El Paso, TX

El Paso Health & Rehabilitation Center

2-star overall rating with 2-star inspections with $20,312 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

11525 Vista Del Sol Dr, El Paso, TX

(915) 855-3636

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

150

Certified beds

Average residents

84

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Advanced Healthcare Solutions

Operator or chain grouping

Approved since

1991-08-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.25

Registered nurse staffing

LPN hours / resident day

1.12

Licensed practical nurse staffing

Aide hours / resident day

2.06

Nurse aide staffing

Weekend hours

2.95

Weekend nurse staffing

RN turnover

75%

Annual RN turnover

Total nurse turnover

32%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.6%
97.1%
2.5 pts better
93.4%
6.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
97.9%
2.1 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 1.8%
3.3%
1.5 pts better
3.3%
1.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.4%
2.7%
2.3 pts better
11.4%
11 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 2.1%
3.3%
1.2 pts better
5.4%
3.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.6%
18.9%
3.3 pts better
19.6%
4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 11.4%
10.8%
0.6 pts worse
16.7%
5.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 13.5%
15.4%
1.9 pts better
16.3%
2.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 21.9%
16.1%
5.8 pts worse
14.9%
7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.5%
0.5 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 0.0%
0.8%
0.8 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 18.2%
15.0%
3.2 pts worse
19.8%
1.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 8.9%
4.2%
4.7 pts worse
5.1%
3.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 80.7%
89.7%
9 pts worse
81.7%
1 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 18.7%
12.0%
6.7 pts worse
12.0%
6.7 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 3.0%
1.5%
1.5 pts worse
1.6%
1.4 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88.1%
88.0%
0.1 pts better
79.7%
8.4 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 34.6%
25.9%
8.7 pts worse
23.9%
10.7 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

11 fire-safety deficiencies

Top issue: Miscellaneous (3 deficiencies)

Cycle 2 Health 2024-06-20 · Fire 2024-06-20

32 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

3 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2023-04-27 · Fire 2023-04-27

22 health deficiencies

Top issue: Resident Rights (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-07

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2026-01-15

F · Potential for more than minimal harm 2025-08-07

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2026-01-15

F · Potential for more than minimal harm 2025-08-07

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2026-01-15

F · Potential for more than minimal harm 2025-08-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2026-01-15

F · Potential for more than minimal harm 2025-08-07

K751 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of flammable curtains.

Corrected 2026-01-15

F · Potential for more than minimal harm 2025-08-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2026-01-15

E · Potential for more than minimal harm 2025-08-07

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2026-01-15

E · Potential for more than minimal harm 2025-08-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2026-01-15

E · Potential for more than minimal harm 2025-08-07

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2026-01-15

E · Potential for more than minimal harm 2025-08-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2026-01-15

E · Potential for more than minimal harm 2025-08-07

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2026-01-15

F · Potential for more than minimal harm 2024-06-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-02

F · Potential for more than minimal harm 2024-06-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-02

F · Potential for more than minimal harm 2024-06-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-02

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-07

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-07

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-07

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-08-28

D · Potential for more than minimal harm 2025-03-27

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-27

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-04-26

F · Potential for more than minimal harm 2025-01-15

F727 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-15

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-15

D · Potential for more than minimal harm 2024-09-23

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-10-16

D · Potential for more than minimal harm 2024-09-17

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-10-10

D · Potential for more than minimal harm 2024-09-17

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-10-10

D · Potential for more than minimal harm 2024-09-17

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-10-10

D · Potential for more than minimal harm 2024-09-17

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-10-10

D · Potential for more than minimal harm 2024-09-17

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-10-10

E · Potential for more than minimal harm 2024-08-05

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-08-26

E · Potential for more than minimal harm 2024-08-05

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-08-26

E · Potential for more than minimal harm 2024-08-05

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-08-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-08-05

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-08-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-06-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-20

F · Potential for more than minimal harm 2024-06-20

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-06-20

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-06-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-06-20

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-06-20

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-06-20

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-06-20

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-06-20

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-06-20

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-06-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-04-16

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-05-16

D · Potential for more than minimal harm 2024-04-16

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-05-16

D · Potential for more than minimal harm 2024-04-16

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-05-16

D · Potential for more than minimal harm 2024-04-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-05-16

D · Potential for more than minimal harm 2024-04-16

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-05-16

D · Potential for more than minimal harm 2024-04-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-16

D · Potential for more than minimal harm 2023-10-11

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-10-12

D · Potential for more than minimal harm 2023-10-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-12

D · Potential for more than minimal harm 2023-10-11

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-10-12

J · Immediate jeopardy 2023-09-01

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-09-05

J · Immediate jeopardy 2023-09-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-05

E · Potential for more than minimal harm 2023-09-01

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-09-01

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-09-05

D · Potential for more than minimal harm 2023-06-09

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-07-07

D · Potential for more than minimal harm 2023-06-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-07-07

F · Potential for more than minimal harm 2023-04-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-04-27

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-04-27

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-06-02

D · Potential for more than minimal harm 2023-04-27

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2023-06-02

C · Minimal harm 2023-04-27

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2023-06-02

E · Potential for more than minimal harm 2023-03-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-03-30

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-04-21

Penalties and ownership

What sits behind the stars

$20,312 2023-09-01

Fine

Fine · fine $20,312

Fine

$0 2023-09-01

Payment Denial

Payment Denial · denial start 2023-10-04 · 8 days

8 day denial

Ownership

West Wharton County Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 96 facilities 2022-09-01
Blake, Gary

Operational/Managerial Control · Individual

0% 136 facilities 2024-02-23
Blake, Malisa

Operational/Managerial Control · Individual

0% 135 facilities 2024-02-23
El Paso Vii Enterprises, L.l.c.

Operational/Managerial Control · Organization

0% 1 facilities 2024-02-23
Huggins, Linda

Corporate Director · Individual

0% 137 facilities 2024-02-23
Thompson, Johnny

Corporate Officer · Individual

0% 69 facilities 2024-01-01
Willig, Zachary

Corporate Director · Individual

0% 77 facilities 2024-02-23

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