Los Arcos Del Norte: Unlawful Restraint Device - TX
Los Arcos Del Norte Care Center installed what staff called a "scoop/booster mattress" on Resident #3's bed to prevent falls and help with repositioning. The device created raised borders designed to keep the resident from rolling off the bed.
But the facility violated federal regulations by failing to follow basic safety protocols before using the restraint-like device.
Resident #3 required maximum assistance for transfers and could not walk independently. A physical therapy evaluation classified the resident as needing maximum assistance for bed mobility. Staff described the resident as having significant deficits affecting self-care tasks and functional mobility.
The Director of Nursing acknowledged during an August 20 interview that she could not recall if there was a physician order for the scoop mattress. She later confirmed no physician order existed for the device.
"There would have to be an order for use of the scoop/booster mattress," the Director of Nursing told inspectors. She also admitted no consent form was obtained before placing the device on the resident's bed.
The facility's own policy required evaluating residents for entrapment risk before installing bed rails or similar devices. Staff never conducted this assessment.
The Director of Rehabilitation explained during an August 21 interview that therapy staff had evaluated 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."
He confirmed the resident was unable to walk and required maximum assistance for bed mobility and transfers. Given these limitations, he said 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."
Most concerning, the Director of Rehabilitation identified a critical safety issue. "If there were an emergency Resident # would not be able to get out of bed on his own," he told inspectors.
The Administrator confirmed during an August 22 interview that 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."
He explained that proper assessment was essential because the evaluation would "make sure the scoop/booster mattress fit Resident #3 and was an enabler as not doing so could be a risk of entrapment."
The resident's nurse practitioner was not involved in the decision to use the device. When interviewed on August 22, NP B stated he was "not too familiar with the scoop/booster mattress" and confirmed "there were no orders for the scoop/booster mattress as he did not give any nor were any asked by the facility to him."
The nurse practitioner warned that without proper evaluation, "the negative outcome would be that the scoop/booster mattress would be not appropriate for Resident #3's use."
Federal regulations require nursing homes to ensure residents are free from restraints unless specifically ordered by a physician for medical reasons. The regulations also mandate proper consent and safety evaluations before using any device that restricts movement.
Los Arcos Del Norte's own policy, dated May 5, 2025, outlined the required safety procedures. The policy stated the facility would "attempt to use appropriate alternatives prior to installing a side or bed rail" and would "ensure the correct installation, use and maintenance of bed rails/side rails when their use was determined to be appropriate."
The policy specifically required that "the resident will be evaluated for the risk of entrapment prior to installation."
The facility listed acceptable alternatives including "roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed." Staff apparently skipped these alternatives and moved directly to the more restrictive scoop mattress without following their own procedures.
The violation affected a vulnerable resident who was completely dependent for lower body dressing and required maximum assistance for upper body dressing and toileting. The resident's cognitive status was also impaired, according to inspection records.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents during their August 22 complaint investigation.
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.
Los Arcos Del Norte Care Center installed what staff called a "scoop/booster mattress" on Resident #3's bed to prevent falls and help with repositioning.
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.