Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to immediately inform the resident, consult with the resident's
physician when there was a significant change in the resident's physical, mental, or psychosocial status for
one (Resident #1) of four residents reviewed for resident rights.
The facility failed to ensure LVN A and LVN B communicate to the physician the need to administer
medications while pending G-Tube placement result from KUB.
This failure could place residents at risk of unmet medical needs and a decreased in quality of life.
The findings included:
Record review of Resident #1's hospital transfer form not dated revealed a [AGE] year-old female who was
admitted to the facility on [DATE] and had diagnoses of: Attention and concentration deficit (Difficulty
staying focused or paying attention, which can affect daily tasks and communication); Cognitive
communication deficit (Problems with thinking and using language, such as trouble understanding,
speaking, or remembering words); Unspecified dementia (general decline in memory and thinking skills,
often due to aging or disease, that affects daily life); Alzheimer's disease (progressive brain disorder that
slowly destroys memory, thinking skills, and the ability to carry out simple tasks); Cervical disc disorder with
radiculopathy (problem with a disc in the neck that is pressing on nerves, causing pain, numbness, or
weakness in the arms or shoulders); Type 2 diabetes with diabetic neuropathy (nerve damage caused by
high blood sugar levels, leading to tingling, pain, or numbness, usually in the feet or hands); Other specified
depressive episodes (period of depression with symptoms like sadness, loss of interest, or fatigue that
doesn't exactly fit the standard categories but still significantly impacts well-being); Gastronomy status
(person has feeding tube directly placed in their stomach); Gastroesophageal reflux disease (GERD)
without esophagitis (stomach acid flows back into the esophagus (food pipe), causing heartburn or
discomfort, but without damage to the esophagus lining); Epigastric pain (pain or discomfort in the upper
belly area, just below the ribs, often related to digestion); Mild protein-calorie malnutrition (not getting
enough calories and protein, which can lead to weakness, weight loss, and poor healing); Essential
(primary) hypertension (high blood pressure with no known specific cause, which can increase the risk of
heart problems over time); Atherosclerotic heart disease without angina (buildup of plaque in the heart's
arteries, reducing blood flow, but without causing chest pain yet); Peripheral vascular disease (poor
circulation in the arms or legs due to narrowed blood vessels, often leading to leg pain when walking)
Record review of Resident #1's physician order dated 07/06/24 revealed every shift for adequate
(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 6
Event ID:
676431
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
05/22/2025
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 0580
nutrition related to mild protein-calorie malnutrition, Glucerna 1.2 at 45ml/hr with water flush 140ml/hr.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #1's physician order dated 6/29/23 revealed mechanical ground texture, nectar
consistency, finely chopped/minced may have thin small quantities with spoon only, hold feeding 30 minutes
before and 30 minutes after.
Residents Affected - Few
Record review of Resident #1's physician order dated 3/3/25 revealed Lasix oral tablet 20mg, give 1 tablet
by mouth one time a day for swelling.
Record review of Resident #1's physician order dated 5/19/23 revealed Plavix tablet 75mg, give one tablet
via g-tube one time a day related to peripheral vascular disease.
Record review of Resident #1's MARS for May 2025 revealed Lasix 20mg tablet and Plavix 75 mg were not
administered on 5/14/25.
Record review of Resident #1's SBAR dated 5/14/25 revealed situation: gastronomy tube blockage or
displacement; vitals: blood pressure 104/48, pulse 62, respiration 17, temperature 98.2 Fahrenheit, weight
96.2 lbs, blood sugar 187; Code status: DNR; Primary care clinician notified yes, date 5/14/25 at 6:55 am,
recommendations of primary clinician KUB Xray.
Record review of Resident #1's progress note dated 5/14/25 written by RN C revealed Notified ADON
on-call, RP, and Dr. r/t resident pulling out her G-tube. New order for STAT KUB placed. Pending Xray in
order to re-start tube feedings. RT with no s/s of pain or discomfort lying in bed, awakens easily to voice.
Record review of Resident #1's progress note dated 5/14/25 written by LVN A revealed Nurse received on
report that the resident removed her peg tube during the night. This nurse replaced new 27F/20mL peg
tube with no problems. No pain or discomfort note or reported. Placement auscultate with 30 mL of
residuals noted. STAT KUB was ordered to confirm placement. MD, ADON and [RP] all aware, evening
nurse notified on report.
During a follow up interview on 5/20/25 at 2:38 pm, LVN A stated that he did not administer any
medications to Resident #1 during his shift based on the report he received from the outgoing nurse (RN
C). LVN A stated that he was informed the physician had directed staff to hold all medications at that time.
LVN A stated that although Resident #1 was on pleasure feedings and might have tolerated medications in
crushed form, no such attempts were made during his shift, as the prior report indicated a hold on all
medications.
During a follow up interview on 5/20/25 at 2:23 pm, The Dr. stated that she did instruct staff to withhold
medications following the dislodgement of Resident #1's G-tube due to that being the primary source of
medication administration until KUB placement was completed to verify placement. The Dr. stated that the
facility had the option to crush and administer medications orally if the resident was able to tolerate it. The
Dr. stated that this was a common alternative when a G-tube was temporarily unavailable, provided the
patient could safely ingest the medication. The Dr. stated that she was not specifically informed whether this
practice was carried out in this case. The Dr. stated that had there been difficulty administering medications,
she expected to have been notified by the facility. The Dr. stated that she did not receive any communication
indicating that medications were withheld or that administration was interrupted during that period. The Dr.
stated that failing to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676431
If continuation sheet
Page 2 of 6
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
05/22/2025
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
administer medications, even in crushed form, could pose a concern if not reported. The Dr. stated that
although medication administration had not previously been problematic, the facility should have reported
any inability to administer medications. The Dr. stated that she did not receive any such report. The Dr.
stated that while regular administration of Lasix or anticoagulants such as Plavix was important, a single
missed dose was unlikely to cause significant harm. The Dr. stated that not administering Lasix while the
resident was not eating or drinking adequately could potentially prevent dehydration. The Dr. stated that
missing one dose of an anticoagulant generally did not result in immediate complications. The Dr. stated
that she had not seen any indications in the hospital records of coagulation-related issues.
During an interview on 5/20/25 at 2:46 pm, LVN B stated she worked the 2-10 shift on May 14th, 2025. LVN
B stated the KUB for Resident #1 was completed at the beginning of her shift. LVN B stated that while
waiting for verification of tube placement, staff were unable to administer anything via the G-tube. LVN B
stated she did not give medications by mouth, as the resident had difficulty swallowing and the physician
had not cleared oral administration. LVN B stated she did not call the physician to clarify if oral
administration was an option. LVN B stated she did not believe there was a risk by not administering the
medications due to learning that Resident #1 was diagnosed with kidney failure her medications may have
led to a more rapid decline.
During an interview on 5/20/25 at 3:28 pm, ADON stated that she did not receive any report indicating
delays in imaging on May 14, 2025. ADON stated that while G-tube administration was not possible due to
the tube's status, medications could have been crushed and administered orally as Resident #1 was
receiving pleasure feedings. ADON stated that in such cases, it was expected that nursing staff follow up
with the physician to clarify whether medications could be given orally . ADON stated that she was not
made aware that medication had been withheld and did not find documentation indicating the physician had
been contacted regarding alternative administration routes. ADON stated that she reviewed the MAR and
found no medications were administered on the day of the G-tube dislodgement. ADON stated that
Resident #1 was prescribed Plavix and Lasix for fluid retention and swelling and had a history of
heart-related conditions. ADON stated that the risks included fluid overload and heart problems.
During an interview on 5/21/25 at 9:21 am, The DON stated that Resident #1 received pleasure feedings
and was not NPO, stating she ate well. The DON stated that medications had been placed on hold, and
while crushed medications could have been considered, she was informed they were held, likely out of
concern that the daughter may not have approved of crushed administration. The DON stated that she
expected nursing staff to follow physician orders and document accordingly. The DON stated that missing a
single dose of medications such as Plavix and Lasix would likely not have posed significant risk, as Plavix
was a long-acting medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676431
If continuation sheet
Page 3 of 6
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
05/22/2025
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 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure labratory services were provided to meet the needs
of the resident in accordance with professional standards of practice, and for 1 of 6 residents (Resident #1)
reviewed for labratory service.
Residents Affected - Few
The facility failed to ensure LVN A followed up with diagnostic lab for Resident #1's stat KUB order.
This failure could place residents at risk of delayed treatment, unmet medical needs, and a decreased in
quality of life.
The findings included:
Record review of Resident #1's hospital transfer form not dated revealed a [AGE] year-old female who was
admitted to the facility on [DATE] and had diagnoses of: Attention and concentration deficit (Difficulty
staying focused or paying attention, which can affect daily tasks and communication); Cognitive
communication deficit (Problems with thinking and using language, such as trouble understanding,
speaking, or remembering words); Unspecified dementia (general decline in memory and thinking skills,
often due to aging or disease, that affects daily life); Alzheimer's disease (progressive brain disorder that
slowly destroys memory, thinking skills, and the ability to carry out simple tasks); Cervical disc disorder with
radiculopathy (problem with a disc in the neck that is pressing on nerves, causing pain, numbness, or
weakness in the arms or shoulders); Type 2 diabetes with diabetic neuropathy (nerve damage caused by
high blood sugar levels, leading to tingling, pain, or numbness, usually in the feet or hands); Other specified
depressive episodes (period of depression with symptoms like sadness, loss of interest, or fatigue that
doesn't exactly fit the standard categories but still significantly impacts well-being); Gastronomy status
(person has feeding tube directly placed in their stomach); Gastroesophageal reflux disease (GERD)
without esophagitis (stomach acid flows back into the esophagus (food pipe), causing heartburn or
discomfort, but without damage to the esophagus lining); Epigastric pain (pain or discomfort in the upper
belly area, just below the ribs, often related to digestion); Mild protein-calorie malnutrition (not getting
enough calories and protein, which can lead to weakness, weight loss, and poor healing); Essential
(primary) hypertension (high blood pressure with no known specific cause, which can increase the risk of
heart problems over time); Atherosclerotic heart disease without angina (buildup of plaque in the heart's
arteries, reducing blood flow, but without causing chest pain yet); Peripheral vascular disease (poor
circulation in the arms or legs due to narrowed blood vessels, often leading to leg pain when walking)
Record review of Resident #1's physician order dated 07/06/24 revealed every shift for adequate nutrition
related to mild protein-calorie malnutrition, Glucerna 1.2 at 45ml/hr with water flush 140ml/hr.
Record review of Resident #1's physician order dated 6/29/23 revealed mechanical ground texture, nectar
consistency, finely chopped/minced may have thin small quantities with spoon only, hold feeding 30 minutes
before and 30 minutes after.
Record review of Resident #1's physician order dated 3/3/25 revealed Lasix oral tablet 20mg, give 1 tablet
by mouth one time a day for swelling.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676431
If continuation sheet
Page 4 of 6
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
05/22/2025
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 0770
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #1's physician order dated 5/19/23 revealed Plavix tablet 75mg, give one tablet
via g-tube one time a day related to peripheral vascular disease.
Record review of Resident #1's MARS for May 2025 revealed Lasix 20mg tablet and Plavix 75 mg were not
administered on 5/14/25.
Residents Affected - Few
Record review of Resident #1's SBAR dated 5/14/25 revealed situation: gastronomy tube blockage or
displacement; vitals: blood pressure 104/48, pulse 62, respiration 17, temperature 98.2 Fahrenheit, weight
96.2 lbs, blood sugar 187; Code status: DNR; Primary care clinician notified yes, date 5/14/25 at 6:55 am,
recommendations of primary clinician KUB Xray.
Record review of Resident #1's progress note dated 5/14/25 written by RN C revealed Notified ADON
on-call, RP, and Dr. r/t resident pulling out her G-tube. New order for STAT KUB placed. Pending Xray in
order to re-start tube feedings. RT with no s/s of pain or discomfort lying in bed, awakens easily to voice.
Record review of Resident #1's progress note dated 5/14/25 written by LVN A revealed Nurse received on
report that the resident removed her peg tube during the night. This nurse replaced new 27F/20mL peg
tube with no problems. No pain or discomfort note or reported. Placement auscultate with 30 mL of
residuals noted. STAT KUB was ordered to confirm placement. MD, ADON and [RP] all aware, evening
nurse notified on report.
During an interview on 5/20/25 at 11:50 am, LVN A stated that Resident #1's stat KUB order was placed
around 7:00 a.m., but the imaging was not completed during his shift. LVN A stated that stat x-ray orders
were typically addressed promptly but may have been delayed depending on the imaging service's
availability. LVN A stated that he contacted the local diagnostic lab and was informed they were booked but
would arrive as soon as possible. LVN A stated that he documented the follow-up but later noted that his
entry did not appear in the system, only in the 24-hour report. LVN A stated that he checked the 24-hour
report and found no documentation completed either. LVN A stated that he could not recall if he reported
the matter to the ADON or DON.
During an interview on 5/20/25 at 1:31 pm, The Dr. stated that the imaging vendor typically responded
within 2-3 hours for stat orders, depending on location, technician availability, and competing priorities. The
Dr. stated that she was not contacted about a delay in imaging after the stat order was placed early on May
14. The Dr. stated that had she been notified by mid-morning (e.g., around 10-11 a.m.) that imaging was
still pending, she might have directed that Resident #1 be sent out to the hospital sooner for timely
intervention. The Dr. stated the potential risk for delayed stat KUB would be risk of delayed treatment.
During an interview on 5/20/25 at 3:08 pm, The imaging representative stated that she reviewed the KUB
X-ray reports associated with the resident's G-tube placement verification. The imaging representative
stated that the first STAT order was entered on May 14, 2025, at 7:20 am CDT (6:20 am MST) The imaging
representative stated that the order was assigned to a technician at 11:29 am CDT (10:29 am MST), The
imaging representative stated that the imaging was completed at 3:41 pm CDT (2:41 pm MST), and the
report was signed by the interpreting physician at 8:18 pm CDT (7:18 pm MST). The imaging representative
stated that two prior time slots had been assigned but were unsuccessful. The imaging representative
stated that she did not recall receiving any follow-up calls from the facility regarding the STAT order.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676431
If continuation sheet
Page 5 of 6
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
05/22/2025
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 0770
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 5/20/25 at 3:28 pm, ADON stated that she received a text message at 5:34 a.m. on
May 14, 2025, from RN C, who was on night shift. ADON stated that RN C reported Resident #1's G-tube
had dislodged and that she was preparing to send the resident to the hospital. ADON stated that shortly
afterward, RN C contacted the Responsible Party who requested that nursing staff attempt reinsertion.
ADON stated that she was later informed around 6:30 am that the G-tube had been reinserted and that a
stat KUB had been ordered to confirm placement. ADON stated that the order was submitted through the
facility's portal system. ADON stated that although stat imaging orders were submitted electronically,
nursing staff were expected to follow up with a phone call to notify the imaging provider that the request
was urgent. ADON stated that while stat responses typically occurred within a few hours, delays could
happen, and staff should monitor and follow up.
During an interview on 5/21/25 at 9:21 am, the DON stated that she was notified by LVN C around 5:45 to
6:00 a.m. that Resident #1's G-tube had become dislodged, and that Resident #1 RP had requested for
LVN A to replace it. The DON stated that by the time she arrived at the facility, the G-tube had already been
replaced and they were awaiting the stat KUB. The DON stated that the imaging contract required a
response within four hours; however, reading the film could take additional time depending on the
availability of the physician. The DON stated she expected the nurses to follow up if diagnostic personnel
had not arrived within the four-hour timeframe and report it to her and the physician. The DON stated failure
to follow up could delay treatment based on results.
Record review of the facility's Test Results policy dated 04/2007 did not address STAT orders.
Record review of the facility's contract agreement with local imaging services read in part Addendum No. 1
Additional Terms and Conditions: #2 Services will be provided twenty-four hours a day for STAT ordered
exams (Radiology) .#4 STAT exams will be performed within 60 minutes of the call to [local imaging
services]. A verbal report will be provided within 120 min or less of completion of the exam. Routine exams
will be provided within 120 min or less of completion of the exam.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676431
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
FAQ · About this visit
Common questions about this visit
What happened during the May 22, 2025 survey of Avir at El Paso?
This was a inspection survey of Avir at El Paso on May 22, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Avir at El Paso on May 22, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.