A list of the most recent deficiencies for El Paso Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-06 | 2023-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-06 | 2023-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-01 | 2023-09-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-08-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-08 | 2023-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-08-28 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-10 | 2023-08-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-10 | 2023-08-25 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-08-10 | 2023-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-10 | 2023-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-08-10 | 2023-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-08-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-10 | 2023-08-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-10 | 2023-08-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-08-22 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-10 | 2023-08-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-10 | 2023-08-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-10 | 2023-08-22 | N |
| Post nurse staffing information every day. | Health | 2023-08-10 | 2023-08-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-10 | 2023-08-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-10 | 2023-08-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-10 | 2023-08-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-10 | 2023-08-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-10 | 2023-08-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-10 | 2023-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-08-22 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-10 | 2023-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-08-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-08-10 | 2023-08-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-10 | 2023-08-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-13 | 2023-07-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-07-13 | 2023-07-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-07-13 | 2023-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-07-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-05 | 2023-07-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-08 | 2023-06-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-23 | 2023-06-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-23 | 2023-06-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-23 | 2023-06-29 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-05-08 | 2023-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-08 | 2023-06-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-08 | 2023-06-16 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-05-08 | 2023-06-16 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-23 | 2023-06-16 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-23 | 2023-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-23 | 2023-06-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-23 | 2023-06-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-23 | 2023-06-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-23 | 2023-06-16 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-02-23 | 2023-06-16 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-23 | 2023-06-16 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-02-23 | 2023-06-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-23 | 2023-06-16 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-23 | 2023-06-16 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-02-23 | 2023-06-16 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-23 | 2023-06-16 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-23 | 2023-06-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-02-23 | 2023-06-16 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-02-23 | 2023-06-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-23 | 2023-06-16 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-02-23 | 2023-06-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-17 | 2023-05-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-13 | 2023-02-02 | Y |
| Keep all essential equipment working safely. | Health | 2023-01-13 | 2023-02-02 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-13 | 2023-02-02 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-11-06 | 2022-11-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-30 | 2022-11-30 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-16 | 2022-11-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-16 | 2022-11-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-01 | 2022-11-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-30 | 2022-11-23 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-30 | 2022-11-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-30 | 2022-11-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-30 | 2022-11-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-16 | 2022-11-23 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-01 | 2022-11-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-01 | 2022-11-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-01 | 2022-11-23 | N |
| Post nurse staffing information every day. | Health | 2022-09-01 | 2022-11-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-01 | 2022-11-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-09-01 | 2022-11-23 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-09-01 | 2022-11-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-01 | 2022-11-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-01 | 2022-11-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-19 | 2022-10-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Develop a communication plan. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-31 | 2022-09-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-17 | 2022-09-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-17 | 2022-09-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-01 | 2022-08-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-22 | 2022-08-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-22 | 2022-08-05 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-12 | 2022-08-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-22 | 2022-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-22 | 2022-07-10 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-22 | 2022-07-10 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-06-22 | 2022-07-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-22 | 2022-07-10 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-06-02 | 2022-06-25 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-02 | 2022-06-25 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-06-02 | 2022-06-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-02 | 2022-06-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-02 | 2022-06-25 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-06-02 | 2022-06-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-06 | 2022-05-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-06 | 2022-05-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-17 | 2022-03-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-10 | 2022-03-26 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-10 | 2022-03-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-02-10 | 2022-03-15 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-02-10 | 2022-03-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-10 | 2022-03-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-02-10 | 2022-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-01 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-10 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-02-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-10 | 2022-02-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-10 | 2022-02-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-10 | 2022-02-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-20 | 2021-11-05 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-29 | 2021-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-29 | 2021-09-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-28 | 2021-09-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-28 | 2021-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-28 | 2021-09-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-07-28 | 2021-09-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-28 | 2021-09-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-28 | 2021-09-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-28 | 2021-09-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-28 | 2021-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-28 | 2021-09-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-28 | 2021-09-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-07-28 | 2021-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-28 | 2021-09-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-28 | 2021-09-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-28 | 2021-09-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-29 | 2021-09-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-27 | 2021-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-27 | 2021-06-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-03 | 2021-03-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-03-03 | 2021-03-23 | Y |
