Health inspection·August 13, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognition to be able to recall and remember BIMS score of 12. Resident #5 ADLs indicated he needed partial/moderate assistance nursing staff to do less than half the effort) to dressing his upper body and substantial/maximal assistance (nursing staff does more than half the effort) for dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was partial/moderate assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Diabetes Mellitus, altered Mental Status (a change in mental function which stems from certain illnesses, disorders and injuries affecting your brain), Rheumatoid Arthritis, and Encephalopathy (a group of conditions that cause brain dysfunction). Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily). Record review of Resident # 5's Order Recap dated 06/23/23, revealed, May use assist bars to bed for bed mobility, positioning and transfers. Record review of Resident # 5's Enabler assessment dated [DATE], revealed, the digital form stated the following: Has the resident expressed a desire to have enablers raised while in bed for their own safety and or comfort? No. Was the resident able to get in/out of bed? No. Was resident able to get out of bed safety? No. Does the resident use enablers for positioning or support? Yes. Do the enablers help the resident rise from a supine position to a sitting/standing positions? No. Digital form was not signed for consent for use of bed rails. Nor was a handwritten signed consent form given to state during visit. Record review of Resident #5's Miscellaneous tap for documents/forms was reviewed on 08/13/24, revealed, there were not consent forms for use of the bed rails. Record review of Resident # 5's Care Plan dated 06/23/23, revealed, may require the use of a supportive device: grab bars, as enablers to promote my independence and facilitate functional mobility, turning, repositioning and transferring while in bed. Grab bars - to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. LN will review quarterly. Record review of Resident #5's PT Evaluation & Plan of Treatment dated 05/29/24-07/27/24, revealed, Bed mobility was total dependence without attempts to initiate. Clinical Impression: Patient presents with decreased strength with decreased activity tolerance, standing balance/tolerance deficits, sitting balance/tolerance deficits, joint stiffness, impaired functional mobility and limiting independence. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for: falls, further decline in function, compromised general health, decreased ability to return to prior level of assistance, decreased ability to return to prior living environment, decreased in level of mobility, limited out-of-bed activity and decreased participation with functional tasks. Observation and interview on 08/13/24 at 10:11 AM, with Resident #5, revealed, Resident #5 to be sitting on his wheelchair on the left side of the bed. His bed was made with call light within reach. Two bed rails (enablers) were seen on both sides of the bed positioned upwards. Resident #5 had stated the facility staff did not want him to be using the bed rails. Resident #5's fingers were contracted sideways going in an outwards direction. Resident #5 stated he was not able to use the bed rails because he could not hold on to them and did not have enough strength to be holding on to anything. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 2 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #5 showed the state surveyor his hands. Resident #5 stated no facility staff had gone to assess him to see if he needed the bed rails (enablers). Resident #5 stated he did not remember signing any consent forms or if any of his family had signed consent forms. During an interview on 08/13/24 at 11:29 AM, with MDS Coordinator B, she stated when an MDS was generated by the MDS Department they gather all the information from interviews, from the IDT, looking at the residents, and from record review. MDS Coordinator B stated Resident #5 did have bed rails (enabler) and used it to assist with turning and with ADLs. MDS Coordinator B stated it was not checked off on the quarterly assessment of 06/01/24 and annual assessment of 04/05/24, because the bed rails were not considered a restraint. MDS Coordinator B stated to her knowledge it would not be coded in the MDS because it was used as an enabler and Resident #5 was still able to use them to turn himself as of now (08/13/24). MDS Coordinator B stated an enabler was to assist a patient with their transfers, bed mobility, and ADLs. MDS Coordinator B after reviewing the physician's orders dated 06/23/23 and the two MDSs dated 04/05/24 (annual) and 06/01/24 (quarterly) stated the MDSs were not inaccurate and were accurate form the information that she had acquired to her knowledge. It was noted that the MDS Coordinator B could not answer the question if she had looked at the physician's orders as the MDS department gathered all the information from interviews, from the IDT, looking at the residents, and from record review. Resident #6 Record review of Resident # 6's Face Sheet dated 08/13/24, revealed, admission on [DATE] to the facility. Resident #6 was an [AGE] year-old female diagnosed with muscle wasting and atrophy (the wasting or thinning of muscle mass), muscle weakness (lack of muscle strength), abnormalities of gait (unusual walking pattern) and mobility, lack of coordination (not able to move different parts of the body together well or easily), and history of falls. Record review of Resident # 6's quarterly MDS dated [DATE], revealed, a severely impaired cognition to be able to recall or make daily decisions with a BIMS score of 7. Resident #6's ADLs for putting on footwear, lower body dressing, shower, toileting was supervision or touch assistance. Resident #6 was supervision to touch assistance for sit to stand, toilet transfer, and shower. Sit to lying and lying to sitting on side of bed was setup or clean up assistance. Roll left and right on bed was independent. Resident #6 was diagnosed with diabetes mellitus, non-Alzheimer's dementia, muscle weakness, lack of coordination, abnormalities of gait and mobility, and repeated falls. Bed rails on section P - Restraints and Alarms (physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily). Record review of Resident # 6's Order Recap dated 09/20/23, revealed, may use ¼ rails to bed (left, Right, or Both) for bed mobility, positioning, and transfers. Record review of Resident # 6's Assessment on 08/13/24, revealed, there were no enabler assessments conducted at all for use of Enablers (bed rails) for Resident #6. Record review of Resident # 6's Care Plan dated 06/23/23, revealed, required the use of a supportive device: grab bars, as enablers to promote independence and facilitate functional mobility, turning, repositioning, and transferring while in bed. Grab bars to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 3 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0641 concerns with the device/function. Licensed Nurse will review quarterly. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's PT Evaluation & Plan of Treatment dated 02/29/24-04/28/24, revealed, Clinical Impression: Patient performs transfers and mobility at supervision. Patient performs ADLs at independence to supervision. Patient was a high risk for falls and was forgetful with decreased safety awareness. RISK factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for compromised general health and falls. Evaluation Summary: Patient presents with impairments in balance, mobility, and strength. Residents Affected - Some Observation on 08/13/24 at 9:09 AM, revealed, Resident #6 was not in her room at that time. Bed was made and had a bed rail (enabler) up on the left side of the bed with the call light cord wrapped around it. During an interview on 08/13/24 at 2:01 PM, with the DON and MDS Coordinator A, MDS Coordinator A stated residents who have bed rails (enablers) will not be marked on the MDS as they were enablers and not considered to be restraints even though it had devices: indicated bed rails, it would not be coded. MDS Coordinator A stated the bed rails used by the residents were not bed rails such as the hospital used, that were the long bed rails and that slide out. MDS Coordinator A stated the facility bed rails (enablers) were smaller and move up and down and were considered enablers. MDS Coordinator A stated residents who need bed rails were evaluated by the therapy department and do not need a physician order. MDS Coordinator stated they generate an MDS by gathering all the information from the facility system and all departments. MDS Coordinator A stated he could not answer if the MDS was inaccurate as he does not generate the long-term MDSs, and his short-term residents do not stay at the facility long enough for him to really enter a lot of information in the MDS. He stated he would not know if coding the bed rails in Section P for devices of bed rails needed to be coded. The DON stated the MDS was an inaccurate MDS because it needed to be coded for bed rails in Section P. Record review of the facility Maintain Minimum Data Set (MDS) Assessments not dated, revealed, policy did not relate to accuracy of MDS assessments. No other policy was brought forth prior to exit. Record review of the facility Documentation in Medical Records policy not dated, revealed, Policy - Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and or responses to care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 4 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 ( Resident #5, and Resident #6) of 5 residents reviewed for enablers (bed rails). Resident #5 did not have a signed consent form for use of bed rails, nor on-going Enabler Assessments being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #4's needs. Resident #6 did not have a signed consent form for use of bed rails, nor was an Enabler Assessment conducted to ensure that the bed rails (Enablers) were appropriate for the residents, and on-going Enabler Assessments was not being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #6's needs. This failure could place residents who have bed [NAME] (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury. Findings included: During an interview on 08/13/24 at 9:19 AM, with the PT, she stated the therapy department conducted bed rail assessments on residents in the facility. The PT stated she had done a PT Evaluation on Resident #4 sometime in February of 2024 and then Resident #4 had left to another facility. The PT stated Resident #4 had bed rails and was able to help nursing staff with ADLs. The PT stated she was not able to find the bed rail assessments for any residents to include Resident #4, Resident #5, and Resident #6 that the therapy department had done. The Pt stated bed rails were recommended by the Therapy department during evaluation of a resident. The PT stated she was not sure if the facility was conducting the Enabler Assessments (or any other bed rail assessments) quarterly or annually or at all. The PT stated Resident #4 was able to use the bed rails as an enabler. During an interview on 08/13/24 at 10:17 AM, with the DON, she stated Resident #4 had an Enabler Assessment that was done last year on 07/18/23 and had not been done quarterly as there were no other enabler assessments for her. The DON stated the Enabler Assessments were done quarterly to see if the resident had a change of condition and to see if the bed rails were safe for her and other residents with bed rails. The DON stated the enablers were placed on Resident #4's bed as per family request and no alternatives were attempted prior to putting on the bed rails. The DON stated she did not know if any of the long-term residents have had any alternatives used before, they had bed rails installed. The DON stated the digital Enabler Assessments were inaccurately done as there were no signatures or digital signatures. The DON stated it was inaccurate documentation. The DON stated the nurses were responsible for documenting accurately. The DON stated it was required to have a physician's order for use of bed rails as enablers and did not see one for Resident #4. Resident #5 Record review of Resident # 5's Face Sheet dated 08/13/24, revealed, admission on [DATE] and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 5 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0700 re-admission [DATE] to the facility. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 5's Clinic History and Physical dated 05/29/24, revealed, a [AGE] year-old male diagnosed with Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints). Residents Affected - Some Record review of Resident #5 annual MDS dated [DATE], revealed, a severely impaired cognition to be able to recall and remember BIMS score of 6. Resident #5 ADLs indicated he needed substantial/maximal assistance (nursing staff does more than half the effort) to dressing his upper body, to dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was substantial/maximal assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Arthritis (painful inflammation and stiffness of the joints), Diabetes Mellitus, Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Muscle Weakness (lack of muscle strength), and Abnormalities of gait (unusual walking pattern) and Mobility. Bed rails on section P Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily). Record review of Resident # 5's quarterly MDS dated [DATE], revealed, a moderately impaired cognition to be able to recall and remember BIMS score of 12. Resident #5 ADLs indicated he needed partial/moderate assistance nursing staff to do less than half the effort) to dressing his upper body and substantial/maximal assistance (nursing staff does more than half the effort) for dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was partial/moderate assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Diabetes Mellitus, altered Mental Status (a change in mental function which stems from certain illnesses, disorders and injuries affecting your brain), Rheumatoid Arthritis, and Encephalopathy (a group of conditions that cause brain dysfunction). Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily). Record review of Resident # 5's Order Recap dated 06/23/23, revealed, May use assist bars to bed for bed mobility, positioning and transfers. Record review of Resident # 5's Enabler assessment dated [DATE], revealed, the digital form stated the following: Has the resident expressed a desire to have enablers raised while in bed for their own safety and or comfort? No. Was the resident able to get in/out of bed? No. Was resident able to get out of bed safety? No. Does the resident use enablers for positioning or support? Yes. Do the enablers help the resident rise from a supine position to a sitting/standing positions? No. Digital form was not signed for consent for use of bed rails. Nor was a handwritten signed consent form given to state during visit. Record review of Resident #5's Miscellaneous tap for documents/forms was reviewed on 08/13/24, revealed, there were not consent forms for use of the bed rails. Record review of Resident # 5's Care Plan dated 06/23/23, revealed, may require the use of a supportive device: grab bars, as enablers to promote my independence and facilitate functional mobility, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 6 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some turning, repositioning and transferring while in bed. Grab bars - to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. LN will review quarterly. Record review of Resident #5's PT Evaluation & Plan of Treatment dated 05/29/24-07/27/24, revealed, Bed mobility was total dependence without attempts to initiate. Clinical Impression: Patient presents with decreased strength with decreased activity tolerance, standing balance/tolerance deficits, sitting balance/tolerance deficits, joint stiffness, impaired functional mobility and limiting independence. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for: falls, further decline in function, compromised general health, decreased ability to return to prior level of assistance, decreased ability to return to prior living environment, decreased in level of mobility, limited out-of-bed activity and decreased participation with functional tasks. Observation and interview on 08/13/24 at 10:11 AM, with Resident #5, revealed, Resident #5 to be sitting on his wheelchair on the left side of the bed. Bed was made with call light within reach. Two bed rails (enablers) were seen on both side of the bed positioned upwards. Resident #5 had stated the facility staff did not want him to be using the bed rails. Resident #5's fingers were contracted sideways going in an outwards direction. Resident #5 stated he was not able to use the bed rails because he could not hold on to them and did not have enough strength to be holding on to anything. Resident #5 showed State his hands. Resident #5 stated no facility staff had gone to assess him to see if he needed the bed rails (enablers). Resident #5 stated he did not remember signing any consent forms or if any of his family had signed consent forms. During an interview on 08/13/24 at 9:19 AM, with the PT, she stated Resident #5 was on case load but was not anymore as he had reached a certain point and could not go any higher (was not declining nor approving) from that point and was released from therapy. The PT stated Resident #5 required maximum assistance to total assistance (dependent on nursing staff for help) especially on his bad days. The PT stated Resident #5 was weak in his hands and arms, and they were not functional to be able to grab or pull on the bed rails. The PT stated Resident #5 having the bed rails right now would not be considered as enablers for him. The PT stated even if the bed rails are in or down resident #5 would not be able to get out of bed because he requires max to total assistance from nursing staff. The PT stated she would see the need for the residents who have bed rails to be assessed for the use of the bed rail and having on-going assessments for the use of bed rails as enablers. The PT stated it would benefit the residents and would make sure the residents can use the enablers, for safety, and not to be a restraint. During an interview on 08/13/24 at 10:17 AM, with the DON, she stated Resident #5 Enabler Assessment was done on 01/22/23 and has not had any other Enabler Assessments conducted since. The DON stated the risk of not conducting the enable assessments was that the facility could overlook any changes of condition and see if they were appropriate for the resident to be using the bed rails as enablers. The DON stated the facility had not done had any other alternative that were used first before using the bed rails for Resident #5 as stated in the facility Side Rails policy where alternative should be used first before using bed rails as enablers. The DON stated there were not consent forms signed for Resident #5. The DON stated she had seen Resident #5 and he would not benefit form the use of bed rails (enablers). Resident #6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 7 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0700 Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 6's Face Sheet dated 08/13/24, revealed, admission on [DATE] to the facility. Resident #6 was an [AGE] year-old female diagnosed with Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Muscle Weakness (lack of muscle strength), Abnormalities of gait (unusual walking pattern) and Mobility, Lack of Coordination (not able to move different parts of the body together well or easily), and History of Falls. Residents Affected - Some Record review of Resident # 6's quarterly MDS dated [DATE], revealed, a severely impaired cognition to be able to recall or make daily decision BIMS score of 7. Resident #6's ADLs for putting on footwear, lower body dressing, shower, toileting was supervision or touch assistance. Resident #6 was supervision to touch assistance for sit to stand, toilet transfer, and shower. Sit to lying and lying to sitting on side of bed was Setup or clean up assistance. Roll left and right on bed was independent. Resident #6 was diagnosed with diabetes Mellitus, Non-Alzheimer's Dementia, Muscle Weakness, Lack of Coordination, Abnormalities of gait and mobility, and repeated falls. Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily). Record review of Resident # 6's Order Recap dated 09/20/23, revealed, May use ¼ rails to bed (left, Right or Both) for bed mobility, positioning and transfers. Record review of Resident # 6's Assessment on 08/13/24, revealed, there were no Enabler Assessments conducted at all for use of Enablers (bed rails) for Resident #6. Record review of Resident # 6's Care Plan dated 06/23/23, revealed, requires the use of a supportive device: grab bars, as enablers to promote independence and facilitate functional mobility, turning, repositioning and transferring while in bed. Grab bars to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. Licensed Nurse will review quarterly. Observation on 08/13/24 at 9:09 AM, revealed, Resident #6 was not in her room at that time. Bed was made and had a bed rail (enabler) up on the left side of the bed with the call light cord wrapped around it. Record review of Resident #6's PT Evaluation & Plan of Treatment dated 02/29/24-04/28/24, revealed, Clinical Impression: Patient performs transfers and mobility at supervision. Patient performs ADLs at independence to supervision. Patient was a high risk for falls and was forgetful with decreased safety awareness. RISK factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for compromised general health and falls. Evaluation Summary: Patient presents with impairments in balance, mobility, and strength. During an interview on 08/13/24 at 9:19 AM, with the PT, she stated Resident #6 was able to use the bed rails as an enabler. During an interview on 08/13/24 at 10:17 AM, with the DON, she stated what qualified residents to have bed rails were family requests and the resident being able to turn using the bed rail. The DON stated if the resident was not able to turn themselves using the bed rail and the family still requested to have them on then the facility will comply with the family request and put on the bed rails. The DON stated the resident will have an Enabler Assessment done to evaluate if they were able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 8 of 9 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 676468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some use the enablers or not. The DON stated the facility had to have had consent forms signed for the use of the bed rails (Enablers). She noted that there were consent forms that were not signed for Resident #4, Resident #5, Resident #6, and some other residents that she had looked up that were using bed rails and had Enabler Assessments done. The DON stated the facility was in violation of not following its facility side policy on having consent forms signed. The DON stated it was the responsibility of the DON/ADONs to oversee and ensure that the facility nurses were documenting accurately. Record review of the facility Proper Use of Bed Rails policy noted dated, revealed, Policy- It was the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used the facility ensures correct installation, use, and maintenance of the rails. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and maybe installed on or used along the side of the bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Physical Restraint was defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: A. Was attached or adjacent to the resident's body; Cannot be removed easily by the resident; and C. Restricts the resident's freedom of movement or normal access to his/her body. Resident Assessment - the following will be considered when determining the resident's needs, and whether or not the use of bed rails meets these needs: Mobility (in and out of bed), underlying medical conditions, medical diagnoses, conditions, symptoms. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. Informed Consent - from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. Ongoing Monitoring and Supervision - ongoing assessment to assure that the bed rails was used to meet the resident's needs. Ongoing evaluation of risk. Record review of the facility provided Assist Bar/Barre d'aide manual not dated, revealed, The purpose of the Assist Bar was to provide the resident a grab bar in which they can use to assist themselves form a sitting position to standing while exiting a long-term care bed. Clinical staff must decide whether a resident would benefit from the use of this aid. Vulnerable patient needs should be considered before using this product. The Assist bar should not be used as a rail. The assist bar was not intended to prevent the resident from rolling out of bed. The facility did not provide any other information from the manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676468 If continuation sheet Page 9 of 9