El Paso Rehabilitation and Health Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's room and to ensure the room was free from food, trash, soiled clothing and dirty floor surfaces for one of four residents (R1) reviewed in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's established bathing/shower schedule and assist a resident with showering for one resident (R2) of four residents reviewed for bathing/showering in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from misappropriation of property for two of four residents (R1 and R7) reviewed for misappropriation of property in a sample of seven.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right by insisting residents provide a two week notice prior to a home visit, for two of five residents (R28 and R90), reviewed for resident rights, in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to distribute mail on Saturdays for three of five residents reviewed (R15, R28 and R90) for mail delivery, in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from verbal and physical abuse for one of two residents (R14) reviewed for abuse in a sample of 36.

Inspectors wroteBased on interview and record review the Facility failed to issue written notification for hospital transfers/discharges to Resident/Resident's Representatives for three of 19 Residents (R5, R14 and R45) reviewed for hospital transfer/discharge in a sample of 36.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a resident who developed a new open skin area received immediate clinical assessment, timely physician notification, and necessary medical orders per facility policy for one of two residents (R4) reviewed for wounds in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter drainage bag remained below the level of the bladder during transfers and routine care for one of one resident (R4) reviewed for urinary indwelling catheters in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the posted diet for three of three residents (R15, R28 and R90), in a sample of 36. The undated facility policy, Menu Substitutions or Changes and Approval directs staff that menu changes are made for instances such as food delivery problems, food quality issues, planned special events or in disaster situations. The facility Spring/Summer Master Menu 2026- week 3 includes the following noon meal for Monday, June 8th: Wheat Roll, Turkey Cutlet and Gravy, Baked Potato, [NAME] Roasted Vegetables and Homemade Frosted Banana Cupcake. The noon meal for Tuesday, June 9th includes: Pork Carnitas and Cheese Quesadilla, Ranchero Beans, Cilantro Coleslaw and Yellow Cake/Chocolate Icing. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the State Guardian of an elopement of a cognitively impaired resident for one of three residents (R1) reviewed for notification in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess a cognitively impaired resident with known exit-seeking behaviors as an elopement risk for one of three residents (R1) reviewed for accuracy of assessments in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement elopement interventions to prevent an elopement of a cognitively impaired resident for one of three residents (R1) reviewed for care plans in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and implement effective interventions to prevent the elopement of a cognitively impaired resident with known exit-seeking behaviors for one of three residents (R1) reviewed for elopement in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse for five of eight residents (R1, R3, R4, R7, and R9) reviewed for abuse in a sample of 9. The facility's Abuse, Prevention and Prohibition Policy, dated November 2025, documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This form also documents that instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from sexual abuse for one of four residents (R1) reviewed for abuse in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family of a resident's return from the hospital for one of three residents (R1), reviewed for family notification, in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to update a plan of care after a resident made repeated attempts, on two different days, to elope from the facility, for one of one resident (R1), reviewed for care plans, in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow diet orders for residents who receive mechanical soft diets, failed to document residents' noncompliance with mechanically altered diets, and failed to educate facility staff on residents who are on mechanically altered diets. These failures resulted in R1, who has a history of choking and requiring the Heimlich Maneuver, being able to purchase snacks from V5 (Medical Records) that were not part of R1's physician ordered diet texture. These failures have the potential to affect all 20 residents (R1, R4 through R22) who reside in the facility that receive a mechanically altered diet. These failures resulted in an Immediate Jeopardy that began on 7/12/25. While the Immediate Jeopardy was removed on 8/08/25, the facility remains out of compliance at a severity level two. [...]

Inspectors wroteBased on record review and interview the facility failed to follow the facility's Discharge/Transfer policy for 1 resident (R2) of 3 residents reviewed for hospitalizations in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse for one of three residents (R2) reviewed for abuse in a sample of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent resident to resident physical abuse by a known perpetrator for two (R22 and R23) of 13 residents reviewed for abuse in the sample of 36. This failure resulted in R22 hitting R23 in the mouth which caused R23 to suffer bleeding from her mouth.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough abuse investigation for three (R22, R23, and R31) of 13 residents reviewed for abuse in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure continuous one-to-one supervision for one known physically aggressive resident (R22) of three residents reviewed for supervision in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter tubing was secured in place for one (R1) of three residents reviewed for indwelling urinary catheters in a sample of 36.

Inspectors wroteBased on interview and record review the facility failed to maintain the privacy of residents' health information for six of six residents (R5, R11, R40-R43) reviewed for confidentiality/privacy in a sample of 43.

Inspectors wroteBased on record review and interview the facility failed to ensure 2 residents (R11 and R31) were free from resident to resident physical abuse of seventeen residents reviewed for abuse in a total sample of 43. Findings Include: The Facility's Abuse, Prevention and Prohibition Policy dated 12/2024 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or their agencies serving the resident, family members or legal guardians, friends or other individuals. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a home-like environment including but not limited to chipped paint, holes, missing trim, loose cable cords and unpainted walls in resident rooms for eight (R10, R11, R17, R26, R46, R59, R66, and R86) of 18 residents reviewed for environment in a sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to process medication orders timely to ensure medications were given per physician order for six of 18 residents (R26, R37, R66, R72, R80, R85) reviewed for physician orders in a sample of 27 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's privacy was maintained (R59) and failed to cover a resident's indwelling urinary catheter bag with a privacy covering (R52) for two of 18 residents reviewed for privacy and dignity in a sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents' activity calendar was able to be visualized for two of two residents (R46 and R60) reviewed for accommodation of needs in a sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a Care plan for Hepatitis C and Blindness for one resident (R60) of 18 residents reviewed for Comprehensive Care plans in a sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to implement nonpharmacological interventions for one (R13) of eight residents reviewed for mood behavior monitoring in a sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the survey book up to date with the most recent survey. This failure has the potential to affect all 88 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to maintain the required minimum of three years of resident grievances results. This failure has the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain a bookkeeping system to adequately record individual resident accounts by not recording the date and amount of all financial transactions and failed to maintain the ongoing balance for any resident's account. This failure affected all 93 residents currently residing at the facility.

Inspectors wroteBased on record review and interview the facility failed to prevent the physical abuse of one of three residents (R3)reviewed for abuse in the sample of eight. Findings Include: The Facility's Abuse, Prevention and Prohibition Policy dated 01/24 documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The policy documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review the facility failed to not base a residents involuntary discharge on the residents status at the time of transfer to an acute care facility and ensure a signed physician discharge order was in place when serving a notice of involuntary discharge for one of three residents (R1) reviewed for involuntary discharge in the sample of eight.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services for one of three residents (R1) reviewed for involuntary discharge in the sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to have a Certified Dietary Manager employed in the kitchen. This has the potential to affect all 95 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staff to serve the residents. This has the potential to affect all 95 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean kitchen including floors, walls, drawers, walk in cooler, reach in coolers, freezers, convection oven, range, grill and range grease trays, dishwasher area including the top of dishwasher, hand washing sink; label large food bins; label and date opened food items in the refrigerator; keep storage containers off of the floor; place eggs on the bottom shelf of refrigerator; maintain the correct chlorine level on the low temperature dish machine; keep a log of the dishwasher chlorine tests; check the sanitation buckets with the appropriate test strips and keep a log of the tests. This has the potential to affect all 95 residents who live in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the large outside garbage dumpster closed and the area surrounding the container free of debris. The is has the potential to affect all 95 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a walk-in refrigerator at the correct temperature; repair/replace the gasket on the door to the walk-in refrigerator in order to seal the door when closed; failed to repair the condenser inside of the walk-in refrigerator; failed to correctly repair a rack on a shelf in the walk-in refrigerator. This has the potential to affect all 95 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep flies and gnats out of the Kitchen, Dining Room and Resident Rooms. This has the potential to affect all 95 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect facility residents from physical abuse by another resident (R32) for nine of nine residents (R2, R43, R55, R56, R57, R58, R67, R68, R89) reviewed for abuse, in a sample of 37.

Inspectors wroteBased on observation and interview the facility failed to provide accommodations for shaving preferences for one of 19 residents (R35) reviewed for accommodation of needs in a sample of 37.

Inspectors wroteBased on record review and interview, the facility failed to acknowledge and comply with the resident's request to discard odorous urine at the bedside for 1 of 19 residents (R60) reviewed self-determination in a sample of 37.

Inspectors wroteBased on record review and interview the facility failed to give a bed hold notification to a resident that was transferred to the hospital for one of three residents (R14) reviewed for hospitalization in a sample of 37. Findings Include: The facility policy named, Bed Hold Policy and Agreement, dated February 2024, documents, Policy: Bed Hold Policy of the Management Company that the facility will establish a system to notify the resident/responsible party/resident representative of the facility bed hold policy. The daily rate required holding a Resident's bed is specific to the room and payment program criteria of the resident. Procedure: The Bed Hold Agreement is to be obtained for each occurrence- hospital or therapeutic home leave. R14's Progress Notes dated 3/13/2024 documents the resident was sent out to the hospital and admitted . [...]

Inspectors wroteBased on record review and interview the facility failed to follow their elopement policy to update a resident's elopement risk care plan and failed to assess a resident's elopement risk quarterly for one of one (R20) resident reviewed for elopement in a sample of 37 residents.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure dialysis (artificial kidney treatment) care was provided per policy, communicate with the dialysis facility before and after treatments, collaborate with the Interdisciplinary Team and ensure a resident's care plan documents detailed dialysis care and required services for a resident receiving renal hemodialysis for one of one resident (R12) reviewed for dialysis in the sample of thirty-seven.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident to resident physical abuse did not occur for two residents (R6, R7) of four residents reviewed for abuse in a sample of four.

Inspectors wroteBased on interviews and record review, the facility failed to follow its abuse policy for a thorough investigation for two residents (R6, R9) of four residents reviewed for allegation of resident to resident abuse in a sample of four.

Inspectors wroteBased on interviews and record review, the facility failed to report allegations of abuse to the State Agency for two residents (R6, R9) of four residents reviewed for allegation of resident to resident physical abuse in a sample of four.

Inspectors wroteBased on interviews and record review, the facility failed to do a thorough investigation for an allegation of resident to resident abuse for two residents (R6, R9) of four residents reviewed for abuse in a sample of four.

Inspectors wroteBased on interview and record review the facility failed to provide evidence of facility's refusal to readmit a resident was not based on the resident's status at the time of transfer and failed to provide documentation by a physician regarding the basis of a resident's involuntary transfer/discharge with indications for why a resident should not return to the facility or what resident needs could not be met at the facility for one (R2) of three residents reviewed for Involuntary Discharge in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to permit resident (R2) to be readmitted to the facility from the hospital after inpatient psychiatric hospitalization for psychiatric assessment and treatment and failed to develop and implement a policy for Transfer/Discharge that addresses permitting residents to return to the facility after a hospital or therapeutic leave for one (R2) of three residents reviewed for facility-initiated transfers in a sample of three. This resulted in the resident (R2) remaining in the hospital for more than 30 days while waiting for nursing home placement.

Inspectors wroteBased on interview and record review the facility failed to provide mail delivery on Saturdays. This failure has the potential to affect all 114 residents in the facility.

Inspectors wroteBased on observations, interview and record review the facility failed to provide a safe, clean and homelike environment at the facility. This failure has the potential to affect all 114 residents who currently reside in the facility. Findings Include: The Facility's Maintenance Person job description (undated) documents The Maintenance Person maintains all building, equipment, systems and grounds in good, safe and presentable conditions. He/She conducts a preventative maintenance program for all mechanical, signal and fire alarm and suppression and other systems. The solicitation of repair/replace construction and other bids from contractor for presentation to the Administrator and Corporate Maintenance Director is expected. [...]

Inspectors wroteBased on interview and record review the facility failed to inform residents of the facility's grievance procedure. This failure has the potential to affect all 114 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient staff to provide care and supervision for dependent residents. This had the potential to affect all 114 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to clean and maintain kitchen equipment. These failures have the potential to affect all 114 Residents residing in the Facility.

Inspectors wroteBased on observation, interview and record review the facility failed to remain in COVID-19 Outbreak Status for ten days after the last person tested positive for COVID-19. This failure has the potential to affect all 114 residents who currently reside in the facility. Findings Include: The Facility's COVID-19 Infection Control Measures Policy dated 5/19/23 documents A COVID outbreak is defined by one staff member or resident testing positive for COVID-19. The policy documents that during Outbreak Status all staff will wear well fitted surgical masks everywhere in the building that residents have access to and that residents would be encouraged to wear masks when out of their rooms. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an Antibiotic Stewardship Program. This failure has the potential to affect all 115 residents who currently reside in the facility Findings Include: The Facility's Antibiotic Stewardship Program dated 11/01/2017 documents the purpose is to improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished by utilizing the Core Elements. This Policy did not list what the Core Elements of Antibiotic Stewardship in Long Term Care are. [...]

Inspectors wroteBased on interview and record review the Facility failed to notify the Facility Ombudsman and the Residents/Resident Representatives, in writing, of Hospital Transfers/Discharges for four of four Residents (R64, R85, R108 and R110) reviewed for Bed Hold Transfer in a sample of 51.

Inspectors wroteBased on record review and interview the Facility failed to issue a Bed Hold Policy upon Discharge/Transfer to the Hospital for four of four Residents (R64, R85, R108 and R110) reviewed for Bed Hold Transfer in a sample of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person centered comprehensive plan of care for Mental illness/Psychtoropic medication use, limitation of range of motion, smoking, for 7 of 25 residents (R4, R22, R41, R45, R82, R104, R110) reviewed for care plans in the sample of 51.

Inspectors wrote2. R67's current computerized medical record, documents R63 has a diagnosis of Post Traumatic Stress Disorder (PTSD). R67's Care Plan dated 12/19/23, documents R63 is known to display fluctuations in mood related to his mental illness diagnosis of PTSD. R67's Care Plan does not document R67's trauma induced triggers for his diagnosis of PTSD or individualized interventions to reduce possible re-traumatization of R67. 3. R93's current computerized medical record, documents R93 has a diagnosis of Post Traumatic Stress Disorder (PTSD). On 2/7/23 at 1:38 p.m., R93 stated he had PTSD from his dad dying unexpectedly while in a car that R93 was driving. R93 stated I haven't been the same since that happened. I had to have an ambulance take me away when it happened because I lost it. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have a clinical indication for use and failed to identify and monitor target behaviors for the use of psychotropics for eight (R10, R45, R56, R60, R85, R92, R110, and R113) of eight residents reviewed for unnecessary medications in a total sample of 51. Findings Include: The Facility's Psychotropic Medication Policy dated 11/28/2017 documents It is the policy of this facility that resident shall not be have unnecessary drugs. Unnecessary drug is any drug used: 1. In an excessive dose, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for its use 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the PASARR (Pre-admission Screening and Resident Review) Level II recommendations for one of three residents (R70) reviewed for PASARR screenings in the sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinent care for one resident (R104) incontinent of bowel of 24 residents reviewed for ADL's (Activities Of Daily Living) in the sample of 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to maintain or prevent further limitation in range of motion for one of two residents (R22) reviewed for range of motion in the sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and prevent repeated falls for one of eight Residents (R110) reviewed for Accidents in a sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure urinary drainage collection bags and urinary catheter tubing were kept off the floor for two residents (R64 and R104) of three residents reviewed for catheters in the sample of 51.

Inspectors wroteBased on interviews and record review, the facility failed to protect residents' right to be free from physical abuse for two residents (R1, R2) reviewed for abuse in a sample of four.

Inspectors wroteBased on interviews and record review, the facility failed to prevent an injury for one resident (R3) reviewed for accident/injury of unknown origin in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer the proper insulin dose as ordered by the physician and report hyperglycemia results to the physician for one resident (R1) and failed to properly administer insulin to two residents (R1 and R2) out of three residents reviewed for diabetes in a sample of three.