Health inspection·July 1, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that a Google review was posted in the facility's website by the resident's family, that stated that a nurse, name unknown, had stolen thirteen thousand dollars from the resident. The Administrator said the facility made several attempts to contact the family but were not successful, and the family did not return their calls. The Administrator said the investigation was concluded and was deemed unfunded since there was no way to gather information. He said that he had not conducted any investigation to determine if a staff member had taken money from the resident, because had had not been able to contact the resident's family member.Telephone interview on 6/30/25 at 11:36 AM with Resident #1's family member, stated Resident #1 had been admitted to the facility for about a month and they visited him frequently. The family member said Resident #1 was very confused and unable to carry meaningful conversations, remember passwords or easily operate his smartphone, so she had removed the passwords to allow him to use the phone without issues. The family member also stated that during one visit, she accessed Resident #1's Bank account app on his smartphone to monitor for activity and observed several transactions made from Resident #1's phone through the Mobile banking on-line application (a popular money transfer service that allows individuals to send and receive money directly between eligible U.S. bank accounts) to a recipient identified as CNA C. These transactions totaled almost thirteen thousand dollars. The family member reported that after noticing these transactions, she reported it to the police and was informed the financial crimes department would investigate the incident. The family member stated she had reported these transactions to Resident # 1's bank on 1/23/25 after Resident # 1 had been discharged from the facility. The family member said on that same date she had contacted the Police department to make a report and stated the Police had advised her to not contact the facility or the administrator to ask questions and to allow the police to investigate.In an interview on 6/30/25 at 12:03 PM with CNA C, stated she started receiving money from Resident #1 around November 2024 through the Mobile banking on-line application, totaling around ten thousand dollars. CNA C explained she was assigned to Resident #1's care and often interacted with him. She stated one day, Resident #1 saw her crying and asked what was wrong, to which she explained she was having financial problems. CNA C said Resident #1 offered her money to help, and she accepted his assistance. CNA C explained Resident # 1 continued to send her money throughout November 2024 and December 2024. CNA C then stated she considered keeping and using the money but became scared and returned it to Resident #1's account. CNA C also stated she had been trained on ANE (Abuse, Neglect, and Exploitation) and misappropriation upon being hired at the facility in 2021 and had been in-serviced several times on ANE, though she could not remember her last training date. CNA C stated she understood she had done something wrong and should not have accepted money from Resident #1, as it could have been perceived as taking advantage of him. CNA C explained she had not informed the Administrator or anyone at the facility that Resident #1 had given her money, nor did she disclose this information to her coworkers, other residents, or Resident #1's family members.In an interview on 6/30/25 at 1:03 PM with LVN D, revealed she was the charge nurse that was assigned to Resident # 1 resided while he was at the facility. LVN D said she remembered Resident # 1 was able to have small talk and answer simple questions such as how are you? and answering, good morning but he was not alert enough to make his own decisions. LVN D stated she had no knowledge of missing funds from the resident and that she was not approached by anyone in the facility to ask her if she knew anything about it.In an interview on 6/30/25 at 3:11 PM with the Bank Teller, revealed that CNAC's bank account had been closed at that bank on 4/8/25 after the account was over drafted. The bank teller stated that in the system he was able to see that on 1/23/25, a claim was made from a different bank account and the amounts that had been deposited via the Mobile-Online bank account had been extracted and returned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 2 of 11 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 07/01/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to the original bank account. The bank teller explained that this happens when a bank gets a fraud report and they put a stop to the transactions from one bank account to the other.Record Review of the facility's policy and procedures revised in February 2021 and titled Resident Rights, read in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be free from abuse, neglect, misappropriation of property, and exploitation.Record Review of the Team Member Handbook Receipt and Acknowledgement, signed and initialed by CNA C on 10/28/21 read in part: By signing in the space below, I am indicating that I have received a copy of this facility Team Member Handbook and agree to abide by the guidelines outlined in the Handbook. Additionally, I specifically acknowledge the following. I understand and agree to comply with [facility] guideline forbidding abuse, neglect and/or exploitation of a patient/resident, including misappropriation of patient/resident property and I understand my obligation to immediately report such behavior including injuries of an unknown source or alleged behavior, as set forth in [facility] guideline.Record Review of the facility's policy and procedures dated April 2025 and titled Gifts and Gratuities, in the employee handbook read in part: The Company strongly discourages accepting gifts, gratuities, or tips from residents or donors and/or giving gifts or gratuities to residents or donors. If a question arises regarding this issue, speak with your supervisor or Administrator. Business and Financial Practices: Fraud is an intentional deception or misrepresentation made by a person who knows the deception could result in some unauthorized benefit or financial gain. The act does not have to be successful; it is enough that the person attempted the deception.Record Review of the Facility's ANE Policy revised in April 2021 read in part: Abuse, Neglect, Exploitation and Misappropriation Prevention Program.Policy Statement:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consist of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. Facility Staff 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; c. theft, exploitation or misappropriation of resident property.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Event ID: Facility ID: 676431 If continuation sheet Page 3 of 11 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 07/01/2025 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 0610 Respond appropriately to all alleged violations. 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 that incidents and investigations were complete and accurately documented for 2 of 6 (Resident #1 and #2) residents reviewed for accuracy and completeness of records. 1. The facility failed to have complete and accurate documentation and investigation for an allegation of misappropriation and exploitation for Resident # 1. 2. The facility failed to complete an incident report or accurately document progress notes, when Resident # 2 exited the facility. These deficient practices could put residents at risk of not receiving needed services such as monitoring or supervision, and incident investigations. Findings included: Resident # 1 Record Review of the admission record dated 6/30/25, revealed an [AGE] year-old male with an original admission date of 11/27/24 and a readmission date of 12/18/24.Record Review of the Initial Evaluation dated 11/27/24 revealed an [AGE] year-old male with a diagnosis of type two diabetes, coronary artery disease (a common and serious condition that affects the heart. It occurs when the coronary arteries, which are the blood vessels responsible for supplying oxygen-rich blood to the heart muscle, become narrowed or blocked), hypertension (a medical condition where the force of blood pushing against the walls of your arteries is consistently too high), and hypothyroidism (or underactive thyroid, is a medical condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs).Record Review of Resident # 1's initial MDS record dated 11/27/24 revealed a BIMS score of 2 reflecting severe cognitive impairment. MDS revealed Resident #1 had short-term memory problems and was moderately impaired to make decisions regarding tasks of daily life. It described the resident as lethargic (a state of extreme tiredness, sluggishness, and lack of energy or enthusiasm. It implies a noticeable decrease in physical and mental activity). MDS indicated Resident #1 had anxiety disorder and depression.Record Review of Resident # 1's Care Plan initiated on 11/29/24 revealed Resident #1 had a diagnosis of depression and at risk of fluctuating moods with little interest or pleasure in doing things with decreased socialization. The care plan called for interventions to encourage frequent socialization, to be an active participant in decision making, and to voice feelings and thoughts. The care plan revealed Resident #1 had episodes of adverse behaviors such as being verbally aggressive evidenced by cursing, racial yelling and screaming and becoming physically aggressive by hitting staff, kicking, and throwing objects.Record Review of the facility's grievances binder on 6/27/25 at 3:30 PM revealed there were no records of the facility investigation on the allegations of exploitation for Resident # 1.Record Review of Resident #1s EMR from 12/27/24 to 7/1/25, revealed there were no progress notes created to document the Exploitation allegation regarding Resident # 1. In an Interview on 6/26/25 at 3:24 PM with ADON A, she stated she did not know anything about this incident. ADON A said she had not discussed the possible misappropriation of the resident's funds with the Administrator or anyone in the facility. ADON A stated any suspicion of exploitation was expected to be thoroughly investigated by gathering information with staff, residents, and family members. ADON A said if she had been overseen the investigating of the incident, she would have documented attempts to contact the family members and would have conducted in-services to employees to make sure everyone knew how to report ANE if they suspected something.In an Interview on 6/26/25 at 3:38 PM with the Administrator, he explained the facility made several attempts to contact the family but were not successful, and the family did not return their calls. The Administrator admitted there were no records of the facility's attempts to contact the family. He stated the investigation was concluded and was deemed unfunded since there was no way to gather information from the family members.In an interview on 6/27/25 at 9:30 AM with the Ombudsman revealed he had no knowledge of the incident in which it was alleged that a staff member from the Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 4 of 11 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 07/01/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility had stolen money from Resident # 1. He stated the facility had not provided information on this incident to him. In an interview on 6/30/25 at 10:06 AM with SW, revealed she remembered Resident # 1 being discharged from the facility in December 2024. SW said she had no knowledge of the incident in which it was reported that someone from the facility had stolen money from Resident # 1. SW stated that whenever there's an allegation of abuse, neglect or exploitation, it was expected for the facility to investigate and make the effort to contact family members and other residents and determine if they felt safe in the facility. SW explained that after an investigation of this nature, the facility gives training to staff to ensure they know how and when to report any suspicions of ANE. In an interview on 6/30/25 at 1:03 PM with LVN D, she stated she was the charge nurse of the hallway on which Resident # 1 resided while admitted in the facility. LVN D said she had no knowledge of missing funds from the resident and that she was not approached by anyone in the facility to ask her if she knew anything about it. In an Interview on 7/1/25 at 3:18 PM, the Administrator revealed he had not documented anywhere the attempts the facility had done to contact Resident # 1's family members and that he did not interview staff or other residents from the facility to thoroughly investigate the allegation of exploitation. The administrator admitted that he had not gathered enough information to find the investigation unfounded, as stated in his Provider Investigation Report. Resident # 2Record Review of Resident #2's admission record dated 6/26/25, revealed a [AGE] year-old female with an admission date of 4/22/25.Record Review of Resident #2's History and Physical dated 4/24/25 revealed a [AGE] year-old female with a diagnosis of atrial fibrillation (An irregular and often rapid heart rate that can lead to symptoms like palpitations, shortness of breath, and fatigue), hypothyroidism (A condition in which the thyroid gland doesn't produce enough crucial hormones. Symptoms can include fatigue, weight gain, constipation, dry skin, and increased sensitivity to cold), morbid obesity and falls with recent right humerus fracture (A break in the humerus bone, which is the long bone in the upper arm that extends from the shoulder to the elbow), impaired gait and mobility (deviation from a normal, healthy walking pattern), generalized weakness, sarcopenia (A progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function).Record Review of the admission MDS dated [DATE] revealed a [AGE] year-old female with a diagnosis of anxiety disorder and depression. MDS revealed under section GG for Functional Abilities that Resident #2 had LROM on lower extremities and required a wheelchair for mobility. It revealed Resident #2 required substantial assistance with personal hygiene and upper body dressing, sitting to standing, transferring to toilet and from chair to bed and for walking ten feet on uneven surfaces. Functional Abilities revealed Resident # 2 was dependent on staff for toileting hygiene, showering, lower body dressing and putting on footwear. MDS revealed under section V for Care Area Assessment that Resident #2 triggered for cognitive loss, dementia, and falls.Record Review of Resident #2's Care Plan initiated on 4/23/25 revealed Resident #2 had episodes of anxiety and was at risk for fluctuations in mood related to a diagnosis of bipolar disorder (a mental health condition that causes extreme and unusual shifts in a person's mood, energy, activity levels, and concentration), episodes of adverse behaviors evidenced by being verbally aggressive, cursing and using racial slurs, yelling and screaming and being physically aggressive evidenced by hitting, pinching, kicking and throwing objects. It revealed Resident # 2 had a tendency for fabricating facts, manipulating staff, and displaying accusatory behavior towards staff. The resident was at risk of complications due to refusing assistance with ADLS and refusing medications.In an Interview on 6/26/25 at 8:45 AM with the DON, she explained the incident should have been recorded at least in a progress note, but to her knowledge, there was no incident report created or recorded about the incident regarding Resident # 2.In an Interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 5 of 11 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 07/01/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6/26/25 at 8:50 AM with ADON A, she stated that to her knowledge, there had been no progress notes entered into EMR regarding Resident # 2 leaving the facility's parking lot on her own. She explained she believed an incident report was not needed because the incident happened while the resident was under the family's care and not the facilities.In an interview on 7/1/25 at 8:30 AM with the Admissions Coordinator, revealed she had not created documentation on her involvement with the incident related to Resident # 2 arguing with her family members and refusing to get into their vehicle. She stated that since she worked on business operations in the facility, she did not have access to EMR to write progress notes in the residents' charts. The Admissions Coordinator said she believed either the Social Worker, ADON A or the Administrator should have documented the incident either in the progress notes or in an incident report.In an interview on 7/1/25 at 8:40 AM with the Administrator, he stated he had not documented anything related to the incident with Resident # 2 because she was under the family's care at that time, but admitted that on hindsight, either progress notes or an incident report should have been completed either by him or ADON A.In an interview on 7/1/25 at 10:12 AM with ADON B stated she was not in the facility the day the incident occurred with Resident # 2 and her family members, however, she expressed that an incident such as this should have been documented in the resident's progress notes by ADON A or as an incident report by the Administrator or the DON. She stated that whenever there's an unusual incident involving a resident from the facility, it should be documented somewhere.In an interview on 7/1/25 at 10:24 AM with CNA I, he stated he assisted ADON A and the Guest Relations staff to get Resident # 2 into the vehicle to then transport her shopping and afterwards, back to the facility. He explained he did not document the incident in the resident's progress notes because he was not directed to document it. CNA I said he had received training in proper documentation but said he thought that either ADON A or the Administrator would create an incident report for the resident.In an interview on 7/1/25 at 10:37 AM the Guest Relations staff revealed she had not created documentation in the resident's progress notes or anywhere else because she was not sure she had to document it. The Guest Relations staff admitted she did not follow up to ask for guidance with ADON A or the Administrator and asked if she needed to write a witness statement or any other documentation explaining what happened with Resident # 2 on 6/23/25.In an interview on 7/1/25 at 10:50 AM with DON revealed she did not document anything because she was not directly involved in the incident with Resident # 2 leaving the facility without her family members. The DON stated the expectation was that someone wrote the incident in the progress notes to have documentation of it or to create an incident report explaining everything that happened that day.Record Review of the facility's policy and procedures dated 2001 titled Charting and Documentation read in part:1. Documentation in the medical record may be electronic, manual, or combination.2. The following information is to be documented in the resident medical record: e. Events, incidents or accidents involving the resident; and3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy. Record Review of the facility's policy and procedures revised in February 2021 and titled Change in a Resident's Condition or Status, read in part:Policy Statement: our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).Policy Interpretation and Implementation.1. The nurse will notify the resident's attending physician or physician on call when there has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 6 of 11 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 07/01/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm a(n):a. Accident or incident involving the resident.2. A significant change of condition is a major decline or improvement in the resident's status.3. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 7 of 11 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 07/01/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents reviewed for accident prevention. The facility failed to provide supervision when Resident #2 exited the facility on 6/23/25 and propelled herself in her wheelchair down towards the sidewalk exiting the parking lot of the facility. This failure could place residents at risk of a fall, weather exposure, or being run over by a moving vehicle, which could result in injuries. Scope and Severity D Findings include:Record Review of Resident #2's admission record dated 6/26/25, revealed a [AGE] year-old female with an admission date of 4/22/25.Record Review of Resident #2's History and Physical dated 4/24/25 revealed diagnoses of atrial fibrillation (An irregular and often rapid heart rate that can lead to symptoms like palpitations, shortness of breath, and fatigue), hypothyroidism (A condition in which the thyroid gland doesn't produce enough crucial hormones. Symptoms can include fatigue, weight gain, constipation, dry skin, and increased sensitivity to cold), morbid obesity and falls with recent right humerus fracture (A break in the humerus bone, which is the long bone in the upper arm that extends from the shoulder to the elbow), impaired gait and mobility (deviation from a normal, healthy walking pattern), generalized weakness, sarcopenia (A progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function).Record Review of the admission MDS dated [DATE] revealed a [AGE] year-old female with a diagnoses of anxiety disorder and depression. MDS revealed under section GG for Functional Abilities that Resident #2 had limited ROM on lower extremities and required a wheelchair for mobility. It revealed Resident #2 required substantial assistance with personal hygiene and upper body dressing, sitting to standing, transferring to toilet and from chair to bed and for walking ten feet on uneven surfaces. Functional Abilities revealed Resident # 2 was dependent on staff for toileting hygiene, showering, lower body dressing and putting on footwear. MDS revealed under section V for Care Area Assessment that Resident #2 triggered for cognitive loss, dementia, and falls.Record Review of Resident #2's Care Plan initiated on 4/23/25 revealed Resident #2 had care areas as follows:*episodes of anxiety and was at risk for fluctuations in mood related to a diagnosis of bipolar disorder (a mental health condition that causes extreme and unusual shifts in a person's mood, energy, activity levels, and concentration), episodes of adverse behaviors evidenced by being verbally aggressive, cursing and using racial slurs, yelling and screaming and being physically aggressive evidenced by hitting, pinching, kicking and throwing objects.*tendency for fabricating facts, manipulating staff, and displaying accusatory behavior towards staff.* at risk of complications due to refusing assistance with ADLS and refusing medications.*on psychotropic medications and was at frequent fall risk.In an Interview on 6/26/25 at 8:45 AM with the DON revealed she received a report from the admissions coordinator that a family member had called the receptionist from the facility stating Resident # 2 was down the street and was requesting assistance. DON stated the ADON, and other staff left the building to look for Resident # 2 and they were able to find her about a block away and after taking her to the store, staff returned to the facility along with Resident # 2. DON stated the incident should have been recorded at least in a progress note, but to her knowledge, there was nothing recorded about the incident.In an Interview on 6/26/25 at 8:50 AM with ADON A stated the family members were talking to an LVN at the nurse's station. She said that later at 1:46 PM, the Administrator sent a group text message to staff informing them that Resident #2 was away from the building exiting the parking lot and requesting their assistance to locate Resident # 2. ADON A said the Admissions Coordinator told her that the family had gone back to the facility to request assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 8 of 11 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 07/01/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because Resident # 2 was refusing to get into her vehicle and was propelling herself in her wheelchair to the store. ADON A stated she and the Admissions Coordinator went looking for Resident #2 and found her at a business parking lot next to the facility. Resident # 2 was arguing with her family member and was shouting and refusing to get into the family's vehicle. ADON A said she stood with the resident for about ten minutes, trying to de-escalate and convince her to go back to the facility, but Resident # 2 declined and insisted on being taken to the store.In an Interview on 6/26/25 at 10:14 AM Resident # 2, revealed she remembered the incident that happened on 6/23/25. Resident # 2 said her family had gone to the facility to pick her up and take her to the store. She stated after having lunch, her family kept talking to a nurse and were taking too long to take her out and she became upset. Resident # 2 said she exited through the front door while a man (name unknown) opened the door, and she took off in her wheelchair to try to get to the store. Resident # 2 said one of her family members came running after her and another family member caught up with them in a nearby parking lot trying to get her in her family's vehicle, but she wanted to go to the store and refused to get into the vehicle. Resident # 2 said some nurses and staff (she did not know their name) went to the parking lot and told her they would take her to the store, and she agreed to get into the vehicle. Resident # 2 said she did some shopping and was taken back to the facility and said she went about her day without concerns.In an Interview on 6/26/25 at 10:51 AM with Family Member J, revealed that she had gone to the facility with another family member to sign out Resident # 2 and take her to the store for groceries. She stated she was talking to a nurse, and Resident # 2 got upset because she was taking too long to take her out and left on her own. Family Member J said a receptionist (name unknown) had opened the door for Resident # 2, and she had gone out unsupervised. Family Member J said she got worried because Resident # 2 could get into an accident if left unsupervised, so she ran out of the facility along with the other family member to look for the Resident. Family Member J said while she got into her vehicle, the other family member ran after Resident # 2, who had already left the facility parking lot and was propelling herself towards the sidewalk. Family Member J said she caught up with Resident # 2 and her family member around the corner in a business parking lot and started to ask Resident # 2 to get into the vehicle, but she kept refusing. Family Member J said she went back to the facility and requested their assistance to get Resident # 2 into her vehicle and went back to the parking lot where Resident #2 and her family were. Family Member J said once she arrived back at the resident's location, the facility staff was already there with her family member, trying to de-escalate the situation and trying to convince Resident # 2 to get back to the facility. Family Member J said she told the facility staff that she needed to leave because Resident # 2 would stay upset while she was in her presence and told them to take care of the Resident. Family Member J said she left the Resident under the facility staff care, and she and the other family member left Resident # 2 with the staff. Family Member J stated the incident would have been avoided if Resident # 2 was supervised while outside the facility or by not allowing her to exit on her own.In an Interview on 6/26/25 at 1:48 PM with Receptionist F revealed she did not go outside the facility to check if Resident #2 was still by the front door or if she was leaving the facility's parking lot. Receptionist F stated she did not receive official training which talked about timeframes for checking on residents who wished to be outside the facility by the front door. Receptionist F stated she had been informed that before letting a resident go out the door she needed to check with a nurse before, and admitted she failed to do so. Receptionist F stated she should have kept the resident inside and in line of sight before allowing her to exit the facility and admitted she failed to report to the Administrator, DON or ADON that she let the resident exit the facility and did not check on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 9 of 11 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 07/01/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few after. In an Interview on 6/26/25 at 11:38 AM with the Administrator revealed that on 6/23/25 the family members talked to LVN D to inform her they were taking the resident out. He stated that later that day at around 1:30, the Admissions Coordinator went into his office and told him Resident # 2's family member was requesting for the facility to assist her because the resident was refusing to get into her vehicle, and she had left the facility parking lot on her own. The Administrator said he sent a group text message to the facility staff so they could assist the family members with the resident. The Administrator said that to his knowledge, a family member had signed Resident # 2 out and after they left the facility, they got into an argument which led to the resident leaving the parking lot on her own and refusing to get into the family' vehicle. The Administrator said the family members left Resident # 2 under the facility staff care, and they took the resident shopping and took her back to the facility later that evening. The Administrator said there was no incident report created for the incident because the resident was under the family's care once they had signed her out but that in hindsight, Him, the DON or ADON should have recorded the incident to have accountability and statements from those who were involved.In an Interview on 6/26/25 at 11:50 AM with LVN D revealed Resident # 2 should not be left outside the facility unsupervised because the resident was impulsive and had the tendency to make rash decisions which could place her in danger, such as leaving the facility on her own in her wheelchair.In an Interview on 6/26/25 at 2:00 PM with the Admissions Coordinator, stated she did not know if Resident # 2 should be left unsupervised outside the facility and said that the facility should train staff better for them to be able to know which residents can be out of the facility by themselves.In an Interview on 6/27/25 at 11:30 AM with the Director of Rehabilitation, explained that Resident #2 was able to propel on her own while in her wheelchair. She stated Resident #2 required supervision while outside the facility due to her history of cognitive deficit. She said the resident could be forgetful and could be non-compliant with treatment and therapy by refusing to do the exercises needed for her recovery. She stated the resident could become agitated, belligerent, and could potentially get confused and not know how to go back to the facility if she left the premises and she could potentially fall off her wheelchair sustaining injuries.In an Interview on 6/27/25 at 2:38 PM with ADON A revealed that Resident # 2 was impulsive and should not be outside the facility without supervision. ADON A said the resident could potentially attempt to leave on her own if left alone outside and could potentially sustain a fall, injuring herself and there was a possibility of dehydration due to the hot weather.In an Interview on 6/27/25 at 2:53 PM with the DON revealed Resident # 2 should not have been left out of the facility on her own without proper supervision. DON said there was a potential for the resident to fall off her wheelchair and sustain injuries and there was a risk of heatstroke due to the hot weather.In an Interview on 6/27/25 at 3:06 PM with LVN G she stated Resident # 2 should not be outside the facility without supervision, and said the resident had strong opinions about things and could be stubborn. LVN G said she had seen the resident argue with her family in the past and said Resident # 2 more than likely would leave the facility if she had the opportunity and was left unsupervised. LVN G explained the resident could potentially fall from her wheelchair if she left on her own. LVN G said the expectation was if a resident exited the building, staff would ask them if they needed help, ask them where they were going, ask them where their family member was, try to redirect and get them back into the building, and contact immediate supervisor for assistance if needed.In an Interview on 6/27/25 at 3:21 PM with CNA H, stated he had been working at the facility for two years and he was familiar with Resident # 2. He stated CNAs knew that if a resident wished to go outside to sit by the entrance of the facility, they needed to consult with a nurse first and ask if it was permitted for the resident to go (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 10 of 11 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 07/01/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete outside. CNA H stated he would not make the decision on his own if a resident could go outside by themselves. CNA H explained that he believed Resident # 2 should not be outside on her own because she can get confused sometimes and if she was left unsupervised, there was a possibility for her to leave without telling anyone in the facility. He stated there was a possibility of the resident getting hurt from having an accident by falling off her wheelchair or if she went on the street there was a risk of a traffic accident.In an Interview on 6/27/25 at 3:35 PM with the Administrator, he said staff should periodically check on those residents who are able to go outside to the front on their own. The Administrator stated the facility did not have a written policy which stated a concrete timeframe for staff to check on residents who are outside. The Administrator explained that staff should have checked if Resident # 2 stayed in the parking lot or if she attempted to leave on her own. The Administrator stated Resident # 2 could potentially leave the premises if she was left unchecked for a long period of time due to resident being impulsive. The Administrator stated there was no policy, procedure or training for staff, including receptionists, on how to check residents' safety while they were outside in front of the facility. In an interview on 6/30/25 at 10:01 AM with the SW she stated Resident # 2 should not be outside on her own because the resident might not be aware of danger. The SW said Resident # 2 should have staff supervising her while outside the facility because there was a potential outcome of her trying to get up from her wheelchair and potentially fall resulting in injuries. SW explained there was the potential of the resident trying to leave the premises if she was left unsupervised.Record Review of the facility's policy and procedure dated 2001 and titled Signing Residents Out, stated in part: Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Inquiries concerning the signing-out of residents should be referred to the director of nursing services or to the administrator. Event ID: Facility ID: 676431 If continuation sheet Page 11 of 11