Health inspection·August 18, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (this usually means the body is fighting an infection, stress, or inflammation), elevated creatinine (if it's high, it can mean the kidneys are under stress or not working as well as they should), low magnesium (too little magnesium can cause weakness, cramps, or irregular heartbeats), hypophosphatemia (low levels can cause fatigue, muscle weakness, or breathing problems), and elevated glucose (blood sugar is higher than normal). A chest X-ray showed central vascular congestion without consolidation (lungs are showing signs of fluid overload (like early heart failure or too much IV fluid), but there's no infection or collapse in the lung tissue). Treatment included two 1,000 mL IV Lactated Ringer's boluses (they're giving IV fluids rapidly to keep blood pressure up and prevent dehydration), oral Tylenol 1,000 mg, and oral potassium phosphate-sodium phosphate for low phosphate. He was diagnosed with dehydration, elevated creatinine, and heat exposure. After IV fluid resuscitation and clinical improvement, he was discharged back to his prior living arrangement with instructions for follow-up and return precautions.Record review of accuweather.com revealed local weather for August 3, 2025, was a low 76F and high 105F. Record review of accuweather.com revealed bordering city and state weather for August 3, 2025, was a low 76F degrees and high 105F degrees. Record review of Maps (ipone cell phone application) revealed by car, the driving distance from the facility to the Santa?[NAME] Port of Entry to Mexico was approximately 13 miles, taking about 19 minutes via I?10 and US?180.During an interview on 8/13/25 at 11:37 am, Resident #1 stated the incident happened the previous week. He stated he had been sitting outside, decided to go for a walk, got a haircut, then went to a corner store for a soda. He stated he had not planned to leave; it was a spur of the moment decision. He stated he became dehydrated, passed out in a truck, and the driver took him to the hospital where he was treated and returned. He stated staff were worried when he got back, and he felt bad. He stated he felt comfortable at the facility, had no desire to leave, and had been drinking water before leaving.During an interview on 8/13/25 at 6:56 pm, Receptionist A stated she was working on 08/03/2025 when Resident #1 left. She stated she opened the door for him, assuming he was a visitor because she did not recognize him. She stated he smiled and pointed to the door without speaking. She later saw on camera the time was about 9:30 a.m. (the video footage was unavailable for review due to it only going back 7 days). She stated she had been trained to verify with staff before letting someone out but admitted she did not follow procedure, which could place the resident at risk. She stated he was wearing pants, a long sleeve shirt, and had shoes on.During an interview on 8/13/25 at 6:44 pm, RN B stated he last saw Resident #1 around 9:15-9:20 a.m. in the lounge after breakfast. He stated the resident was independent and usually visited friends. He noticed Resident #1 was missing before lunch (approximately 11:30 am), searched his usual spots, and learned from another resident that he had purchased a soda and chips before leaving. RN B stated he notified his supervisors, directed staff to search the facility, and then searched outside up to the fence near a local high school without finding him. RN B stated he was later returned to the facility after he finished his shift. RN B stated Resident #1 had not voiced wanting to leave the facility in the past and did not have history of wandering or exit seeking. During an interview on 8/14/25 at 12:01 pm, the Administrator stated the expectation was for the receptionist to get a sign out sheet signed by the nurse or whoever was taking the resident out and then open the door for him. The Administrator stated Receptionist A did not follow the procedure because she did not get a sign-out sheet signed, and she opened the door for Resident #1. He stated the facility changed the procedure to sign-in/sign-out where everyone needed to sign, the receptionist was educated on the new policy. The Administrator stated Resident #1 had not voiced wanting to leave the facility and did not have exit seeking/ wandering behaviors. The Administrator stated this was the first time Resident #1 had attempted to leave the facility and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676431 If continuation sheet Page 2 of 3 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 08/18/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there had not been any indication for it. The Administrator stated the facility contacted local hospitals to inquire about the resident's whereabouts and was able to locate him. A police report was also filed.Record review of the facility's Signing Resident's Out policy dated August 2006 revealed in part All residents leaving the premises must be signed out. #1- Each resident leaving the premises (excluding transfers/discharges) must be signed out; #6- Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once.Record review of the facility's Wandering and Elopements policy dated 2001 revealed in part The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. #2- If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises The facility completed the following corrective actions to address the non-compliance after the incident occurred and prior to the surveyor entering on 8/13/25.Record review: Record review of an in-service dated 8/3/25 revealed the topic was resident sign-out procedure and had the Signing Resident's Out policy dated August 2006 policy attached for reference was signed by all staff.Record review of Resident #1's elopement assessment dated [DATE] revealed he was a high risk. Record review of Resident #1 physician order dated 8/3/25 revealed Resident has exit seeking behaviors. Wander Guard to be placed for resident safety. Placement location - right wrist.Record review of Resident #1's progress notes revealed no other elopement's were attempted/ reported. Record review of Resident #1's care plan dated 8/3/25 revealed focus area for elopement risk/wander risk as evidenced by history of wandering off in last 30 days. Impaired safter awareness and require a wander guard for safety with interventions that included Check wander guard placement every shift to ensure wander guard is functioning to right wrist; Visually check wander guard placement every 2 hours. Observations: Observation on 8/13/25 at 11:37 am, revealed Resident #1 was observed with a wander guard to his right wrist. Observation on 8/14/25 at 2:20 pm, recalled Resident #1 was observed with a wander guard to right wristThe facility posted signs at the door All visitors must sign in upon entering and must sign out upon exiting the facility, by entrance door and the reception desk informing all visitors must sign in and out of the facility.Interviews:During an interview on 8/14/25 at 2:30 pm, Resident #1 verbalized understating on the need to sign out and notify the nurse of his outing. He stated he was ok with wearing the wander guard in case he got confused and got out the facility, they would know and get him back inside. He stated he felt ok and felt safe inside the facilityInterviews from 8/13/25 at 6:37 pm- 8/14/25 at 12:01 pm with Receptionist A, RN B, Receptionist C, BOA, LVN D, RN E, and LVN F reflected they had received the in-service on visitor sign in and out sheet on 8/3/25 and verbalized they needed to ask the residents if their nurses were aware of their outing and confirm with the nurses this was signed by all staff. The staff reported that they would reference the elopement binder located in the receptionist area and verify with the nurses. During an interview on 8/14/25 at 12:01 pm, the Administrator stated that the receptionist along with the rest of the staff received an in-service regarding the procedure of signing in and out of the facility. He stated that in order for the incident to not repeat itself again, the facility implemented the process that day for signing in/out, they put Resident #1 on a wander guard and the facility updated his care plan and the elopement assessment to reflect there was a risk of him eloping. Event ID: Facility ID: 676431 If continuation sheet Page 3 of 3