Health inspection·August 14, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of psychiatric service progress note, dated 06/02/2024, stated Resident #10 was being seen for evaluation of dementia, depression, anxiety, and psychosis. It further showed that Resident #10 confirmed with [NAME]-[NAME] syndrome that was stable at the time on current medication managed by PCP. Resident #10 was not exhibiting signs of aggression. During an interview on 8/14/2024 at 9:00 a.m., Resident #10's LAR (an individual or judicial or other body authorized under applicable law to make decisions on behalf of another individual) said Resident #10 was admitted to the nursing facility in April and she had noticed that Resident #10 had not been visited by the Local Authority for a few months. LAR said she reached out to the Local Authority to find out what was going on. LAR said there was a meeting held at the facility on 07/31/2024 as Resident #10 was PASRR positive (individuals who test positive at Level I are then evaluated in depth called Level II PASRR). LAR said she never received a letter showing that Resident #10 was PASRR negative (indicates person is not suspected of having an intellectual disability, developmental disability and/or mental illness). LAR said she does not believe there were any delays in Resident #10's services. The LAR said Resident #10 was supposed to receive services for more than 30 days at the nursing facility. During an interview on 08/14/2024 at 9:13 a.m., Local Authority (an entity that provides mental health services to a specific geographic area, also known as a local service area) RP said Resident #10's guardian had contacted her in June 2024 regarding wanting to transition Resident #10 from the nursing facility to the SSLC. Local Authority RP said she checked the system and found out there was no PASRR in the system for Resident #10. Local Authority RP said she reached out to the facility through email and received no response from the facility. Local Authority RP said she visited the facility on 7/17/2024 and was assured that the facility would submit a PASRR into the system that same day. Local Authority RP said she followed up on 7/22/2024 about not receiving a PL1 alert. Local Authority RP said on 7/29/2024 they got the alert of the positive PASRR. Local Authority RP said current plans were for Resident #10 to stay at the nursing facility until guardianship was resolved. Local Authority RP said upon admission the PASRR should have been done and once the Local Authority receives the alert, they have 72 hours to assess the patient and seven days to enter the portal and fourteen days to conduct the meeting. Local Authority RP said Resident #10 was doing well at the nursing facility at the time and had improved. Local Authority RP said part of the services they provide are occupational, speech, and physical therapy. Local Authority RP said during the meeting with the facility she learned the facility was paying for the therapies but not under PASRR. During an interview on 08/14/2024 at 11:28 a.m., MDS Nurse C said he had been working at the facility since 05/15/2024. MDS Nurse C said the purpose of a PASRR was to identify if residents have any needs that may need accommodations and resources. MDS Nurse C said Resident #10 was admitted to the facility on [DATE]. MDS Nurse C said Resident #10 was screened by hospital staff upon admission to the facility on [DATE]. MDS Nurse C said review of Resident #10's medical records shows that the facility received the PL1 and uploaded the document into the resident record on 04/09/2024. MDS Nurse C said the facility then was to upload the PASRR information into the LTC Online Portal. MDS Nurse C said review of the LTC Online Portal revealed that Resident #10's PASRR PL1 information was not submitted until 05/31/2024. MDS Nurse C said he did not know why the information was uploaded on 05/31/2024 rather than immediately in April 2024. MDS Nurse C said the hospital PASRR did not deem Resident #10 PASRR positive on the PL1. MDS Nurse C said this was most likely an error on the part of the hospital screener because Resident #10 should have been PASRR positive for IDD, specifically with diagnosis of [NAME]-[NAME] syndrome. MDS Nurse C said part of facility MDS process was to review the admitting diagnoses and note any discrepancy. The MDS Nurse C said the discrepancy should have been caught before by the former MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 2 of 5 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 676431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at El Paso 7441 Paseo Del Norte El Paso, TX 79911 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm nurse who is no longer working at the facility. MDS Nurse C said he did not know why but another PASRR was done on 07/24/2024 and Resident #10 was deemed positive for suspected IDD. MDS Nurse C said that information was uploaded into the LTC Online Portal on 07/31/2024. MDS Nurse C said that although the diagnosis was missed by the facility initially, Resident #10 received speech, occupational and physical therapy as a skilled nursing patient. Residents Affected - Few During an interview on 08/14/2024 at 2:14 p.m., the DON said back in April 2024, both her MDS nurses quit. The DON said she did not know that Resident #10's PL1 had not been entered into the LTC Online Portal when Resident #10 was first admitted to the facility. The DON said she did not remember when the facility realized that the PASRR from the hospital for Resident #10 was wrong. The DON said the facility MDS nurse ended up doing a new screening because the PASRR was wrong. The DON said the diagnosis of [NAME]-[NAME] should have been care planned but was not. The DON said Resident #10 had received occupational, speech, and physical therapy services because she was skilled nursing resident. The DON said the purpose for PASRR was to help patients with disabilities to maintain their quality of life. The DON said residents who are PASRR positive get special services because of their disability. The DON said by failing to follow the PASRR process, there was a risk to residents of not capturing the services and extra layer of help they can get with PASRR. Review of schedule of therapy services provided to Resident #10 from 04/09/2024 to 08/14/2024, revealed Resident #10 was assessed by therapy services on 04/09/2024. Skilled PT was warranted to minimize falls and increase range of motion and strength. Duration was for 60 days at five times a week from 4/9/2024 to 6/7/2024. Records show that Resident #10 continued to receive occupational and physical therapy services from 6/10/2024 to 07/12/2024. Therapy services started up again on 08/01/2024 to 08/14/2024. Review of facility Resident Assessment - Coordination with PASARR Program policy dated 07/2022, reads in part This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State's Medicaid rules for screening. PASSARR Level I initial pre-screening is completed prior to admission. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. Review of the Long-term Care (LTC) User Guide for Preadmission Screening and Resident Review (PASRR), dated 2024, reads in part, An initial PASRR Level 1 (PL1) Screening Form is completed for every person seeking admission to a Medicaid-certified NF to identify people suspected of having MI, ID, and/or DD . The information on the hard copy of the PL1 Screening Form, which is completed by the referring entity (RE), is submitted directly on the LTC Online Portal by either the NF or the LA . If the person is PASRR negative based on the PE, a letter will be provided to the person and their legally authorized representative (LAR) if an LAR is documented on the PE. If the person does not agree with this result, the person or LAR can contact the PASRR evaluator at the LA stated in the letter with questions regarding the reason for the determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 3 of 5 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 676431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at El Paso 7441 Paseo Del Norte El Paso, TX 79911 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)

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 interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs and describes the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #10) of 6 residents reviewed for comprehensive care plans in that: -The facility failed to develop a comprehensive care plan for Resident #10's diagnosis of [NAME]-[NAME] syndrome. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings include: Record review of Resident #10's admission Record dated 08/14/2024, revealed Resident #10 was admitted to the facility on [DATE] and originally admitted on [DATE] with diagnoses to include cerebral palsy (congenital disorder of movement, muscle tone or posture due to abnormal brain development, often before birth), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and [NAME]-[NAME] Syndrome (genetic disorder that causes obesity, intellectual disability, and shortness in height). Record review of Resident #10's quarterly MDS assessment dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Section I Active Diagnoses shows Resident #10 was diagnosed with [NAME]-[NAME] syndrome. The quarterly MDS did not reflect any information for PASRR. Record review of Resident #10's Order Summary Report dated 08/14/2024, revealed an order dated 05/28/2024 for Resident #10 to be evaluated and treated as warranted by physician for diagnosis [NAME]-[NAME] with suspected pseudobulbar affect (neurological condition that causes people to have sudden, uncontrollable, and inappropriate episodes of laughing or crying). Record review of psychiatric service progress note, dated 06/02/2024, stated Resident #10 was being seen for evaluation of dementia, depression, anxiety, and psychosis. It further showed that Resident #10 confirmed with [NAME]-[NAME] syndrome that was stable at the time on current medication managed by PCP. Resident #10 was observed laughing hysterically during the consultation. Resident #10 was not exhibiting signs of aggression. Record review of Resident #10's Care Plan dated 08/14/2024, revealed no focus or intervention plan addressing [NAME]-[NAME] syndrome. During an interview on 08/14/2024 at 2:14 p.m., the DON said the purpose of a care plan is to help the staff know the patient's needs. The DON said she reviewed Resident #10's care plan and noted that a [NAME]-[NAME] syndrome specific focus was not included in the care plan. The DON said it should have been care planned. The DON said she would follow-up to find out why it was not care planned. The DON said Resident #10's initial PASRR was wrong and was redone on 07/24/2024 finding resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 4 of 5 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 676431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at El Paso 7441 Paseo Del Norte El Paso, TX 79911 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete PASRR positive for IDD. The care plan did not include any information on specialized services or rehabilitation services as a result of PASRR. The DON said the risk to the resident was missing services and a risk for decline in areas associated with the diagnosis. The DON said Resident #10 was stable at the time with no behavioral issues reported. Review of facility provided Comprehensive Care Plans policy dated 07/2022, reads in part, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: 1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 3) Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. Event ID: Facility ID: 676431 If continuation sheet Page 5 of 5