El Paso Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at El Paso Rehabilitation and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600May 8, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents were free from physical and verbal abuse by R16, a [AGE] year old independent ambulatory man, with a known history of frequent resident to resident altercations with 1:1 Staff present, failed to institute new safety interventions to protect against resident to resident altercations, failed to provide supervision to protect a resident R1, with offensive behaviors, from retaliatory physical and verbal abuse despite 1:1 supervision. These failures had the potential to affect all 118 residents residing in the facility. […]

• Immediate jeopardy, widespreadF610Feb 23, 2023

  Based on observation, interview and record review, the facility failed to investigate an allegation of sexual abuse made by R6 against R9 (on 1/05/23) and protect R6 from potential further abuse, failed to investigate and implement measures to prevent an ongoing sexual relationship between a resident (R6, who lacks the mental capacity to legally consent) and R15, failed to investigate multiple allegations of abuse made by residents during Resident Council meetings, which included sexual abuse, verbal abuse, staff retaliation and misappropriation, and failed to investigate an allegation of verbal abuse made by R3 against V3 (Registered Nurse) on 1/24/23. […]

• Immediate jeopardy, widespreadF835Feb 23, 2023

  Based on observation, interview and record review, the facility Administration failed ensure a safe living environment and quality care and services were provided to all residents, failed to provide leadership and institute their Abuse Prevention program and failed to have an effective, comprehensive approach to numerous significant resident concerns regarding the quality of resident life within the facility. The facility has been unable to maintain consistent Administrative leadership over the last 12 months. V1 (Administrator in Training) failed to respond to resident allegations of abuse, neglect and mistreatment. Cross reference to F600, F610 and F692 (Identified Immediate Jeopardies) and additional findings at F584, F607, F609, F693, F741, F760 and F943. […]

• Immediate jeopardy, patternF803Aug 8, 2025

  Based 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. […]

• Immediate jeopardy, patternF600Feb 23, 2023

  Based on observation, interview and record review, the facility failed to ensure residents (R6, R10, R11, R18) were free from sexual and verbal abuse by R9, who had known history of sexually inappropriate behaviors towards females, for five of 12 residents reviewed for abuse in a sample of 25. These failures resulted in R6 being groped in a sexual manner and verbally abused, experiencing psychological distress. This facility was previously cited for sexual abuse on 1/09/22 for R9 groping R6's breast. Additionally, the facility failed to prevent known, ongoing sexual relations between R9 and R6, who is Intellectually Disabled, unable to consent, and has a State Appointed Guardian. […]