Arc at El Paso

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse prevention policy for three of four residents (R2, R3, and R4) with abuse-related concerns.

Inspectors wroteBased on observation, interview and record review the facility failed to serve hot foods in a sturdy bowl, this failure caused R8 to spill hot chili on her chest causing a burn with blistering that required treatment for one resident (R8) reviewed for a burn injury in a total sample of thirty eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions by not cleaning a debris/grime covered exhaust vent located above kitchen food preparation area. This failure has the potential to effect all 55 residents residing in the facility. Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/26/26, signed by V1/Administrator, document 55 residents reside in the facility. On 5/27/26, at 11:30 a.m., the exhaust vent, located above the kitchen's food preparation area, was covered with debris/grime. On 5/27/26, at 11:30 a.m., V7/Regional Dietary Manager confirmed the exhaust vent, above the food preparation area, should be cleaned. Facility Policy, entitled, On Tray Dietary Policies and Procedures Ceiling, Vents, document: Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 55 residents residing in the facility. Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/26/26, signed by V1/Administrator, document 55 residents reside in the facility. On 5/26/26, at 9:30 a.m., during the Initial kitchen tour, the two outside trash dumpsters were not secured as lids, on both were open. On 5/26/26, at 9:30 a.m., V8/Cook confirmed the trash dumpsters should have the lids closed. The facility's Pest Control Policy, effective 1/2026, document: Put garbage in sealed plastic bags before placing them in a covered, rodent-proof dumpster.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement an infection prevention and control system to identify, report, and manage infections and symptoms associated with communicable illnesses among residents; and failed to ensure proper disinfectant monitoring practices, including the use of testing protocols to verify acceptable disinfectant ranges and documentation of testing results for Legionella. These failures have the potential to affect all 55 residents who reside in the facility. Findings Include:On 5/27/2026 at 12:10 PM, V2 (Director of Nursing) confirmed she has no log that track infections or symptoms residents exhibit daily to track communicable infections and diseases. On 5/27/2026 at 12:30 PM, V13 (Maintenance Director) stated the Water Management Program Committee Protocol items listed to be completed are not completed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to include a resident's wish to eat in their room for 15 residents (R2, R4, R8, R11, R20, R21, R28, R32, R38, R39, R41, R47, R50, R53, R58) of twenty residents who have indicated that they wish to eat in their room instead of the main dining room for meals in a total sample of thirty eight.

Inspectors wroteBased on interview and record review, the facility failed to inspect and regularly check the mattress and bed rails for areas of possible entrapment for 3 (R2, R6, and R8) of 3 residents reviewed for bedrails in a sample of 38. 1. R2's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Morbid Obesity, Type II Diabetes Mellitus and Chronic Respiratory Failure with Hypoxia. R2's Medical Record documents she cognitively intact and makes her own decisions. Throughout the survey R2's upper half side rails on both sides were up while she was in bed. On 5/27/2026 R2 stated she used the side rails for turning in bed. R2's Side Rail assessment dated [DATE] documents the side rails do not restrict mobility or prevent independent functioning. R2's Side Rail Assessment documents the side rails are used for increased mobility in bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent resident to resident abuse from occurring for one of two residents (R10), reviewed for abuse, in a sample of 38. R10's facility admission Record documents R10 was admitted to the facility on [DATE] with the following diagnoses Dementia, Anxiety and Depression. R10's current Care Plan, dated 3/23/26 documents R10 has the following Focus Areas: Behavior Problems due to anxiety, wandering, yelling at staff; Wandering/poor safety awareness and Impaired Communication. The facility report, Final Abuse Investigation Report, dated Initial Report: 4/14/26 and Final Report: 4/20/26. At 6:25 P.M. on 4/14/26, (V1) was notified of an alleged physical altercation between (R10 and (R18) in the hallway near the nurse's station. Both residents were immediately separated. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately reflect a resident's injection and insulin status related to the Minimum Data Set assessment for 1 (R21) of 24 residents in a sample of 38.

Inspectors wroteBased on interview and record review the facility failed to monitor a resident's condition after return from the hospital for one resident (R2) of four residents reviewed for hospitalizations in a total sample of thirty eight. R2's Medical Record documents she was admitted to the facility on [DATE] with diagnosis to include acute and Chronic Respiratory failure with Hypoxia, Type II Diabetes Mellitus, Congestive Heart Failure and Hypertension. R2's Progress Notes dated 11/25/2025 document 2 was being sent to the emergency room for abnormal Hemoglobin. R2's admission assessment dated [DATE] documents she returned from the hospital after hospitalization for low Hemoglobin that was treated with blood transfusions. R2's Medical Record does not contain any other follow up or mention of R2's condition after hospitalization. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to put a splint on as ordered for one resident (R6) of one resident reviewed for positioning/mobility in a total sample of thirty eight. R6's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Bipolar, Post Traumatic Stress Disorder and Encephalopathy. R6's Physical Therapy Discharge summary dated [DATE] documents, (R6) exhibits good improvements in right ankle range of motion. Correspondence with primary caregivers (facility staff) to facilitate development and follow-through of patient's plan and discussed equipment needs in preparation for next level of care. The facility's Training Acknowledgement training sign in sheet documents the topic as correct donning right AFO (Ankle Foot Orthosis). Put on Right AFO in the morning and remove before bed. for (R6). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure prompt communication between Hospice Services and the facility for one resident (R6) of three residents reviewed for Hospice Services in a total sample of thirty eight. The Facility's Hospice Services Agreement signed and dated 8/1/2023 documents Hospice personnel shall provide all necessary oversight of services provided to Residents in accordance with the Hospice Plan of Care. Hospice shall review documentation of such services and shall communicate weekly Facility personnel to ensure that the needs of Residents are met in a comprehensive, coordinated fashion twenty-four hours a day. Such communication shall be documented pursuant to Hospice Policy. R6's Medical Record documents she was admitted to the facility on Hospice Services on 12/10/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident rooms in a clean and safe manner for four residents (R6, R8, R12, and R13) of four reviewed for safe, clean and homelike environment in a sample of 15. Findings Include:Facility's Maintenance Director Job Description dated 3/2024 documents: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. On 9/3/25 at 1:30 PM V1 stated he is unable to locate a policy for cleaning the air conditioner units in resident rooms. [...]

Inspectors wroteBased on interview and record review the facility failed obtain physician ordered weekly weights for one resident of three residents (R1) reviewed for weights in a sample of 15. Findings Include:The facility's Significant Weight Gain or Loss Policy dated 02/2025 documents, All residents will be weighed monthly unless physician order indicates differently. R1's physician's orders, dated 9/5/25, document weekly weights were ordered to begin for R1 on 6/23/25. R1 also has orders to receive the following medications for the diagnosis of congestive heart failure: Torsemide 20mg (milligrams) by mouth daily, Diltiazem 300mg by mouth daily, Metoprolol Succinate ER 50mg by mouth daily, and Aldactone 12.5mg by mouth. On 9/3/25 at 11:17 AM, R1 stated she has not been getting weighed because the machine used to weigh her has been broken. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement new interventions after falls and failed to complete a thorough post fall assessment for three of three residents (R2, R4 and R5.) reviewed for falls in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to prevent staff to resident verbal abuse for two of three residents (R2 and R3) reviewed for abuse in a sample of three.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's haircut was done safely for 1 of 5 residents (R1) reviewed for safety in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prepared refrigerated foods were labeled and dated with an expiration date, opened foods were stored in covered containers to prevent contamination, the kitchen floor/dry storage room floor were kept clean and free of debris, and kitchen surfaces were kept free from dust and debris. These failures have the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer Covid-19 vaccinations and vaccination education to all employees. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) were provided and completed Dementia training in a 12 month period. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to date oxygen tubing and bag when not in use, place an oxygen sign on resident doors, and ensure a nebulizer facemask and tubing was changed weekly for four of five residents (R2, R6, R7, R11) reviewed for respiratory care in a sample of 36.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented for five of five residents (R2, R10, R17, R47, and R51) reviewed for infection control in a sample of 36. The facility's Enhanced Barrier Precautions Policy, dated 3/2024, documents, Statement of Purpose: Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Personnel: Personnel providing direct care. Personal Protective Equipment: Gown and gloves. Policy: EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains etc. (Etcetera). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with new diagnoses of mental illness after admission was referred to the state agency for a level II PASARR (Preadmission Screening and Resident Review) evaluation for one of two residents (R7) reviewed for PASARR screening in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a Physician's Wound Order for one of two residents (R47) reviewed for wound care in a sample of 36. Findings Include: The Facility's Pressure Injury and Skin Condition Assessment Policy, dated/revised 01/2018, documents, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses noted. R47's Physician Order Sheet, dated 3/19/2025, documents Non-Pressure Wound of the Right Second toe. Dressing Treatment Plan, Primary Dressing: Betadine apply once daily for 23 days. Secondary Dressing: Gauze Island with border apply once daily for 23 days. On 3/25/2025 at 11:06 AM, V11 (RN/Registered Nurse) entered R47's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative services were being provided for 3 of 3 residents (R1, R2, R3) reviewed for restoratives and range of motion in a total sample of three.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of resident property for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for missing medications, in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to keep medications secure for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for medication storage, in a sample of 15. The facility policy, Narcotic/Controlled Substances- Counting, dated (reviewed) 11/2023 directs staff, To count controlled substances with a partner and to verify the accuracy of the log sheets. General Guidelines: Always participate in the counting of the controlled substances at the beginning and ending of your shift. If you do not observe the medication that you sign as being present, you may be implicated if the medications are later missing. Follow your facilities specific guidelines and use their specific log sheet. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a staff member treated a resident with respect for one of six residents (R1) reviewed for resident rights in the sample of five.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to a resident identified as an elopement risk, who had been exhibiting an increase in verbalizations of exit seeking behavior. On the morning of 05/18/24, R1 removed his (elopement alert bracelet) and exited the facility unnoticed. R1 was later found propelling his wheelchair approaching a road containing a high volume of traffic. R1 was one of three residents reviewed for wandering/elopement in the sample of three. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 07/10/2024, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their In-service training and Quality Assessment oversight.

Inspectors wroteBased on interview and record review the facility failed to: 1) implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections; 2) ensure antibiotic usage was appropriate, and 3) use of a nationally recognized surveillance criteria to define infections for 3 of 3 (R34, R57, R58) residents reviewed for the Antibiotic Stewardship Program in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing to meet the needs of the residents for four residents (R1, R2, R4, and R5) out of five residents reviewed for activities of daily living and call lights in a sample of five.