Los Arcos Del Norte: Residents Forced to Wait in Soiled Briefs - TX
The violation at Los Arcos Del Norte Care Center came to light after a family member filed a grievance in June, describing how staff repeatedly refused to change Resident #2 when she needed assistance near mealtime.
"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," the family member wrote in the June 9 complaint.
The family member pressed facility leadership for an explanation. An administrator said he would consult with the director of nursing about finding a solution. When the family member contacted an ombudsman about the supposed regulation, they learned the restriction was "baseless."
Resident #2 confirmed the practice during an August 20 interview with state inspectors. She said staff required her to "ask in advance" for toileting assistance because if it was close to mealtime, she had to wait until after eating.
"She stated she was not given a reason for this but was told it was just how the facility operated," inspectors wrote.
The resident described sitting through meals while soiled. She called the experience "uncomfortable, embarrassing, and irritating."
Nobody had told her she could refuse this treatment.
"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," the inspection report stated.
The facility's handling of the family's grievance revealed additional problems. The social worker who received the complaint determined it was reportable to the state because it mentioned neglect, but then failed to complete required documentation.
"She stated it was not completed because it was reportable," inspectors noted of the social worker's explanation.
The social worker acknowledged she hadn't reviewed the facility's grievance policy before that day, despite having access to it. When inspectors showed her the policy during their visit, she realized nothing in it supported skipping documentation for reportable complaints.
"The SW stated that if it had not been reported to the state, the grievance could have fallen through the cracks," the report stated.
The director of nursing admitted the investigation wasn't documented at all. She told inspectors the administrator and social worker had conducted an investigation and resolved the matter, but acknowledged the risks of their approach.
"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," inspectors wrote.
The facility's own grievance policy, dated October 2019, required staff to complete and sign all appropriate sections of complaint forms. It also mandated that the social worker "ensures all sections of the Complaint/grievance report are completed appropriately and signed by the staff completing the investigation and developing the resolution."
The social worker acknowledged that even with the state report filed, "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."
The practice of delaying personal care for meals appears to have been widespread enough that residents accepted it as normal facility operation. Resident #2's assumption that the policy was standard suggests other residents may have experienced similar treatment without complaint.
Federal regulations require nursing homes to provide necessary care and services to maintain each resident's highest level of physical and mental well-being. The regulations make no exception for meal service times.
The family member who filed the original grievance described feeling that "the patients are being neglected and the progress of the staff was making has faltered." Their complaint specifically noted the administrator's promise to find a solution, suggesting facility leadership recognized the practice was problematic.
The ombudsman's response that the restriction was "baseless" and suggestion to file a grievance indicates the practice violated established standards of care. State health services investigators confirmed no regulation or law supported the facility's approach.
The violation occurred despite the facility having clear policies requiring proper grievance documentation and investigation. The social worker's admission that she hadn't reviewed the policy she was responsible for implementing points to broader compliance issues.
The administrator's initial response to the family complaint suggested awareness that the practice might be inappropriate, yet the facility continued requiring residents to wait for personal care during meal periods.
State inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the impact on Resident #2 was significant enough that she described feeling uncomfortable, embarrassed, and irritated by the forced delays.
The case illustrates how nursing home practices can become normalized even when they violate basic dignity standards. Resident #2's acceptance of the policy as "just how the facility operated" suggests inadequate communication about resident rights.
The facility's failure to document its investigation of the grievance left no record of what corrective actions, if any, were taken to address the meal-time restriction policy.
The social worker's acknowledgment that grievances could "fall through the cracks" without proper reporting procedures reveals systemic weaknesses in the facility's complaint resolution process.
Los Arcos Del Norte Care Center's practice of making residents wait in soiled briefs during meals had no regulatory foundation, yet continued until a family member's persistent questioning exposed the policy as unfounded.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Los Arcos Del Norte Care Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LOS ARCOS DEL NORTE CARE CENTER in EL PASO, TX was cited for violations during a health inspection on August 22, 2025.
The family member pressed facility leadership for an explanation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.