Ignite Medical Resort El Paso, LLC

Inspectors wroteBased on interview and record review the facility failed ensure alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 residents (Resident #1) reviewed for reporting. The facility failed to report abuse of Resident #1 to State Office Agency, Law Enforcement. This failure could place residents at risk for abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician was immediately notified of a need to alter treatment (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) to meet the needs of each resident for 1 (Resident #2) of 9 residents reviewed for physician notifications. -The facility failed to notify the physician when Resident #2 experienced elevated blood glucose levels exceeding 400 mg/dL from 02/26/2026 through 03/02/2026. An Immediate Jeopardy (IJ) situation was identified on 03/12/2026. While the IJ was removed on 03/13/2026, the facility remained out of compliance at the scope of isolated and a severity level of no actual harm with the potential for minimum harm, due to the facility's need to evaluate the effectiveness of their corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provided needed care and services that are centered in accordance with residents preferences, goals for care and professional standards of practice that meet each residents physical, mental, and psychosocial needs for 1 (Resident #2) of 10 residents. The facility failed to assess Resident #2 prior to admission and failed to identify and implement physician orders related to antibiotic therapy and blood glucose management for readings outside established parameters which resulted in hospitalization with diagnoses of DKA and sepsis. An Immediate Jeopardy (IJ) situation was identified on 03/12/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents are free of any significant mediation errors for 1 (Resident #2) of 3 residents reviewed for medication administration errors. The facility failed to assess Resident #2 prior to admission and failed to identify and implement physician orders related to antibiotic therapy and blood glucose management for readings outside established parameters. An Immediate Jeopardy (IJ) situation was identified on 03/12/2026. While the IJ was removed on 03/13/2026, the facility remained out of compliance at the scope of isolation with the potential for more than minimal harm , due to the facility's need to evaluate the effectiveness of their corrective systems. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1of 8 resident (Resident #9) reviewed for Injury of unknown origin. The facility failed to ensure Resident #9 injury of unknown origin was reported to the state agency. This failure could have resulted in protection of residents from further potential harm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 7 residents (Resident #10 and Resident #11) reviewed for infection control. The facility failed to ensure RN M performed hand hygiene and/or used PPE while conducting a blood glucose check. The facility failed to ensure LVN R properly discarded of used lancet after use. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents had the right to a dignified existence for 2 (Resident #2 & Resident #3) of 3 residents reviewed for resident rights. The facility failed to ensure the urinary collection bags for Resident #2 and Resident #3's catheters were covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Resident #2 Record review of Resident #2's face sheet dated 12/15/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included type 2 diabetes with hyperglycemia (high amount of glucose in blood), Hypermagnesemia (too much magnesium), and Acute kidney failure (kidneys stop working). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 2 reviewed for medication administration in that: The facility failed to ensure that Resident #1 was provided with wound care treatment according to physician's routine, PRN, and STAT orders, due to the order being placed incorrectly in the MAR. This failure could place residents at risk of a decline in health due to incorrect medication administration and inaccurate orders. Record review of Resident #1's face sheet dated 12/15/2025, revealed admission on [DATE] to the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #2) reviewed for infection control. The facility failed to ensure the urinary catheter bag for Resident #2 was anchored and secured to prevent infection. This failure could place residents at risk of infection due to improper care practices. Record review of Resident #2's face sheet dated 12/15/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included type 2 diabetes with hyperglycemia (high amount of glucose in blood), Hypermagnesemia (too much magnesium), and Acute kidney failure (kidneys stop working). [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to have an adequately equipped system that allowed residents to call for staff assistance through a communication system for 2 of 2 call light systems viewed for resident call system. The facility failed to ensure that residents call lights for 3 of 3 Resident Halls were functioning properly. This failure put residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by the resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment including other personnel, including but not limited to nurse aides for 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) of 5 residents reviewed for sufficient staff. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 (Resident #1, #2, #,3, #4, and #5) of 5 residents reviewed for pharmacy services. 1. The facility failed to administer Dapagliflozin Propanediol, Levothyroxine, Acetylcysteine Solution, Eliquis, Memantine HCI, to Resident #1 according to physician's orders. 2. The facility failed to administer Farxiga and Folic Acid, to Resident #2 according to physician's orders. 3. The facility failed to administer Pravastatin Sodium, Alendronate Sodium, Sodium Chloride, Linagliptin, and Calcium 600 + D to Resident #3 according to physician's orders. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish procedures for storing and disposing of drugs and biological in accordance with federal, state, and local laws. -The facility failed to ensure medication deliveries were not left unattended at the nurse's station. -The facility failed to ensure licensed staff did not leave medications unattended at the nurse's station This failure could place residents living at the facility at risk of drug diversion.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were accurately documented for 1 (Resident #22) of 8 residents reviewed for medical records. -The facility failed to ensure LVN A documented in the Nurse's Notes on 11/18/25 when she notified the physician of resident family's non-compliance of NPO status. -The facility failed to ensure that licensed staff promptly wrote physician's telephone orders and entered new orders in the medication administration record. This failure could place residents at risk of residents records not reflecting accurate and complete information.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors, for 1 of 1 nursing unit reviewed for nurse staffing information. The facility failed to post and maintain the required nursing staffing information since 11/20/25. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding facility regarding staffing schedule and facility census.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for two residents (Residents #1, and #2) of 4 residents reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident # 1 and #2 to address resident's wound vac. These failures could affect residents and put them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (7/30/25) tested for nutritive value, flavor, and appearance:The facility failed on 7/30/25 to serve and address the residents concerns regarding their meals not being at a safe and palatable temperature for residents who were served their meals in their rooms. The facility failed on 7/30/25 to serve a sample food tray for the surveyors at a safe and palatable temperature. The facility failed on 7/30/25 to serve meals at a safe temperature. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction due to not providing appetizing temperature meals.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that:The facility's kitchen staff failed to thaw food properly. This failure could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 Residents (Resident #62) reviewed for accommodation of needs. The facility failed to ensure Resident #62's call light was in reach. This failure could affect the residents' dependent on staff for transferring in and out of their bed and/or wheelchair by causing feelings of isolation, frustration, hunger, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 2 of 18 residents (Resident #2 and Resident # 49) reviewed for accidents. The facility failed to properly dispose of shaving razors in a sharps container in Residents #2 and 49's shared room. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for infection control. (Residents #62)CNA A failed to perform hand hygiene after disposing of dirty briefs and before putting on new clean briefs for Resident #62. These failures could place the residents who required incontinent care at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -Access to trash can next to handwashing sink was not hands free as the lid of the trash can was damaged. -The facility failed to ensure food items in the facility's only walk-in refrigerator were sealed and labeled appropriately. -The facility failed to ensure food items in the facility's only walk-in freezer were dated and stored appropriately. -The dishwashing and sanitization machine was dirty with dried caked on substance on top of the machine and streaking down the front of the machine. -The kitchen ice machine was dirty with dried caked on substance around the ice dispenser door. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #1) of 4 residents whose records were reviewed for accuracy and completeness. -The facility failed to document Resident #1's fall incident per policy in an incident report. This deficient practice could place residents at risk for improper care due to incomplete or inaccurate records.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #3) r esidents reviewed for infection control in that: The facility failed to dispose of Resident #3's dirty brief and wipes smeared with feces that were left on the room floor wrapped in a linen. This failure could place residents at risk for cross contamination resulting in acquired infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to conduct assessments that accurately reflected the resident's status for 4 of 12 residents (Residents #10, #15, #28, and #237) reviewed for resident assessments. The facility failed to ensure Resident #10's admission MDS Assessment accurately reflected her diagnosis of anxiety. The facility failed to ensure that Resident #15's admission MDS Assessment accurately reflected his skin status or diagnosis of anxiety/use of anti anxiety medication. The facility failed to ensure Resident #28's Medicare 5 Day MDS Assessment accurately reflected his diagnosis of Diabetes Mellitus. The facility failed to ensure Resident #237's admission MDS Assessment accurately reflected his diagnosis of chronic pain. [...]

Inspectors wroteResident #15 Care Planning Copied from another care area: [NAME], [NAME] (26221) 06/04/24 02:23 PM No communicateion w VA as res believes documented Based on interviews and record review the facility failed to develop and implement a comprehensive, person centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well being for 3 of 6 residents (Residents #10, #15, and #28) reviewed for care plans. Resident #10 did not have a care plan to address her antipsychotic use. Resident #15 did not have a care plan to address CAA areas of vision, psychosocial status, urinary status, skin status, active diagnosis, or anti anxiety use. Resident #28 did not have a care plan to address his diabetic status or insulin use. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents who have not used psychotropic drugs [NAME] not given these drugs unless the medication [NAME] necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Residents #10, #21, and #137) of 5 residents reviewed for unnecessary medications., The facility failed to ensure Resident #10 had an appropriate diagnosis for the use of Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure Resident #21 was not given risperidone (an antipsychotic) without a diagnosis. The facility failed to ensure that Resident #137 did not receive an antipsychotic (Seroquel/Quetiapine Fumarate) that was not necessary to treat Dementia. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments for 3 of 4 medication carts reviewed for medication storage and security. Medication Carts 100, 200, and 300 were left in the hallway unlocked and unattended. These failures could place clients at risk for drug diversion or accidental ingestion.

Inspectors wroteBased on observations and interviews and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored foods were properly stored, labeled, and dated. This failure could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 4 (Resident #137, #8, #15, #87 ) of 6 reviewed for incontinent care and 3 of 4 residents reviewed for infection control practices. The facility failed to ensure that CNA D performed proper hand hygiene and glove changes while providing incontinence care to Resident #137. The facility failed to ensure residents were identified for enhanced barrier control for Residents #8, #15, #87. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 residents (Resident #237) reviewed for peripheral intravenous care. The facility failed to ensure Resident #237's midline dressing was changed after becoming soiled on 6/2/24. This failure could place residents at risk of developing an infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide laboratory services to meet the needs of its residents, for 1 of 3 (Resident # 136) residents reviewed for laboratory orders. The facility failed to follow physician orders on 05/29/24 that required obtaining a lab and provide needed treatment for Resident #136. This failure could place residents at risk for untreated medical issues and diminished quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #3) of 6 residents reviewed for repositioning. The facility failed to ensure Resident #3 was repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition.

Inspectors wroteFACILITY Medication Administration 04/11/23 04:28 PM Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #247) of 3 reviewed for medication administration. The facility failed to ensure LVN D administered Resident # 247 medications according to the physician ' s order. This deficient practice could place residents with g-tubes at risk of not receiving their medication in accordance with the physician ' s order.

Inspectors wroteFACILITY Kitchen 04/11/23 08:02 AM Culinary Director [NAME] - in refrigerator open bag with three hotdog buns with no label. unlabeled open container of chocolate syrup with Exp date of 11/04/2022. Risk - don't know when opened so don't know how long it will be good. Possible a threat to the safety of the product for residents to consume. Residents could have stomach issues, diaharrea. 04/11/23 11:10 AM CD [NAME] and cook [NAME] - issues with gloving in process of doing Puree - Puree OK but issues with infection control - uses same gloves to wash blender parts and then in preparation of pureed vegetables without glove change or hand washing. Wash water seen dripping from inside right hand glove onto surface of blender while in the process of blending the vegetables. [...]

Inspectors wroteResident #23 Advance Directives [DATE] 10:44 AM [DATE] 02:37 PM on [DATE] - DNR order on Facility Record - No document in Documents file. Review of hard chart reveals no DNR document and front page states Full Code. [DATE] 03:03 PM interview and record review with RN [NAME] - reviews [NAME] electronic chart for code status and states he is a DNR. Reviews hard chart and states that there is a sticker that says full code. Reviews resident chart and states she is unable to find a copy of the TX OOH DNR. Reviews residetn IDt admission Evaluataion with Baseline Care plan and states that it indicates no Advance Directives - . Says that this puts residetn at risk of delayed response to emergency sitatuaion. States she is not able to find the completed DNR form in the residetn's chrat. [...]

Inspectors wroteResident #96 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 04/12/23 11:16 AM Resident is in the Initial Pool. According to RR the resident takes an Antianxiety. Buspiron 10 mg TID According to RR the resident takes an Anticoagulant. - Lovenoz 30 MG Q AM According to RR the resident takes an Insulin. - she is not taking insulin - Actos 15 MG - for blood sugar but not insulin. According to RR the resident takes an Opioid. - Tramaol 50 MG Q 6 hrs PRN - Has not requested this According to RR the resident takes an Antidepressant. - Lexapro 20 MG Q day. Anticoagulant is on the MDS but not on either care plan baseline or comprehensive care plan. 04/14/23 11:17 AM DON - anticoagulans shouldb on base [NAME] care plan - If resident is h ere long enough woul be o n comprehansive. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change midline dressing in accordance with physician orders and the comprehensive care plan for 1 (Resident #39) of 16 residents reviewed for quality of care The facility failed to change Resident #39 Midline dressing according to physician ' s orders. These deficient practices could have placed residents at risk for cross-contamination resulting in acquiring infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 3 (Resident #8, Resident #5, and Resident #96) of 5 residents observed for oxygen management. 1. The Facility failed to change oxygen tubing for Resident # 8 according to physician's orders. 2. The facility failed to ensure Resident # 5's oxygen sign was posted on entrance door to resident's room. 3. The facility failed to store Resident #96 ' s respiratory treatment mask with a protective cover. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, and expose them to oxygen hazards.

Inspectors wroteFACILITY Infection Control [DATE] 04:08 PM Resident [NAME] - 310 - [NAME] - worked for the state 1991 - worked as a case worker eligibility - Has been does not know. - Fell and has been here because of fractured tibia - Feels very lucid today - usually feels confused and asks that I call husband - they treat her very good. Bath room looks fine. Infection control concern the treatment mask is not bagged. [DATE] 09:04 AM [NAME], RN - states that treatment mask should be in bag because of infection control concerns. Resident might breath in things that get in mask like germs. on her hospital paper work said Buspirone 2 5 MG pills - TID for anxiety. Mitirats a pin 7.5 MG at HS depression. escitaopran - 20 MG q day - Depression. admit date [DATE] [DATE] 11:15 AM DON - between treatments masks whold be stored in bags - for infecgtion prevention - risk to resident of infection. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet the individual needs for 1 (Resident # 246) of 2 residents reviewed for dietary services. The facility failed to ensure Resident #246's lunch meal was a thin liquid consistency diet as ordered by the physician. This failure could place residents at risk of choking and aspiration by not serving the prescribed liquid consistency.