Avir at El Paso: Elopement Immediate Jeopardy - TX
Federal inspectors rated the failure immediate jeopardy, meaning the lapse created a situation likely to cause serious harm or death.
The resident, identified in inspection records only as Resident 1, was assessed as high risk for elopement. His history of wandering off in the prior 30 days was documented. Despite that, the safeguards that would eventually be put in place after he left, a wander guard on his right wrist, a care plan flagging the elopement risk, a physician order addressing his exit-seeking behaviors, none of those existed when he walked out.
The facility moved quickly once the incident happened. On August 3, 2025, ten days before inspectors set foot in the building, a physician order was written directing staff to place a wander guard on Resident 1's right wrist. That same day, the facility held an in-service for all staff on the resident sign-out procedure, attaching a policy from August 2006 for reference. Staff signed off on it. The care plan was updated to reflect the elopement risk and to direct staff to check the wander guard placement every shift and visually confirm it every two hours.
By the time inspectors arrived on August 13, the wander guard was on his wrist. It was still there the following afternoon.
When an inspector spoke with Resident 1 on August 14, he said he understood he needed to sign out and let his nurse know before leaving. He said he was fine with wearing the wander guard. "In case he got confused and got out the facility, they would know and get him back inside," he told the inspector. He said he felt safe.
The staff told a similar story. A receptionist, two registered nurses, a director of business operations, and two licensed vocational nurses, all interviewed between the evenings of August 13 and the afternoon of August 14, said they had attended the August 3 in-service. They said they now knew to ask residents whether their nurses were aware of a planned outing and to confirm it before anyone left. They pointed to an elopement binder kept at the reception desk as the reference point going forward.
The administrator told inspectors the facility had put the sign-in and sign-out process in place the same day as the in-service, updated Resident 1's care plan, completed the elopement assessment, and placed him on the wander guard. "In order for the incident to not repeat itself again," he said.
Signs were posted at the entrance and at the reception desk telling visitors they must sign in and out.
What the record does not show is any of this happening before Resident 1 left. The physician order is dated August 3. The in-service is dated August 3. The updated care plan is dated August 3. The elopement assessment listing him as high risk is dated the same day. The incident that prompted all of it happened before that date, in a facility that had a 2006 policy on its books and a resident whose wandering history was already known.
Inspectors noted no additional elopement attempts in Resident 1's progress notes after August 3.
The immediate jeopardy determination was in place when surveyors entered on August 13. The facility's corrective actions had all been completed before that visit, and the inspection record reflects that the jeopardy had been addressed by the time surveyors completed their review. What it cannot address is the window between when Resident 1 first wandered and when anyone put a device on his wrist.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At El Paso from 2025-08-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Avir at El Paso in El Paso, TX was cited for immediate jeopardy violations during a health inspection on August 18, 2025.
Federal inspectors rated the failure immediate jeopardy, meaning the lapse created a situation likely to cause serious harm or death.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.