Health inspection·December 3, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 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.Findings included: Resident #1Record review of Resident #1's admission record dated 10/27/2025 revealed a [AGE] year old male with an admission date of 09/22/25.Review of Resident #1's history and physical dated 09/23/2025 revealed resident had a left 5th toe amputation and the presence of a wound vac to distal lower leg.Review of Resident #1 's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Section M- skin conditions -revealed surgical wound care and application of dressing to feet.Review of Resident #1's Physician orders dated 09/24/2025 revealed WOUND CARE TO LEFT FOOT: NPWT@125mmHG CONTS. NOT TO BE REMOVED/CHANGED UNTIL SEEN BY SURGEON ON 9/25.Review of Resident #1 's Care Plan initiated on 09/23/2025 revealed the care plan did not address resident's use of wound vac.Resident #2Record review of Resident #2's face sheet revealed a [AGE] year-old male with an admission date of 10/01/25.Record review of Resident #2's history and physical dated 10/01/25 revealed medical history of high blood pressure, chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste products from the blood), coronary artery disease (heart condition where the arteries that supply blood to the heart become narrowed or blocked), and diabetic foot ulcer (open sore or wound that develops on the foot of a person with diabetes). Record review of Resident #2's 5 day MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact. Section M- Skin Conditions revealed surgical wound care, and application of dressings to feet.Record review of Resident #2's physician orders dated 10/01/2025 revealed WOUND CARE TO RIGHT FOOT:IRRIGATE WITH NSS, PAT DRY, APPLY SKIN PREP TO PERIWOUND, APPLY TRANSPARENT FILM TO PERIWOUND, FILL SPACE WITH BLACK GRANUFOAM, SECUREWITH TRANSPARENT FILM, ATTACH STINGRAY, RESUME NPWT @125mmHG CONTS. 3XWK every day shift every Mon, Wed, Fri.Record review of Resident #2's care plan with initiation date of 10/01/25 revealed the care plan did not address resident's use of wound vacIn an interview on 10/27/25 at 1:40pm with RN A revealed if a resident was using wound vac, that treatment would have to be included in the care plan, as the care plan was a blueprint of residents care and the wound vac was something that needed to be taken care of. She stated that a risk of not being care planned would be the chance of it being missed by someone new to caring for the resident.In a telephone interview on 10/28/25 at 10:54am with RN B revealed that the admitting nurse was responsible for completing a baseline care plan. She stated that she then was (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 2 Event ID: 676428 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 676428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort El Paso, LLC 3421 Joe Battle Boulevard El Paso, TX 79936 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)