 8/20/25 at 1:33 pm, the DON stated Resident #2 RP approached her and requested his mother be changed while trays were out in the hall. She stated the facility's best practice was not to perform incontinence care in the unit while meal trays were actively being served and consumed. The DON stated there was no written policy, only best practice. The DON stated CNAs washed their hands, but if a roommate was eating in the room while another resident was being changed, it violated dignity for the roommate. The DON stated staff were trained to wash their hands after care per standard precautions, so cross-contamination should not be a concern, stated she did not initially think of it in that way. The DON stated she had previously referenced regulations but upon review had not found any supporting regulation. The DON stated she reviewed infection control policy the day prior (8/19/25) and did not find anything that prohibited changing during meals. The DON stated the risk of delaying care was skin breakdown, infection, and resident discomfort. During an interview on 8/20/25 at 4:08 pm, the SW stated she had heard of the concept that CNAs could not change a resident during mealtime due to concerns of cross-contamination and dignity, and because the odor might be unpleasant for the roommate and cause nausea or loss of appetite. The SW stated she was not aware if residents had been asked whether they were comfortable being changed during meals or if they had been offered the option to step out during the brief change. The SW stated that if it had been her in that situation, and she had to wait to be changed for the sake of her roommate's dignity, she would have felt dirty having to eat her meal while soiled. When asked about cross-contamination, she stated she did not know much about it and referred the question to the nursing staff. During an interview on 8/22/25 at 9:02 am, the NP stated that usually when residents were eating, staff were also busy cleaning trays in the hallway and attending to other tasks. He stated that residents should be cleaned when needed and thought it was unusual that staff did not change residents' minutes before or during meals. He stated he did not believe there was significant risk if the wait was less than two hours, but if it exceeded two hours, then it became a concern. During an interview on 8/22/25 at 11:05 am, the Administrator stated that the facility does not have a written policy that prevents residents from being changed minutes before or during meals. The Administrator explained that some staff may believe this practice relates to infection control, particularly if a resident has an explosive bowel movement, but stated that delaying care could have a negative emotional impact on residents. 676283 Page 3 of 10 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Administrator clarified that he has never told staff that this was a regulation or requirement, nor has he heard the Director of Nursing communicate such a rule. Record review of the facility's Patient/Residents Rights dated 2023 read in part Policy: The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. Resident rights: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section; A resident must receive and consent with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality; The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Record review of the facility's Infection Prevention and Control Program and Plan policy dated May 15, 2023, revealed there was nothing that indicated staff could not provide soiled brief changes minutes prior and during meals due to cross contamination concerns. 676283 Page 4 of 10 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 (Resident #2) of 8 residents reviewed for resident rights. The facility failed to complete a grievance for Resident #2 RP who requested Resident #2 to be changed during a mealtime. This failure could place residents at risk for grievances not being addressed or resolved promptly. Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 5/15/25 revealed diagnoses of Hemiplegia, affecting left non-dominant side (means there is paralysis (loss of movement) on the left side of the body. Since most people are right-handed, the left side is considered the non-dominant side.), Unspecified dementia (a condition that affects memory, thinking, and daily functioning. Unspecified means the exact type of dementia (like Alzheimer's or vascular dementia) has not been clearly identified), Unspecified abnormalities of gait and mobility (means the person has trouble walking or moving around normally, but the exact cause or type of walking problem hasn't been clearly described), and Muscle wasting and atrophy (refers to the muscles getting smaller, weaker, and thinner over time, often because they are not being used enough or due to a medical condition). Record review of Resident #2's annual MDS dated [DATE], revealed, an intact cognition with no impairment BIMS score of 15 to be able to recall or make daily decisions. ADLs for toileting was partial/moderate assistance (Staff does less than half the effort). Resident was always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 6/24/25 revealed a focus for requires assist to complete ADL tasks due to impaired cognition, impaired mobility and incontinence with goal of will maintain a sense of dignity by being clean, dry, odor free and well-groomed thru the next review date and interventions included toileting- partial/moderate assistance. Record review of Resident #2's grievance dated 6/18/25 revealed it was written by Resident #2Resident #2's RP and it was communicated to the DON, Administrator, and SW. The grievance was communicated verbally, and the concern was mistreatment. The concern in detail read patients not being changed in a timely manner and left soiled through lunch. Separate sheet with details. the Documentation investigation and post investigation follow up were left blank and it was only signed by Resident #2Resident #2's RP. Record review of Resident #2's grievance typed report (which was referred to above as separate sheet with details) dated 6/18/25 written by Resident #2 RP revealed On 05/02/2025 Around 11:45 AM. I went to DON office to get assistance to have someone change [Resident #2] who was soiled, call light was on for about 20 minutes, no one was around the hall nor in the nurse's station. I asked DON if she can have someone change my [Resident #2], she then in turn tells me that they can't right now because it's lunch time and that state regulations or law prohibits them to do so during lunch because it's unsanitary. [Resident #2] sat through lunch soiled for almost an hour. I spoke to [Administrator] about what had transpired with DON, and he tells me pretty much the same thing agreeing with what DON told me. I replied, that if not changing [Resident #2] who was soiled is not sanitary during lunch, is it sanitary for the patients to sit through lunch soiled? Would any of them sit through lunch soiled? I also told him that I had asked before lunch not during lunch. 15, 20 minutes 676283 Page 5 of 10 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few before lunch. [Administrator] said that he would talk to DON to see if they can come up with a solution. 06/09/2025 At 11:17 AM, [Resident #2] tells me she needs to be changed because she pooped, I press the call switch the light goes on. Shortly afterwards [SW] walks in and asked who needed assistance, I responded that [Resident #2] needed to be changed. She said she would get someone and left the room, shortly she returns saying in an apologetic manner that [Resident #2] could not be changed at the moment cause the food trays were going to be distributed to the residents. I feel that the patients are being neglected and the progress of the staff was making has faltered. I have reached out to [Ombudsman] about what the Administrator and DON said about the regulations or law about changing patients at lunch or before lunch. His response was I have sought out law or regulation about patients being changed during this information is baseless and suggested I file a grievance report. During an interview on 8/20/25 at 9:12 am, Resident #2 stated she needed assistance with toileting and wore briefs. She stated that if she was soiled, she had to ask in advance because if it was close to mealtime, she had to wait until after she finished eating. She stated she was not given a reason for this but was told it was just how the facility operated. She stated there were times she sat in soiled briefs during meals and that it was uncomfortable, embarrassing, and irritating. She stated she had not told anyone because she was informed by staff that she had to wait and assumed it was the norm at the facility. During an interview on 8/20/25 at 1:33 pm, the DON stated the Social Worker and Administrator conducted the investigation. The DON stated that for a typical grievance, the process would be completed online; however, since this was reportable, the investigation continued and was resolved. The DON stated they completed the investigation but did not document it. She explained the risk of not completing the documentation was that if it was not documented, it did not happen, and without follow-up it could not be supported.During an interview on 8/20/25 at 3:39 pm, the SW stated she had received the grievance from Resident #2's RP. The SW stated she had reviewed the notes and the additional page where the RP mentioned [Resident #2] being neglected, which led her to determine it was reportable. The SW stated that whenever a grievance mentioned neglect or resident rights not being met, it was considered reportable, and a self-report required to the state office. The SW stated the Administrator then took over and conducted the report but emphasized that the complaint itself was still her responsibility. She stated it was not completed because it was reportable. The SW stated she had reviewed the policy with the surveyor on 8/20/25 and identified that nothing in the policy reflected that the grievance form should not be completed due to a self-reportable. The SW stated that although she had access to the policy, she had not reviewed it prior to that day. The SW stated that if it had not been reported to the state, the grievance could have fallen through the cracks. The SW stated that even with the self-report, there could be a negative outcome because without proper documentation, there was no way to confirm if it was resolved or who had investigated it.Record review of the facility's Complaint/ Grievances Process policy dated 10/23/19 read in part Procedures: 2- Upon receipt of the grievance/ complaint the receiver completes and signs all appropriate sections of the current complaint/grievance form; 4- The SW/ designee ensures all sections of the Complaint/grievance report are completed appropriately and signed by the staff completing the investigation and developing the resolution. Ensure any supportive documentation related to the grievance is attached. 676283 Page 6 of 10 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #3) of 4 residents reviewed for enablers (bed rails). The facility failed to ensure that Resident #3 had a Scoop/Booster Mattress Assessment done to ensure the scoop/booster mattress was appropriate for use as an enabler.The facility failed to ensure that Resident #3 had orders for the scoop/booster mattress (enablers) use. The facility failed to obtain a Consent for use of the scoop/booster mattress for Resident #3. This failure could place residents who have scoop/mattresses (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury.Findings include:Record review of Resident #3's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's facility history and physical dated 07/08/25, revealed, an [AGE] year-old male diagnosed with Dementia and Diabetes, right humeral neck fracture, left intertrochanteric femur fracture as well as a chronic right humerus head fracture with possible new medial displacement. Record review of Resident #3's quarterly MDS dated [DATE], revealed, a severe impaired cognition BIMS score of 2 to be able to recall or make daily decisions. Resident #3's functional ability was substantial/maximal assistance (staff does more than half the effort) for roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed to chair transfer. Resident #3 was not coded in section P - Restrains and Alarms: P0100. Physical Restraints (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) for used in bed. Record review of Resident #3's care plan dated 07/10/25, revealed, Problem: Risk for injury related to impaired mobility and recent left hip fracture. Approach: Place resident on scoop mattress as ordered to assist with proper positioning, reduce pressure points, and prevent further injury. Record review of Resident #3's orders reviewed on 08/21/25, revealed, there was no orders for the use of a scoop/booster mattress for Resident #3. Order dated 02/05/25, revealed, bed mobility with assist of 1 person. Record review of Resident #3's Consent reviewed on 08/21/25, reviewed, there were no consent for use of scoop/booster mattress. Record review of Resident #3's PT Evaluation & Plan of Treatment dated 07/09/25-09/06/25, revealed, Reason for Referral / Current illness: Resident #3 was a LTC resident referred to skilled PT services due to an unwitnessed fall resulting to a left femur fracture and re-fracture of right upper extremity. Right Lower extremity strength was impaired, left lower extremity was impaired, hip impaired, knee impaired, and ankle impaired. Bed mobility was max, supine was max, sit was max, transfers was max. Gross motor was impaired. Clinical Impression: Resident #3 exhibits weakness, balance deficits and decrease activity tolerance. Resident #3 requires encouragement for participation; requires MAX Assistance for functional mobility, per nursing report, resident #3 was easily agitated and can be aggressive. Record review of Resident #3's OT Evaluation & Plan of Treatment dated 07/09/25-09/06/25, revealed, Reason for Referral /Current illness: Resident #3 referred to OT due to exacerbation (a sudden worsening or flare-up of symptoms of a chronic disease) of decrease in functional mobility, decrease in range of motion, decrease in strength, reduced dynamic balance, reduced static balance (having a decreased ability to hold a stable, fixed body position without moving) and reduced ADL participation. Right Upper Extremity ROM was impaired, shoulder was impaired, right upper extremity was 676283 Page 7 of 10 676283 08/22/2025 Los Arcos Del Norte Care Center 11169 Sean Haggerty El Paso, TX 79934

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired. Toileting was dependent, upper body dressing was Max assistance, lower body dressing was total dependence. Clinical Impressions: upon evaluation Resident #3 demonstrates significant deficits affecting selfcare tasks and functional mobility. During an interview on 08/20/25 at 2:02 PM, with the DON, she stated Resident #3 was a high fall risk. The DON stated Resident #3 had a scoop/booster mattress to help repositioning, to help find the borders for him, and to prevent him from rolling off the bed. The DON stated Resident #3 was able to get in and off the bed by himself. The DON stated Resident #3 was evaluated for the scoop/booster mattress but did not know if he was evaluated to see if he was able to in and out of bed. The DON stated she could not recall if there was a physician order for the scoop/booster mattress. The DON stated there was no physician order seen for the scoop/booster mattress. The DON stated Resident #3 was care planned for the scoop/booster mattress. The DON stated the care plan mentioned to place resident on scoop mattress as ordered. The DON stated there would have to be an order for use of the scoop/booster mattress. The DON stated there was no consent form seen for use of the scoop/booster mattress. The DON stated the nurses were responsible for getting the orders and the consent for use. During an interview on 08/21/25 at 10:25 AM, with the DOR, he stated the therapy had done their own evaluation of Resident #3 but do not do evaluation on residents to see if they are able to use bed rails or scoop/booster mattress to see if they can use them as enablers. The DOR stated Resident #3's PT evaluation for bed mobility stated he was a max assistance and also with transfers. The DOR stated Resident #3 was unable to walk. The DOR stated Resident #3 would not be able to use the scoop/booster mattress to get out of bed or help him use it as an enabler. The DOR stated he did not see the negative outcome of Resident #3 using the scoop/booster mattress. The DOR stated if there were an emergency Resident # would not be able to get out of bed on his own. During an interview on 08/22/25 at 11:24 AM, with the Administrator, he stated a scoop/booster mattress was ordered for Resident #3. The Administrator stated Resident #3 did not have a physician order, nor consent form for use of the scoop/booster mattress, and no therapy or nursing assessment conducted to see if Resident #3 was able to use the scoop/booster mattress. The Administrator stated the purpose of the therapy/nursing assessment was to make sure the scoop/booster mattress fit Resident #3 and was an enabler as not doing so could be a risk of entrapment. During an interview on 08/22/25 at 1:32 PM, NP B stated he was not too familiar with the scoop/booster mattress. NP B stated there were no orders for the scoop/booster mattress as he did not give any nor were any asked by the facility to him. NP B stated as per policy the negative outcome would be that the scoop/booster mattress would be not appropriate for Resident #3's use. Record review of the facility Bed Rails and Side Rails, installation and use Policy, dated 05/05/25, revealed, Policy - The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use was determined to be appropriate for the patient/resident. Procedures: Acceptable alternatives will be considered prior to the installation of bed rails. Alternatives include but are not limited to roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed. -The resident will be evaluated for the risk of entrapment prior to installation. 676283 Page 8 of 10 676283 08/22/2025 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 observation, 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 of 6 residents (Resident #2) reviewed for medical records. The facility failed to ensure Resident #2's facility provider report to the state agency failed to accurately document the treatment and administration in the record for perineal care for Resident #2. This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting in inadequate treatment/care. Findings include:Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 5/15/25 revealed diagnoses of Hemiplegia, affecting left non-dominant side (means there is paralysis (loss of movement) on the left side of the body. Since most people are right-handed, the left side is considered the non-dominant side.), Unspecified dementia (a condition that affects memory, thinking, and daily functioning. Unspecified means the exact type of dementia (like Alzheimer's or vascular dementia) has not been clearly identified), Unspecified abnormalities of gait and mobility (means the person has trouble walking or moving around normally, but the exact cause or type of walking problem hasn't been clearly described), and Muscle wasting and atrophy (refers to the muscles getting smaller, weaker, and thinner over time, often because they are not being used enough or due to a medical condition). Record review of Resident #2's annual MDS dated [DATE], revealed, an intact cognition with no impairment BIMS score of 15 to be able to recall or make daily decisions. ADLs for toileting was partial/moderate assistance (Staff does less than half the effort). Resident was always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 06/19/25, revealed, Problem: Family frequently voices concern that resident was not being changed or cared for adequately, despite care being provided per facility protocols. Document all care provided.Record review of Resident #2's facility provider report dated 06/26/25, revealed, Resident #2's family member #1 stated in a grievance that he submitted on 6/19/25 that I feel that the patients are being neglected again and that the progress the staff was making has faltered. Skin sweeps conducted on hall, changed tray times on 400 hall, implemented an order for resident to be changed before meals. In-service on Abuse and Neglect, Residents rights and Dignity, Compassionate and timely Incontinent Care. Notification to Family, Physician/NP, Ombudsman, and state. Facility conclusion was inconclusive. Record review of Resident #2's progress notes generated by LVN H dated 06/19/25, revealed, LVN H asked Resident #2 if she felt neglected while residing in the facility. Resident #2 denied any feelings of neglect and stated, I really like it here. The staff are so nice and attentive to me. LVN H further inquired if the resident's needs were being met and the resident responded, Yes, I am very comfortable here. When asked if she felt safe in the facility, the resident stated, Yes, I feel very safe here. LVN H provided education to the resident about having a CNA assist with changing her brief prior to all meals. The resident verbalized understanding of this process. Additionally, the resident was informed that meal tray delivery will be adjusted to allow for brief changes before trays are served in the hallway. This change was in alignment with CMS and state infection control guidelines. On 08/20/25 a documentation policy was requested but one was not provided by the facility. During an interview on 08/20/25 at 1:56 PM, with the DON, she stated the Suggest Questions for Accused was provided to CNA C, CNA D, and LVN F but they were not being accused of any allegations. The DON stated they were given that documents form to gather information as it was being investigated as a concern and grievance from family member #1 676283 Page 9 of 10 676283 08/22/2025 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 for Resident #2. The DON stated the form should have been adjusted to say something different other then, Suggest Questions for Accused. The DON stated it was a documentation error and all staff have been trained on how to documents properly. The DON stated the negative outcome of improper documentation would be failure in documenting of the care and what was done for the resident. During an interview on 08/21/25 at 9:21 AM, CNA C stated family member #1 had voiced that Resident #2 was not being changed. CNA C stated they were changing Resident #2 and were marking the changes down on a log every time they changed her. CNA C stated she was called into the office and was asked to fill out a document. CNA C stated she does not read English and was not told that the documents title was Suggested Questions for Accused was accusing her of the allegation. CNA C stated if she would have known she would have not filled out and signed the document.During an interview on 08/21/25 at 9:52 AM, with CNA D, she stated family member #1 was complaining that staff were not changing Resident #2. CNA D stated CNA C and her were told to go to the DON's office to fill out the Suggest Questions for Accused documentation. CNA D stated she was informed that the Suggest Questions for Accused was an attention to a concern with a resident and not a write up. CNA D stated she did not read English and did not know what she was filling out other then what she was being told. During an interview on 08/21/25 at 3:33 PM, with LVN F, she stated Resident #2's family member #1 had made a complaint that staff was not changing Resident #2. LVN F stated she filled out the Suggest Questions for Accused but did not realize what she was signing. LVN F stated the staff were not suspended as it was not a write up but only information that the facility was requesting for the investigation. LVN F stated if she would have paid better attention to the document that she would have questioned it. LVN F stated the nursing staff was providing perineal care all the time. During an interview on 08/22/25 at 11:05 AM, with the Administrator, he stated the title Suggested Questions for Accused documents where the nursing staff had filled out, was a template that was given to them by corporate and should have had the part of accused being changed to something else as the nursing staff was not being accused of anything. The Administrator stated that staff are trained on documenting. The Administrator stated the nursing staff should have known how to document, clearly, and to be able to capture what was being done. The Administrator stated the negative impact would affect reimbursement and not knowing what the residents' needs are if not documented accurately and correctly. 676283 Page 10 of 10