Health inspection·February 4, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 (Resident # 28) out of 8 residents reviewed for person-centered care plans in that: Record review of Resident #28's care plan revealed it did not contain measurable goals and objectives for removing undergarments outside Resident #28 private room area. This failure could affect residents in the facility by placing in them at risk for not being provided necessary care and services, and not having plans developed to address their needs. The findings included: Record review of Resident #28's Physician Order Summary report dated 02/03/2022 revealed Resident #28 was a [AGE] year-old male who was admitted to facility on 02/20/2019 with diagnoses that included: Mild Cognitive Impairment, Dementia in Other diseases with behavioral disturbances and Alzheimer's Disease. Record review of Resident #28's Quarterly MDS, dated [DATE], revealed the resident was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 9 out of 15. Required extensive assistance x two staff for assist for Activities of Daily Living on bed mobility, transfer, and toilet use. Resident #28 was always incontinent for bladder and frequently incontinent for bowel. Record review of Resident #28's comprehensive care plan date initiated 10/30/20 revealed Resident #28 has bowel/bladder incontinence due to Alzheimer's, impaired mobility, neurogenic disorder. Interventions; Activities: notify nursing if incontinent during activities. Brief Use: use disposable brief. Change every two hours and prn. Encourage fluids during the day to promote prompted voiding responses. Ensure there is an unobstructed path to the bathroom. Incontinent: check as required for incontinence. Wash, rinse dry perineum. Change clothing PRN after incontinence episodes. Monitor/document for signs and symptoms UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #28's progress notes dated 12/09/21 revealed: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 455625 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 455625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Rehabilitation and Healthcare 510 Paredes Line Rd Brownsville, TX 78521 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)