Ignite Medical Resort El Paso, LLC

In the surveyor’s words

From the most serious findings on record at Ignite Medical Resort El Paso, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF580Mar 13, 2026

  Based 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. […]

• Immediate jeopardy, patternF684Mar 13, 2026

  Based 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. […]

• Immediate jeopardy, patternF760Mar 13, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF919Dec 4, 2025

  Based 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. Findings included: During an observation 12/01/25 at 12:53 PM in Hall 200 revealed, two residents had turned on the Nurse Call Lights. It was observed that the corridor lights for Nurse Call were on, room [ROOM NUMBER] and 209, and were not ringing in the residents' rooms or at the nurse's station. […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2025

  Based 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. […]