Avir At El Paso
Inspection Findings
F-Tag F0689
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 REDACTED] 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.
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Avir at El Paso in El Paso, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in El Paso, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at El Paso or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.