Health inspection·January 31, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. Findings include: Resident #3: Record review of Resident #3's admission Record, dated 01/29/2025, reflected a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Record review of Resident # 3's History and Physical dated 03/16/2023, revealed diagnoses to include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe). Record review of Resident # 3's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 was receiving oxygen therapy. Record review of Resident #3's Order Summary Report dated 01/30/2025, revealed an order with start time of 10/08/2024 for O2 at 2 liters, keep O2 saturations above 85%. Review of Resident #3's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 94% to 97%. Record review of Resident #3's comprehensive care plan dated 01/30/2025, revealed Resident #3's oxygen therapy was not care planned. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675831 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)