That document, a bed-hold notice, is supposed to travel with a resident every time they leave for the hospital.
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That resident, identified in inspection records as Resident 9, had lived at the facility with a stroke diagnosis and right-side paralysis.
They also called two of his co-workers.
They needed help with basic tasks: bathing, rolling over in bed, moving from bed to a chair.
Staff discovered he was missing at 5:00 a.m.
In the second one, conducted by a different surveyor four hours later on May 28, the physician's account shifted.
The other exits are locked and alarmed, the executive director acknowledged, but they are not connected to the wander guard system at all.
The resident, identified in inspection records only as Resident 1, had a peripherally inserted central catheter running into his right upper arm.
The facility's own interdisciplinary team was identified as responsible for reviewing those inventories.
The resident, identified only as Resident 1 in a May 28, 2026 complaint inspection, could not swallow.
On the evening of April 14, 2026, two residents at ARC at El Paso ended up in a physical confrontation in the hallway.
The facility had placed these residents on Enhanced Barrier Precautions precisely because of that vulnerability.