Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arc At El Paso during CMS and state inspections, most recent first.
Failure to prevent resident-to-resident abuse occurred when a resident with dementia and behavior issues pushed another resident’s wheelchair without being asked, leading to a physical altercation in which the other resident hit back and the resident pulled her hair. A CNA witnessed the incident, separated the residents, and reported it, while the facility’s abuse investigation confirmed no staff saw the initial event.
Surveyors observed that air conditioner units in two resident rooms had visible mildew and holes in the surrounding foam, with staff unable to provide a cleaning policy for these units. The Maintenance Director reported that cleaning occurs twice per season but was unsure of any formal procedures, resulting in a failure to ensure a clean and safe environment.
A resident with congestive heart failure and physician orders for weekly weights did not have weights obtained as required, with only three weights recorded over several weeks. The resident reported not being weighed because the weighing equipment was broken, and facility staff confirmed the mechanical lift with the scale had been nonfunctional, leading to missed weight monitoring.
Three residents with cognitive and mobility impairments experienced unwitnessed falls, but staff failed to complete thorough post-fall assessments and did not implement new, individualized interventions. Documentation was incomplete, with key risk factors and environmental factors not assessed, and care plan updates were either generic or not carried out as described.
Two residents experienced verbal and physical abuse from a CNA, including the use of profanity, yelling, and rough handling during care. Staff statements confirmed a pattern of abusive behavior, and the incidents were reported and investigated, with the CNA suspended and later resigning.
A resident with cognitive impairment and multiple medical conditions was injured during a haircut and beard trim performed by a CNA who was not a licensed beautician. The CNA removed the guard from electric clippers, resulting in cuts and a rash on the resident's neck and head, despite the resident's protests. Multiple staff and the resident's family observed the injuries, and the facility lacked a policy governing hair or beard cuts for residents.
The facility did not provide the required eight consecutive hours of RN coverage on a specific day, as confirmed by staff schedules and postings. Only LPNs were available, and the absence of an RN was acknowledged by the Administrator and an LPN/Infection Control Preventionist, who noted ongoing RN shortages every other weekend. This deficiency potentially affects all 49 residents.
The facility failed to label and cover refrigerated foods properly and maintain cleanliness in the kitchen and dry storage areas. Observations included unlabeled and uncovered food items, a dirty dry storage room floor with cigarette butts, and a kitchen with dirt, debris, and grease buildup. The cook confirmed these deficiencies, indicating non-compliance with the facility's sanitation policies.
The facility did not offer COVID-19 vaccinations or provide vaccination education to all employees, potentially affecting all 49 residents. The LPN/Infection Control Preventionist confirmed the lack of documentation for offering vaccines or education to staff. Employees are directed to local pharmacies for vaccination at their own expense unless extra vaccines are available after resident vaccinations.
The facility did not ensure CNAs completed required dementia training within a 12-month period, affecting all 49 residents. The facility's assessment tool required dementia management and abuse prevention training as part of the annual 12-hour in-service training. However, training reports for three CNAs showed no completed dementia training. The administrator confirmed the lack of training, despite several residents having dementia.
The facility failed to follow its policy on respiratory equipment management, resulting in undated and un-bagged nebulizer masks and tubing, and missing oxygen signs on resident doors. Residents with conditions like COPD were affected, as their equipment was not properly maintained or labeled, and an LPN confirmed these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by their policy. Staff did not wear gowns during high-contact care activities, and there was a lack of signage and PPE outside residents' rooms. The Infection Control Preventionist confirmed the absence of necessary precautions, indicating a systemic issue in infection control adherence.
A facility failed to refer a resident with new mental illness diagnoses for a Level II PASARR evaluation. The resident was initially admitted with no known mental health issues, but later diagnosed with Major Depressive Disorder and Psychotic Disorder with Hallucinations. Despite these new diagnoses, no further PASARR screening was documented. The Social Service Director acknowledged the oversight, noting the resident was on the list for a new screening but had not yet been submitted.
A facility failed to follow a physician's wound care order for a resident with a non-pressure wound on the right second toe. The order required Betadine application followed by a gauze island dressing. An RN applied Betadine but omitted the dressing, unaware of the correct order. The LPN responsible for entering wound orders admitted to missing the updated order, leading to an incorrect entry in the resident's chart.
The facility failed to inform residents and their representatives about the implications of signing a binding arbitration agreement, affecting all 49 residents. The Social Service Director admitted that residents were not told they were giving up the right to sue the facility. Interviews revealed that residents and a Power of Attorney were unaware of the agreement's meaning, leading to confusion and concern.
The facility failed to provide sufficient staffing, impacting care for all 60 residents. Staffing levels were below the required number, with CNAs unable to complete assignments and residents lacking assistance with activities. The CNA Scheduler scheduled based on census rather than the facility assessment, contributing to the issue.
The facility failed to provide restorative services for three residents, as evidenced by incomplete ROM exercises, inconsistent dressing and grooming assistance, and inadequate ambulation support. Interviews revealed that residents did not receive necessary therapy or assistance, and a CNA admitted to lacking time for restorative tasks. The DON acknowledged the deficiency.
The facility did not post the Daily Staffing Report in a visible location, affecting all 58 residents. The report was obscured by a portable stand and had not been updated since 10/29/24. Several residents were unaware of its location. The DON and Interim Administrator confirmed the issue.
The facility inaccurately reported its PBJ staffing information, affecting all 58 residents. The deficiency was due to the former administrator not including agency nurses and CNAs in the reports, and management staff not clocking in when covering shifts. Observations and interviews indicated adequate staffing levels, but the oversight led to reported staffing levels appearing lower than they were.
A former RN at a facility misappropriated narcotics, resulting in 898 missing pills from nine residents. The issue was discovered after the State Attorney General's office informed the facility of an investigation into the RN's activities at multiple nursing homes. An internal audit revealed that the RN diverted medications during pharmacy deliveries, violating the facility's abuse prevention policy.
A facility failed to secure medications for nine residents, leading to the misappropriation of 898 narcotic pills. The facility's policy required staff to count controlled substances with a partner and verify log sheets, but these guidelines were not followed. An investigation revealed that a staff member misappropriated medications during pharmacy deliveries. The affected residents had various conditions requiring pain management, and the medications involved included Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Morphine Sulfate.
A resident reported a disrespectful interaction with a CNA during a night shift, where the CNA ignored the resident's instructions regarding a malfunctioning bed remote, leading to a blown breaker and deflated air mattress. The CNA raised her voice and made a dismissive comment, which the resident found disrespectful. The CNA later admitted to trying to fix the remote despite the resident's objections.
A resident identified as an elopement risk exited a facility unnoticed after removing his elopement alert bracelet. Despite verbalizing his intent to leave and having a care plan in place, the facility failed to provide adequate supervision and monitoring. The resident was found near a busy road, highlighting the facility's failure to implement necessary interventions and ensure the functionality of elopement prevention measures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving one resident with dementia, anxiety, and depression who had care plan focus areas for behavior problems, wandering, yelling at staff, poor safety awareness, and impaired communication. The resident was involved in an altercation in the hallway near the nurse’s station with another resident, and both residents were separated after the incident was reported. The facility’s abuse investigation documented that no staff witnessed the initial allegation, and the residents and employees with knowledge of the event were interviewed. The investigation and later interviews showed that the resident was pushing the other resident’s wheelchair without being asked, despite repeated requests to stop. The other resident stated she reached back and hit the resident, after which the resident pulled her hair and caused pain. A CNA stated she saw the resident pushing the wheelchair, heard yelling, saw the other resident reach back toward the resident, and then witnessed the resident pull the other resident’s hair before separating them and reporting the incident to the nurse. The facility policy stated residents have the right to be free from abuse and defined abuse as the willful infliction of physical harm, pain, or mental anguish.
Failure to Maintain Clean and Safe Resident Rooms Due to Mildew on AC Units
Penalty
Summary
Surveyors found that the facility failed to maintain resident rooms in a clean and safe manner for four residents. Observations revealed that air conditioner units in two resident rooms had vent slats with multiple pinpoint black spots, identified by the Maintenance Director as likely mildew. Additionally, there were foam tubes around the AC units with holes large enough to allow daylight to be seen. The Maintenance Director stated that the units are cleaned twice per season to prevent mildew buildup but was unsure if a formal policy exists for cleaning the air conditioner units. The facility was unable to provide a policy for cleaning these units during the survey. These findings were based on direct observation, staff interviews, and review of facility documentation, and they demonstrate a failure to ensure a safe, clean, and homelike environment as required by regulation.
Failure to Obtain Physician-Ordered Weekly Weights Due to Equipment Malfunction
Penalty
Summary
The facility failed to obtain physician-ordered weekly weights for one resident who was prescribed this monitoring due to a diagnosis of congestive heart failure and related medications, including Torsemide, Diltiazem, Metoprolol Succinate ER, and Aldactone. According to the facility's policy, residents are to be weighed monthly unless otherwise ordered by a physician. In this case, the physician ordered weekly weights to begin on 6/23/25. However, the resident was only weighed on three occasions between 6/23/25 and 8/17/25, and no weights were recorded from 7/8/25 through 9/3/25. The resident reported not being weighed due to a broken weighing machine, and facility staff confirmed that the mechanical lift with the scale had not been functioning since 7/10/25, resulting in the failure to obtain the required weights.
Failure to Implement New Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to implement new interventions after falls and did not complete thorough post-fall assessments for three residents with a history of falls. For one resident with dementia, cerebral infarction, and hemiplegia, documentation after an unwitnessed fall was incomplete, with several relevant risk factors such as medication use, impaired vision, and participation in restorative programs not assessed or marked. The care plan intervention added after the fall was not substantially different from existing interventions, and the interdisciplinary team did not identify or implement a new, individualized approach. Another resident with dementia, anxiety, and a thoracic spine fracture experienced an unwitnessed fall, but the post-fall assessment form was inadequately completed, omitting key risk factors such as osteoporosis, pain, and use of anti-hypertensive medication, all of which were present in the resident's medical record. Environmental and situational factors were also not assessed. The care plan referenced a floor bed and mat, but the resident was observed with a regular bed, and the intervention added after the fall was generic and not clearly linked to the specific circumstances of the incident. A third resident with Alzheimer's disease, gait abnormalities, and osteoporosis also had an unwitnessed fall. The post-fall assessment lacked documentation of environmental, physiological, and situational risk factors, and the facility was unable to provide evidence of a 72-hour monitoring assessment as claimed by the DON. The facility's fall prevention policy requires individualized assessment and immediate changes in interventions after falls, but these requirements were not met for the residents reviewed.
Failure to Prevent Staff-to-Resident Verbal and Physical Abuse
Penalty
Summary
Staff failed to prevent verbal and physical abuse towards two residents by a Certified Nursing Assistant (CNA). One resident reported that the CNA used profanity and yelled at her while providing care, as corroborated by another CNA who overheard the incident and reported it to a nurse. Multiple staff statements indicated that the CNA had a pattern of being rude, using curse words, and yelling at residents. The facility's 24-hour Abuse Investigation Report documented that the CNA was suspended immediately pending investigation after the incident was reported. Another resident described being physically handled roughly by the same CNA when she refused to get out of bed, stating that the CNA held her arms down and insisted she get dressed despite her continued refusal. The resident reported the incident to the next shift. The facility's investigation confirmed that the CNA was suspended following these allegations, but the CNA resigned before the investigation was completed. The facility's policy prohibits all forms of abuse, including verbal and physical abuse, and defines verbal abuse as the use of oral, written, or gestured communication that is abusive toward residents.
Untrained Staff Causes Injury During Resident Haircut
Penalty
Summary
A resident with a history of cerebral infarction, vascular dementia, aphasia, and moderate cognitive impairment received a haircut and beard trim from a CNA who was not a licensed beautician. The CNA used electric clippers, removed the guard during the process, and cut the resident under the chin, causing the resident to yell out in pain. Despite the resident's protests, the CNA continued the haircut, resulting in additional discomfort and visible injuries, including a large red area, razor rash, and nicks on the resident's neck and behind the ear. Multiple staff members and the resident's daughter observed and confirmed the injuries and the resident's distress following the haircut. The facility administrator acknowledged that the CNA was not authorized or trained to provide haircuts and that no CNAs in the facility were licensed beauticians. The facility was unable to provide any policy related to hair or beard cuts for residents, though an in-service sign-in sheet indicated that only licensed barbers or hairstylists were permitted to perform such services. The incident was further corroborated by interviews with other CNAs, who reported seeing the resident's injuries and hearing the resident's complaints. The facility's Resident Rights policy requires services to maintain residents' physical and mental health at their highest practical levels, but this standard was not met in this instance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of a Registered Nurse (RN) daily, as required by CMS minimum staffing requirements. This deficiency was identified through interviews and record reviews, which revealed that on a specific date in March 2025, the facility did not have any RN coverage for the entire day. The facility's nursing staff schedule and daily staff postings confirmed the absence of an RN, with only Licensed Practical Nurses (LPNs) providing care. The Administrator and an LPN/Infection Control Preventionist acknowledged the accuracy of the staffing records and confirmed the lack of RN coverage, citing ongoing RN shortages every other weekend. This failure potentially affects all 49 residents residing in the facility.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that prepared refrigerated foods were labeled and dated with an expiration date, and that opened foods were stored in covered containers to prevent contamination. During an inspection of the kitchen, it was observed that several food items, including green beans, ham salad, fruit crisp, cooked cabbage, peeled potatoes, and green gelatin, were not labeled with expiration dates. Additionally, the fruit crisp was found uncovered. The cook verified these observations and acknowledged that the items should have been labeled and covered as per the facility's policy. The inspection also revealed that the kitchen and dry storage areas were not maintained in a clean and sanitary condition. The dry storage room floor was covered in dirt, debris, and cigarette butts, which the cook confirmed should have been cleaned. The kitchen floor had dirt, debris, old food, and crumbs underneath the preparation tables. The stove had a thick grease splatter, and the oven had black crusted matter built up inside. Dust and debris were also found on a shelf above the stove and underneath the steam table. The cook acknowledged that these areas needed cleaning, indicating a failure to adhere to the facility's sanitation policies.
Failure to Offer COVID-19 Vaccinations and Education to Staff
Penalty
Summary
The facility failed to offer COVID-19 vaccinations and vaccination education to all employees, which has the potential to affect all 49 residents residing in the facility. According to the facility's Interim COVID-19 Vaccination Guidelines, staff should be provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine and offered the vaccine or information on obtaining it. However, the Licensed Practical Nurse/Infection Control Preventionist (V13) stated that there is no documentation to show that COVID-19 vaccinations are offered to all employees or that they are given education related to the vaccine. Staff are instructed to go to the local pharmacy to get vaccinated if they choose, and they are expected to pay for it themselves unless there are extra vaccines available after vaccinating residents.
Failure to Provide Required Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received and completed required dementia training within a 12-month period, potentially affecting all 49 residents. The facility's assessment tool, dated July 1, 2024, indicated the need for dementia management training and resident abuse prevention training as part of the required 12 hours of annual in-service training for nurse aides. However, a review of the training reports for three CNAs (V18, V19, and V20) revealed no documentation of completed dementia training from March 2024 to March 2025. The administrator, who started in January, confirmed the absence of dementia-specific training for CNAs, despite several residents having a dementia diagnosis.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to adhere to its own Oxygen and Respiratory Equipment-Changing/Cleaning Policy, resulting in several deficiencies in respiratory care for residents. Specifically, the facility did not date oxygen tubing and bags when not in use, failed to place oxygen signs on resident doors, and did not change nebulizer facemasks and tubing weekly for four residents. These residents were observed with undated and un-bagged nebulizer masks and tubing, and rooms lacking necessary oxygen signage. The policy clearly outlines the need for weekly changes and proper storage of respiratory equipment to minimize infection risk, but these procedures were not followed. The residents involved had various medical conditions requiring respiratory support, such as Chronic Obstructive Pulmonary Disease and the need for continuous oxygen therapy. For instance, one resident's nebulizer mask and tubing were found lying undated and un-bagged on their bed, while another resident's nasal cannula was undated and un-bagged, with no oxygen sign outside their room. An LPN verified these deficiencies, acknowledging that all respiratory equipment should be changed and dated every seven days, and bagged between uses, with oxygen signs placed outside rooms when residents are on oxygen therapy.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for five residents who required such measures due to chronic wounds or indwelling medical devices. The facility's policy mandates the use of gowns and gloves during high-contact care activities for residents with these conditions, regardless of their multidrug-resistant organism status. However, observations revealed that staff did not adhere to these precautions. For instance, a registered nurse performed wound care on a resident's buttock without wearing a gown, and another nurse treated a wound on a resident's foot without using any personal protective equipment (PPE) aside from gloves. Additionally, the facility did not display signs or provide PPE outside the rooms of residents who required EBP, such as those with enteral feeding tubes or indwelling urinary catheters. This lack of signage and PPE storage was confirmed by the facility's Infection Control Preventionist, who acknowledged that the necessary precautions were not in place for the affected residents. The failure to implement EBP as per the facility's policy was observed across multiple instances, indicating a systemic issue in adhering to infection control protocols.
Failure to Conduct PASARR Level II Evaluation for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with new diagnoses of mental illness after admission was referred to the state agency for a Level II PASARR evaluation. The facility's policy requires screening all potential admissions on an individualized basis and conducting PASARR Level I for all new and readmissions to determine if the individual meets the criteria for mental disorder, intellectual disability, or related condition. Annually and with any significant change of status, the facility is required to complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The resident in question was admitted to the facility with no known or suspected mental health diagnosis according to the most recent Level I PASARR evaluation. However, after admission, the resident was diagnosed with Major Depressive Disorder and Psychotic Disorder with Hallucinations due to a known physiological condition. Despite these new diagnoses, the resident's medical record did not document any further PASARR screening or evaluation since admission. The Social Service Director confirmed that the resident had not had a PASARR re-screen or a Level II screening, acknowledging that the resident was on the list for a new screening due to the new diagnoses but had not yet been submitted for it.
Failure to Follow Physician's Wound Care Order
Penalty
Summary
The facility failed to adhere to a physician's wound care order for a resident with a non-pressure wound on the right second toe. The physician's order, dated 3/19/2025, specified that Betadine should be applied once daily, followed by a gauze island dressing with a border. On 3/25/2025, a registered nurse (RN) cleansed the wound with normal saline and applied Betadine but did not apply the required protective island dressing. The RN acknowledged the omission, stating she was unaware of the correct order. Additionally, the licensed practical nurse (LPN) responsible for reviewing and entering wound orders admitted to missing the updated order, resulting in the incorrect entry in the resident's chart.
Failure to Inform Residents About Arbitration Agreement
Penalty
Summary
The facility failed to adequately inform residents or their representatives about the binding arbitration agreement, which had the potential to affect all 49 residents residing in the facility. The Administrator admitted there was no policy in place for the arbitration agreement, and the Social Service Director revealed that residents and their representatives were shown a video and given a contract to sign, but were not explicitly informed that signing the agreement meant giving up the right to sue the facility. This lack of clear communication was evident in interviews with residents and a Power of Attorney, who expressed confusion and lack of understanding about the arbitration agreement. During a Resident Council Meeting, several residents confirmed they did not understand what an arbitration agreement was and that it was never explained to them. One resident, who had recently been admitted, expressed a desire to change the agreement upon learning its implications. The Ombudsman reported that this resident was shocked and upset upon discovering the meaning of the arbitration agreement, indicating a significant gap in the facility's communication and consent process regarding arbitration agreements.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to care for dependent residents, affecting all 60 residents residing in the facility. The Facility Assessment Tool indicated that staffing should include one RN, one LPN, and six CNAs for both day and evening shifts, and one LPN and five CNAs for night shifts. However, on the day in question, the facility's Daily Staffing Sheet documented that the first shift was staffed with one RN, one LPN, and five CNAs, while the second shift had two LPNs and five CNAs. This staffing level was below the required number as per the facility's assessment. Interviews with staff and residents revealed the impact of insufficient staffing. CNAs reported being unable to complete their assignments, with each caring for 10-15 residents, leaving no time for restorative or walking activities. Residents confirmed the lack of assistance with walking or range of motion activities. Additionally, a strong urine smell was noted in one of the rooms, which was later addressed by the staff. The CNA Scheduler admitted to scheduling based on census rather than the facility assessment, leading to inadequate staffing levels. The Director of Nursing acknowledged the issue and indicated awareness of the urine smell problem.
Failure to Provide Restorative Services for Residents
Penalty
Summary
The facility failed to provide restorative services for three residents, as observed through a combination of observation, interviews, and record reviews. The facility's Restorative Nursing Program policy, revised in January 2019, aims to promote residents' independence through various programs, including range of motion (ROM) exercises, dressing and grooming, and mobility assistance. However, the records for three residents showed significant gaps in the implementation of these restorative services. For instance, one resident's active ROM exercises were not completed on several shifts, and their dressing and grooming assistance was also inconsistent. Another resident's bed mobility and ambulation with staff were not performed as required, with ambulation distances falling short of the prescribed 100-200 feet. The third resident did not receive daily restorative programs for dressing and grooming, with staff performing these tasks for them instead. Interviews with the residents and staff further confirmed the lack of restorative care. One resident reported not receiving therapy or walking assistance with their wheeled walker, relying solely on a wheelchair. Another resident stated that no staff assisted them with moving their arms or legs or dressing. A third resident, who required a mechanical lift for mobility, mentioned that staff did not engage them in any restorative program for dressing and grooming. A CNA admitted to not having time to complete restorative tasks or assist residents with walking. The Director of Nursing acknowledged the deficiency, agreeing that restorative services were not being adequately provided.
Failure to Post Daily Staffing Report
Penalty
Summary
The facility failed to post the Daily Staffing Report in a location visible to all residents and visitors, affecting all 58 residents. On 11/6/24, the Nurse Staffing posting was found near the Receptionist desk, obscured by a portable stand, and had not been updated since 10/29/24. Residents R2, R9, R10, and R12 were unaware of the posting's location. The Director of Nursing confirmed the posting's location and acknowledged it had not been updated. The Interim Administrator also confirmed the posting was not easily visible and should be updated daily.
Inaccurate PBJ Staffing Reporting
Penalty
Summary
The facility failed to accurately report its Payroll-Based Journal (PBJ) staffing information, affecting all 58 residents. The deficiency was identified through a review of the facility's PBJ Staffing Data Report for fiscal year Quarter 3, 2024, which indicated excessively low weekend staffing. Observations and interviews with residents and staff revealed that the facility was generally perceived to have adequate staffing levels, with six CNAs, two RNs, and one LPN working on the day shift. Residents and staff reported that their needs were being met, and no complaints about staffing were raised during Resident Council meetings. The issue arose because the former administrator did not include the hours worked by agency nurses and CNAs in the PBJ staffing reports. Additionally, management staff, who were salaried, did not clock in when covering shifts, leading to their hours not being counted in the PBJ reports. This oversight resulted in the facility's reported staffing levels appearing lower than they actually were. The VP of Clinical Operations discovered these discrepancies after comparing staff timecard reports to daily schedules and confirmed that the facility had more staff than reported.
Misappropriation of Narcotics by Former RN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically narcotics, by a former employee, a registered nurse (RN) identified as V6. The issue was discovered when the facility was informed by the State Attorney General's office that V6 was under investigation for narcotic diversion at multiple nursing homes. The facility's own investigation revealed that V6 had misappropriated full cards of narcotics during the time they worked at the facility, resulting in 898 missing narcotic pills from nine residents. The medications involved included Norco and Oxycontin, which were dispensed to residents but went missing. The facility's policy on abuse prevention and reporting, which includes the protection of residents from misappropriation of property, was not followed. The missing medications were identified through an audit conducted by the Regional Director of Operations, who found that the misappropriation occurred when the local pharmacy made deliveries. The residents affected by the missing medications were reimbursed by the facility, and the incident was reported to the residents' medical doctors, the local police department, and the Ombudsman. The facility suspended V6 pending the investigation, but V6 did not participate in the investigation and was subsequently terminated.
Medication Security Breach in LTC Facility
Penalty
Summary
The facility failed to maintain secure storage of medications for nine residents, as identified in a sample of 15. The facility's policy on narcotic and controlled substances counting requires staff to count controlled substances with a partner and verify the accuracy of log sheets at the beginning and end of each shift. However, the facility did not adhere to these guidelines, leading to the misappropriation of medications. The investigation revealed that during the days a specific staff member, identified as V6, worked, there were discrepancies in medication counts. This staff member was able to misappropriate full medication cards of narcotics during pharmacy deliveries by not following the facility's policy. The investigation, conducted by the Regional Director of Operations, found that 898 narcotic pills were missing from nine different residents. The residents affected had various medical conditions requiring pain management, including peripheral vascular disease, osteoarthritis, joint replacement aftercare, and multiple sclerosis. The medications involved included Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Morphine Sulfate, which were prescribed for pain management. The failure to secure these medications compromised the facility's ability to provide appropriate care to these residents.
Resident Rights Violation Due to Disrespectful Staff Interaction
Penalty
Summary
The facility failed to ensure that a staff member treated a resident with respect, violating the resident's rights. The incident involved a cognitively intact resident who reported that a Certified Nursing Assistant (CNA) acted disrespectfully during a night shift. The resident had requested assistance with a urinal, and the CNA attempted to adjust the bed using a remote control that the resident had informed her worked in reverse. Despite the resident's instructions to leave the remote alone, the CNA proceeded to tamper with the cords under the bed, resulting in a blown breaker and a deflated air mattress. The resident expressed feeling disrespected when the CNA raised her voice and made a dismissive comment, telling the resident to "get your big boy pants on." The CNA admitted to trying to fix the remote despite the resident's objections and mentioned that she speaks loudly due to hearing issues. The Director of Nursing confirmed that the CNA received education on resident rights and the importance of treating residents with dignity and respect.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement risk, leading to an incident where the resident exited the facility unnoticed. The resident, who had been exhibiting increased verbalizations of exit-seeking behavior, managed to remove his elopement alert bracelet and left the facility. He was later found propelling his wheelchair towards a busy road, posing a significant risk to his safety. This incident was part of a review of three residents identified for wandering or elopement risks. The resident's medical record indicated a history of cognitive impairment, including diagnoses of vascular dementia and delusional disorder, which contributed to his elopement risk. Despite being assessed as at risk for elopement and having a care plan in place, the facility failed to implement necessary interventions such as frequent monitoring and ensuring the functionality of the elopement alert bracelet. On the day of the incident, the bracelet was not checked during the day shift, and the resident was able to exit the building without triggering an alarm. Interviews with staff revealed that the resident had been verbalizing his intent to leave the facility, and his personal belongings were packed, indicating a plan to elope. However, staff did not provide the required 1:1 supervision or increased monitoring, despite being aware of the resident's intentions. The facility's failure to act on these warning signs and ensure the proper functioning of elopement prevention measures resulted in the resident's unsupervised departure and subsequent immediate jeopardy.
Removal Plan
- R1 was assessed by nursing and no pain or skin issues were identified.
- R1 was reassessed for risk of elopement and community survival skills.
- R1 was placed on 1:1 supervision that later decreased to 15 minute checks, documented on Monitoring logs.
- Maintenance staff checked the functionality of the exit door and elopement alert bracelet alarm system.
- The front door alarm code was changed and the keypad code posting was removed.
- All facility residents' most current Elopement Risk Assessments were reviewed for accuracy.
- New Elopement Risk Assessments were completed for every resident in the facility.
- Residents will be evaluated for elopement risk at admission, readmission, quarterly, annually, with a significant change, and incidentally if risk behaviors are identified.
- Elopement Drill/Post-Elopement Checklist logs were completed.
- Nursing staff check residents with elopement alert bracelets each shift to ensure the bracelet is in place.
- Elopement alert bracelets are checked for functionality by nursing and maintenance.
- Facility staff and agency staff have binders to access at the nurse's station containing the facility's Elopement Device policy and Code Pink-Missing Resident/Elopement policy.
- In-services were conducted on Elopement Policy & Procedure, Identifying Risks of Elopement, Wandering/Exit Seeking Behavior, and When to Provide/Implement Increased Supervision.
- In-services were conducted on Elopement and Elopement Alert Bracelets.
- In-services were conducted on 1:1 Supervision specific to nursing staff who provide 1:1 supervision.
- In-services were conducted on Supervision of Elopement Risk Residents Outdoors.
- Staff members were called and given in-service education over the phone.
- A Quality Assurance form titled 'Ad Hoc Quality Assurance (Plan of Correction)' was completed regarding the facility's elopement policy and procedure.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 116 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Paso Rehabilitation And Health Care Center | 0.5 mi | — | 8 | 0 |
| Flanagan Rehabilitation And Health Care Center | 10.3 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Home | 11.4 mi | ★★★★★ | 8 | 0 |
| Loft Rehabilitation & Nursing | 13.9 mi | ★★★★★ | 2 | 1 |
| Mclean County Nursing Home | 14.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.