Health inspection·May 15, 2023

F 0656 -was at risk of developing pressure ulcers. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #81's MARs and TARs dated 04/01/23 to 04/30/23 indicated order negative pressure therapy machine, monitor and document if device is on @ 120 mmHG every shift for wound care. The TARs indicated the order was completed from dates 04/20/23 to 04/26/23. Residents Affected - Some Record review of Resident #81's care plans last revised on 04/25/23 revealed it did not include a care plan to address Resident #81's order for use of a wound vac. 2. Record review of Resident #23's admission record dated 04/27/23 indicated Resident #23 was an [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident #23's diagnosis included sepsis (blood poisoning), disruption of internal operation (surgical wound), diabetes (high blood sugars), dementia (decline in cognitive function), cognitive communication deficit and acute posthemorrhagic anemia (quick loss of blood.) Record review of Resident #23's physician orders dated as of 04/27/23 indicated orders for a negative pressure therapy machine (wound vac), monitor and document if device is on @ 120 mmHG every shift for wound care, start date 04/20/23. Record review of Resident #23's quarterly MDS dated [DATE] indicated Resident #23 -cognitive skills for daily decision making were severely impaired (never, rarely made decisions). -was total dependent on two persons for bed mobility and toilet use. -required extensive assistance by one person for dressing, transfers, and bathing. -had impairment on both sides of lower extremity (hip, knee, ankle, foot.) -was at risk of developing pressure ulcers. Record review of Resident #23's MARs and TARs dated 04/01/23 to 04/30/23 indicated order negative pressure therapy machine, monitor and document if device is on @ 120 mmHG every shift for wound care. The TARs indicated the order was completed from dates 04/20/23 to 04/27/23. Record review of Resident #23's care plans last revised on 04/25/23 revealed it did not include a care plan to address Resident #23's order for use of a wound vac. Observation and interview on 04/25/23 at 11:06 am revealed Resident #81 in her room in bed. Resident #81 was alert and stated she had been admitted to the facility and was receiving an antibiotic and getting wound treatment with a wound vac for her amputation of her toe. Resident #81 was observed with a wound vac connected to her right ankle. Observation and interview at 04/25/23 at 10:23 am revealed Resident #23 lying in bed with head of bed inclined, placed with a wound vac. Resident #23 stated staff took very good care of her. Observation and interview on 04/27/23 at 9:25 am revealed Resident #23 lying in bed, placed with a wound vac. Resident #23 said she was getting medicine and treatment for her hip surgery and had a wound vac for the surgery wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 2 of 19 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 05/15/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 04/26/23 at 3:01 pm with LVN E revealed Resident #81 did have an order for a wound vac that was in place as ordered. LVN E said the WCN C was responsible to treat the wound and apply the wound vac. LVN E said a care plan to address the process for the wound vac for residents should be developed with interventions to look for redness, tenderness, swelling around the wound edge and the specific orders pertaining to the wound vac. LVN E said he did not know if there was a care planned developed for residents with wound vacs or if one was developed for Resident #81. Interview on 04/26/23 at 3:18 pm with the MDS Coordinator F said nurses were responsible to develop or create a care plan in their areas of care. The WCN C was responsible to develop a care plan to address Resident #81 and Resident #23's use of wound vac as ordered. Interview on 04/27/23 at 8:41 am with WCN C revealed the specific orders of a wound vac for Resident #81 and Resident #23 should have been care planned. The WCN C said she met with the DON and with an IDT on morning meetings and discussed the care plans needed for each resident. A care plan should have been developed to address the process of applying, monitoring for patency of the wound vac, if suctioning properly, since the wound can get overflowed with fluids. The WCN C said she and the IDT overlooked the developing of a care plan to address the use of a wound vac on both residents. Interview on 04/27/23 at 9:41 am with the DON revealed both Resident #81 and Resident #23 had orders for wound vacs that should have been care planned. The WCN C and himself were mainly responsible to develop these care plans and with discussions with the IDT teams in morning minutes. The DON said they had missed the opportunity to develop the care plans for the order of wound vacs for both residents. The DON said he did not think there was a negative outcome in not care planning the use of the wound vacs, but the care plan would serve as a communication process within all the staff. 3.Record review of Resident #11's admission record dated 04/26/23 documented a [AGE] year-old female with an admission date of 12/14/18. Resident #11's diagnoses include: schizoaffective disorder (mental health disorder characterized by abnormal thought process including hallucinations, delusions, unstable mood, etc.), type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes blood sugar with elevated blood sugar levels), gastrostomy status (an artificial opening into the stomach for nutritional support or gastric decompression), essential hypertension (condition in which the blood pressure is persistently elevated with no secondary cause identified). 1. Record review of Resident #11's active physician orders dated 04/26/23 documented an order for left leg scratches: cleanse with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), leave open to air until resolved, every day, shift for red scabs. Order for left leg scratches dated 03/10/23 with a start date 03/11/23. 2. Further record review of Resident #11's active physician orders dated 04/26/23 documented an order for right leg scratches: cleanse with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), leave open to air until resolved, every day, shift for red scabs. Order for right leg scratches dated 03/10/23 with a start date 03/11/23. Record review of Resident #11's quarterly minimum data set (MDS) dated [DATE] documented a BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 3 of 19 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 05/15/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some score of 07 which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #11 required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, toilet use, and personal hygiene. Record review of Resident #11's care plan with an initiated date 12/24/18 and a revised date of 12/28/18 failed to reveal a care plan including problems, goals, and interventions for skin scratches to bilateral lower extremities. In an observation of Resident #11 and interview on 04/26/23 at 03:45 p.m. with CNA J stated Resident #11 did have scratches to bilateral lower extremities. She stated she had a new scratch that was self-inflicted to her left lower extremity. CNA J stated she had reported it to the nurse. Stated she documented her findings in the care plan under a tab named Alert. She stated that in documenting it there the nurse would see her findings and would be able to address. In an interview on 04/26/23 at 03:50 p.m. with RN L revealed the process of initiating a care plan started when a documented assessment triggered a change of condition on their computer system, such as skin scratches for Resident #11. RN L stated the computer would alert the nurse to notify the physician of that change of condition. RN L stated the nurse responsible for the resident's care would then notify the physician, obtain orders, notify the family, and initiate the care plan. RN L stated that every change of condition gets discussed and reviewed during the interdisciplinary team's morning meetings. RN L stated the change of condition gets passed down with information on the change of report so that the oncoming nurse can have this information and therefore, the change of condition will be placed in the 24-hour report. RN L stated for skin issues, the wound care nurse would be the responsible person to update the care plan. In an interview on 04/26/23 at 04:10 p.m. with MDS Cord K revealed RN/MDS coordinator opens the initial care plan upon admission and every department entered their own pertinent department including skin/wound, dietary, physical therapy, etc. MDS Cord K stated that if there was a change of condition, the ADON would then be responsible for entering the new section pertaining to new focus area, example antibiotics, falls, physical therapy, etc. MDS Cord K stated for Resident #11, both the wound care nurse and the ADON would be responsible, but she was not sure who saw the change of condition first. MDS Cord K stated that every treatment should be care planned. MDS Cord K stated wound care nurse is responsible for updated the care plan for wounds because she is the one responsible for skin assessments. MDS Cord K stated the DON audits the wound care nurse assessments and care plans. MDS Cord K stated that physician's orders are being carried out even without a care plan in place, but there is no nursing interventions to assess and will not let the nurses know if a goal is not working. MDS Cord K stated care plan is a source of communication, if something is not working, it lets the physician know to change the plan, interdisciplinary team, and to notify the family. MDS Cord K stated an initial care plan should be initiated between 24-48 hours and 48-72 hours for a change of condition. She stated it is essential to have a care plan in place. In an interview on 04/27/23 at 11:30 a.m. with WCN C revealed she was not sure how the care plan for Resident #11 was not initiated because the change of condition was triggered before her assignment to the position. WCN C stated after a change of condition, nurse who is assigned will obtain orders from the physician and initiate the care plan. WCN C stated that she must give weekly reports to the interdisciplinary team at the morning minimum data set (MDS) meetings. In an interview on 04/27/23 at 11:50 a.m. with ADON D revealed there was not a specific person who audited the resident's charts for care plans. ADON D stated the IDT team reviewed care plans in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 4 of 19 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 05/15/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some weekly or morning meetings to go over change of conditions and orders. ADON D stated treatments are implemented immediately, and a resident gets care right away; therefore, no negative outcome to Resident #11 is expected since she is getting treatment. ADON D stated that not having a care plan for skin scratches was human oversight. ADON D stated facility has up to 48 hours to implement an initial care plan and could not specify a time frame to initiate a care plan for a change of condition. ADON D stated initiate the care plan for a change of condition as soon as possible. ADON D stated there should always be a care plan because it describes the care that is being provided to the resident. ADON D stated initiating a care plan for a change of condition lies on the person who is in the position for example the wound care nurse; however, it is ultimately a team effort. In an interview on 04/27/23 at 02:25 p.m. with the DON revealed care plans were initiated depending on the focus area. The DON stated Resident #11 was discharged and when she was Medicare reactivated, he was not sure if the MDS staff focused on reactivating the skin scratches to the care plan. The DON stated the nurses would initiate the care plan based on whether the resident was scratching at the time the care plan was to be initiated again or not. The DON stated responsible people who audit charts to make sure care plans are initiated are the DON, who helps with falls and changes of conditions. He further went on to state that other personnel responsible were the ADON and the MDS nurses. The DON stated he was not sure if Resident #11 was treated for the skin scratches and could not state whether not having a care plan for skin scratches would negatively affect the resident because he was not sure she was being taken care of for that focus area. Record review of the facility's policy on Comprehensive Person-Centered Care planning with a revision date of 01/22, quoted in part, it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment .6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments . 7. The facility IDT includes, but is not limited to the following professionals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 5 of 19 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 05/15/2023 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rates of five percent. There were 2 errors in 25 opportunities which resulted in an 8% error rate involving 1 of 4 residents (Resident #70) observed. Residents Affected - Few 1. LVN H administered Potassium Chloride liquid 20 meq (milliequivalents)/15 mL (milliliters) via g-tube (gastric tube) without diluting with 4-6 ounces of water prior to administration. 2. LVN H failed to administer 5mL (milliliters) of Chlorhexidine Gluconate 0.12% solution via g-tube as ordered by physician for Resident #70 and without confirming the order with the physician prior to administering the medication. This deficient practice placed residents on hall 1 who received potassium chloride and chlorhexidine gluconate via g-tube at risk for not receiving the intended therapeutic benefit of their medication, increased risk for drug reaction and a decreased quality of life. Findings Include: 1. During an observation of the medication pass on 04/26/23 at 08:20 a.m., LVN H administered Potassium Chloride liquid 20 meq/15 mL to Resident #11 via g-tub without diluting it in 4-6 ounces of water prior to administration. Record review of Resident #11's active physician orders dated 04/26/23 documented an order for Potassium Chloride Liquid 20 meq/15 mL (10 %) with a start date of 02/03/23. Orders were as follows: Give 30 mL via g-tube one time a day for hypokalemia (low potassium). Give 30 mL to equal 40 meq; dilute with four (4) to six (6) ounces (oz.) of water. Record review of Resident #11 medication administration record (MAR) revealed Potassium Chloride was scheduled for 09:00 a.m. Further review of Resident #11 MAR revealed LVN H and 2 other nurses signed off daily administration of Potassium Chloride 20meq/15mL. An interview on 04/26/23 at 09:50 a.m. with LVN H revealed she had not checked the orders prior to administration of Potassium Chloride. LVN H stated she would have to inform the DON and the physician of this error. LVN H stated Potassium Chloride should not have been given without being diluted. LVN H stated she would have to verify Potassium Chloride was not pre-diluted with the DON. LVN H stated the bottle containing medication Potassium Chloride did have a yellow label that stated, must dilute before using and a manufacturer's label that stated, dilute prior to administration. Later that morning, at 10:50 a.m., LVN H revealed she had informed both the DON and the resident's physician of the medication errors. She stated both the DON and Resident #11's physician verified to her that Potassium Chloride had to be diluted. She stated Potassium Chloride's potential negative effect on the resident could include gastrointestinal irritation and a laxative effect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 6 of 19 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 05/15/2023 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 04/26/23 at 09:55 a.m. with RN I revealed LVN H should not have given Potassium Chloride to Resident #11 without diluting the medication first. She stated she did not know the negative effects or consequences. She stated she would have to look up the side effects of this medication. An interview on 04/26/23 at 09:55 a.m. with DON revealed LVN H should not have given Potassium Chloride to Resident #11 without diluting the medication first. He stated, I am not going to lie, going on to state he would have to look up the negative effects or consequences because he did not know what the side effects were to Potassium Chloride. Later that morning at 11:30 a.m. the DON stated he had spoken to their own pharmacist who had confirmed to him that the nurse should have diluted Potassium Chloride prior to administering the medication to the resident. The DON provided a document from his research stating that he had found side effects of Potassium Chloride and most of the negative outcomes were GI symptoms including stomach irritation and laxative effects. 2. During an observation of the medication pass on 04/26/23 at 08:20 a.m., LVN G administered 5 mL of Chlorhexidine Gluconate 0.12% solution to Resident #11 via g-tube without verifying the order with the physician prior to administering the medication. Record review of Resident #11's active physician orders dated 04/26/23 documented an order for Chlorhexidine Gluconate 0.12% solution. Give 5 mL via g-tube after meals for gingivitis (gum disease that can cause irritation, redness and swelling of the gums/base of your teeth); rinse gums with toothbrush. Record review of Resident#11 medication administration record (MAR) revealed Chlorhexidine Gluconate 0.12% was scheduled for 09:00 a.m., 01:00 p.m., and 06:00 p.m. Further record review of Resident #11's MAR revealed LVN H administered Chlorhexidine Gluconate 55 times between 03/01/23 through 04/25/23. An interview on 04/26/23 at 09:50 a.m. with LVN H revealed she had not checked or verified the orders prior to administration of the Chlorhexidine Gluconate 0.12%. LVN H stated she would have to inform the DON and the physician of this error. LVN H stated she would call the physician to verify the order for Chlorhexidine Gluconate because it read via g-tube and it also read rinse mouth and gums. LVN H stated she would also clarify this order with the resident's physician because this medication was to be given oral and the consistency would have to be altered due to the resident's inability to swallow. LVN H stated Chlorhexidine Gluconate's potential negative effect on the resident could include gastric ulcers. An interview on 04/26/23 at 09:55 a.m. with RN I revealed LVN H should not have given Chlorhexidine Gluconate 0.12% to Resident #11 without diluting the medication first. She stated she did not know the negative effects or consequences. She stated she would have to look up the side effects of this medication. An interview on 04/26/23 at 09:55 a.m. with the DON, stated LVN, G should not have given Chlorhexidine Gluconate without verifying the order with the physician prior to administering the medication. The DON also stated he did not know what the negative outcomes of this medication was. He stated he would have to look up the negative effects or consequences because he did not know what the side effects to Chlorhexidine Gluconate were. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 7 of 19 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 05/15/2023 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility policy and procedures titled Medication Administration (no date), revealed Medication Administration-Oral: It is the policy of this facility to accurately prepare. Administer and document oral medications: Procedures: Preparing Liquid Medications: 3. Read medication card. 4. Read the label on the bottle as it is removed from the shelf and check label with medication card. 5. Read the label again prior to pouring the drug. 7. Read label before returning bottle to the shelf. 8. Verify with medication card as drug is placed on medication tray. Essential points: 8. If there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage. Review of a facility policy titled Medication Administration via Feeding Tube dated 1/ 2022 revealed the quoted in part: A physician's order is required for the administration for the administration of any medication via feeding tube. Liquid dosage forms should be ordered if available . To ensure that medications administered via feeding tube are administered safely and accurately .Guidelines: 2 .The order must specify the medication, dose route (tube), frequency, and volume of water to be administered with the medication. The amount of water used to flush, mix, and administer the medication must be considered when calculating the total free water prescribed by the physician .Procedure: 1 .Confirm physician's order. Review of documentation provided by DON (no source or date) quoted in part, Potassium Chloride liquid can cause electrolyte disturbances and congested states including central and peripheral edema . Increased dilution of the solution and taking with meals may reduce gastrointestinal irritation. The most common adverse reactions to oral potassium salts are nausea, vomiting, flatulence, abdominal pain/discomfort, and diarrhea. Potassium Chloride Liquid must be completely dissolved in at least one-half glass of cold water or juice to reduce its possible stomach-irritating or laxative effect. Record review of [NAME] Advisor, Potassium Chloride, https://advisor.lww.com/lna/document.do?bid=6&did=1232821&searchTerm=potassium%20chloride&hits=potassium,chlori quoted in part, Potassium supplements .Administration .Give with meals and a full glass of water or other liquid to minimize GI (gastrointestinal irritation) . Adverse reactions .GI: nausea, vomiting, abdominal pain, diarrhea, flatulence .Nursing considerations . Patients at increase risk for GI lesions when taking oral potassium include those with scleroderma, diabetes, mitral valve replacement, cardiomegaly, or esophageal strictures, and older adults or patients who are immobile. Record review of https://www.drugs.com/mtm/chlorhexidine-gluconate-oral-rinse.html, Chlorhexidine Gluconate quoted in part, may cause serious allergic reaction that may be life-threatening . do not swallow the mouthwash .an overdose of chlorhexidine would occur only if the medicine were swallowed .overdose symptoms may include nausea, stomach pain, or the appearance of being drunk .can cause a rare but serious allergic reaction that may be life-threatening. Get emergency medical help if you have any of these signs of an allergic reaction: hives, severe skin rash, wheezing, difficulty breathing, cold sweats, feeling light-headed, swelling of your face, lips, tongue, or throat .this is not a complete list of side effect and others may occur. Four (4) residents were observed during medication pass. Based on information gathered from the Facility's Resident Matrix, dated 04/25/23, confirmed a census of 85. Hall 1 had 26 residents, two (2) who had g-tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 8 of 19 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 05/15/2023 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #70) out of 7 residents reviewed for significant medication errors in that: Residents Affected - Some 1. LVN H administered Potassium Chloride liquid 20 meq (milliequivalents)/15 mL (milliliters) via g-tube (gastric tube) without diluting with 4-6 ounces of water prior to administration 26 times from 03/01/23-04/25/23 2. LVN H failed to administer 5mL (milliliters) of Chlorhexidine Gluconate 0.12% solution via g-tube as ordered by physician for Resident #70 and without confirming the order with the physician prior to administering the medication 55 times from 03/03/23-04/25/23. 3. Chlorhexidine Gluconate route was administered via G-tube from 11/09/22 until 04/26/23, by facility nursing staff including the DON and the ADON without verifying the route and obtaining a physician consultation. An Immediate Jeopardy (IJ) situation was identified on 05/11/23. The IJ template was provided to the facility on [DATE] at 05:25 p.m. While the IJ was removed on 05/15/23, the facility remained out of compliance at a scope identified as isolated and a severity level of potential for minimal harm that was not immediate jeopardy due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. These deficient practices placed residents who receive medications administered by the facility at risk for serious injuries up to and including cardiac arrest, increased drug reactions, and decreased quality of life. The findings included: Record review of Resident #70's admission record dated 04/26/23 documented a [AGE] year-old female with an admission date of 06/17/21. Diagnoses include dysphagia (difficulty in swallowing food or liquid), cerebral infarction (a brain lesion in which a cluster of brain cells die when they do not get enough blood), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis of one side of the body following a stroke and affecting the left non-dominant side), dysarthria (difficulty in speech due to weakness of speech muscles), speech and language deficits, gastrostomy status (having a creation of an artificial external opening into the stomach for nutritional support or gastric decompression), apraxia (motor disorder caused by damage to the brain which causes difficulty with motor planning to perform tasks or movements), weakness, cognitive communication deficit (difficulties with communication), dementia (group of symptoms that affect memory, thinking, and may interfere with activities of daily life). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 9 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #70's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility was unable to obtain a brief mental interview for status (BIMS) score for the resident. It also revealed Resident #70 required extensive assistance with one-person physical assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS also revealed Resident #70 had a feeding tube, received 26-50% of total calories through parenteral or tube feeding and 501 cubic centimeter (cc)/day or more of fluid intake per day by tube IV or tube feeding. Residents Affected - Some Record review of Resident #70's Lab Results Report dated 03/20/23 revealed a potassium level of 4.4 mmol (millimoles)/L (liter). Reference range 3.6-5.0. Record review of Resident #70's order summary report dated 05/10/23 revealed 20 Fr (French) G-tube inserted on 11/08/22 with a discontinued date of 11/09/22. 1. Record review of Resident #70's active physician orders dated 04/26/23 documented an order for Potassium Chloride Liquid 20 meq/15 mL (10 %) with a start date of 02/03/23. Orders were as follows: Give 30 mL via g-tube one time a day for hypokalemia (low potassium). Give 30 mL to equal 40 meq; dilute with four (4) to six (6) ounces (oz.) of water. Record review of Resident #70's March and April 2023 medication administration record (MAR), revealed Potassium Chloride liquid 20 milliequivalents (meq)/15 milliliters (mL) (10%) 30 mL =40 meq was scheduled to be given at 09:00 a.m. Further record review of Resident #70's MAR revealed LVN H administered Potassium Chloride 36 times between 02/01/23 through 04/25/23. Record review of Resident # 70's MAR between February through April 2023 revealed Potassium Chloride was scheduled at 0900 a.m. Record review of Resident #70's Potassium Chloride medication bottle revealed a label with medication name and dose as follows: Potassium Chloride Oral Solution, USP 10% 20 meq (milliequivalent)/15 mL (milliliters) Dilute prior to administration. Medication bottle also contained medication label with orders as follows: Give 30 ml (milliliters) per tube 1 time daily. Label had yellow alert sticker with following alert: Do not use a salt substitute without checking with your doctor or pharmacist, (in bold) take with food and must dilute before using. During an observation of the medication pass on 04/26/23 at 08:20 a.m., LVN H administered Potassium Chloride liquid 20 meq/15 mL to Resident #70 via g-tub without diluting it in 4-6 ounces of water prior to administration. An observation of Resident #70 on 04/26/23 at 08:25 a.m. revealed resident in bed with bed in lowest position, bed rails down, call light within resident reach. Resident #70 awake, alert, and unable to answer surveyor questions or make needs known. Resident in no distress at that time. An interview on 04/26/23 at 09:50 a.m. with LVN H revealed she had not checked the orders prior to administration of the Potassium Chloride. LVN H stated she would have to inform the DON and the physician of this error. LVN H stated Potassium Chloride should not have been given without being diluted. LVN H stated she would have to verify Potassium Chloride was not pre-diluted with the DON. LVN H stated the bottle containing medication Potassium Chloride did have a yellow label that stated, must dilute before using and a manufacturer's label that stated, dilute prior to administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 10 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Later that morning, at 10:50 a.m., LVN H revealed she had informed both the DON and the resident's physician of the medication errors. She stated both the DON and Resident #70's physician verified to her that Potassium Chloride had to be diluted. She stated Potassium Chloride's potential negative effect on the resident could include gastrointestinal irritation and a laxative effect. LVN H stated she did not initiate a change in condition, document in the computer or monitor for 72 hours but she did assess Resident #70 to make sure she was ok. Residents Affected - Some An interview on 04/26/23 at 09:55 a.m. with RN I revealed LVN H should not have given Potassium Chloride to Resident #70 without diluting the medication first. She stated she did not know the negative effects or consequences. She stated she would have to look up the side effects of this medication. An interview on 04/26/23 at 10:00 a.m. with DON revealed LVN H should not have given Potassium Chloride to Resident #70 without diluting the medication first. He stated, I am not going to lie, going on to state he would have to look up the negative effects or consequences because he did not know what the side effects were to Potassium Chloride. Later that morning at 11:30 a.m. the DON stated he had spoken to their own pharmacist who had confirmed to him that the nurse should have diluted Potassium Chloride prior to administering the medication to the resident. The DON provided a document from his research stating that he had found side effects of Potassium Chloride and most of the negative outcomes were GI symptoms including stomach irritation and laxative effects. Review of documentation provided by DON (no source or date) quoted in part, Potassium Chloride liquid can cause electrolyte disturbances and congested states including central and peripheral edema . Increased dilution of the solution and taking with meals may reduce gastrointestinal irritation. The most common adverse reactions to oral potassium salts are nausea, vomiting, flatulence, abdominal pain/discomfort, and diarrhea. Potassium Chloride Liquid must be completely dissolved in at least one-half glass of cold water or juice to reduce its possible stomach-irritating or laxative effect. An interview on 05/10/23 at 10:40 a.m. with LVN H revealed she had worked at the facility since 2022 and was assigned to work in Hall 1 since November 2022. LVN H stated she had cared for Resident #70 since November 2022 when Resident #70 had her G-tube placed. Prior to medication observation on 04/26/23, LVN H stated she never diluted Potassium Chloride when administering it to Resident #70. LVN H stated she did look at the orders and did look at the labels on the bottle, which included labels that indicated Potassium Chloride must be diluted. LVN H stated she corrected her medication administration after 04/26/23 and diluted it with 30 mL (milliliters) or four to five mL of water. LVN H stated she informed Resident #70's physician and DON of the medication error but failed to document in the resident's progress notes. LVN H stated the physician's response to her was that Potassium Chloride had to be diluted and that adverse effects to look for would include loose stools. 2. Record review of Resident #70's active physician orders dated 04/26/23 documented an order for Chlorhexidine Gluconate 0.12% solution with a start date of 11/09/22. Orders were as follows: Give 5 mL via g-tube after meals for gingivitis (gum disease that can cause irritation, redness and swelling of the gums/base of your teeth); rinse gums with toothbrush. Record review of Resident #70 medication administration record (MAR) revealed Chlorhexidine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 11 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Gluconate 0.12% was scheduled for 09:00 a.m., 01:00 p.m., and 06:00 p.m. or after meals. Further record review of Resident #70's MAR revealed LVN H administered Chlorhexidine Gluconate 82 times between 02/01/23 through 04/25/23. Record review of Resident #70 MAR revealed Chlorhexidine Gluconate 0.12% was administered by 9 different nurses between 02/01/23 through 04/25/23 including LVN M LVN N, LVN O, LVN P, WCN W, RN Q, the ADON and the DON. Record review of Resident #70 Chlorhexidine Gluconate medication bottle revealed label as follows: Chlorhex Glu Sol 0.12 % Rinse with 5ml (milliliters) po (by mouth) after meals. Yellow alert label read as follows: keep out of reach of children, swish in mouth. Then spit. Do Not swallow. During an observation of the medication pass on 04/26/23 at 08:20 a.m., LVN H administered 5 mL of Chlorhexidine Gluconate 0.12% solution to Resident #70 via g-tube without verifying the order with the physician prior to administering the medication. An interview on 04/26/23 at 09:50 a.m. with LVN H revealed she had not checked or verified the orders prior to administration of the Chlorhexidine Gluconate 0.12%. LVN H stated she would have to inform the DON and the physician of this error. LVN H stated she would call the physician to verify the order for Chlorhexidine Gluconate because it read via g-tube, and it also read rinse mouth and gums. LVN H stated she would also clarify this order with the resident's physician because this medication was to be given oral and the consistency would have to be altered due to the resident's inability to swallow. LVN H stated Chlorhexidine Gluconate's potential negative effect on the resident could include gastric ulcers. An interview on 04/26/23 at 09:55 a.m. with RN I revealed LVN H should not have given Chlorhexidine Gluconate 0.12% to Resident #70 without diluting the medication first. She stated she did not know the negative effects or consequences. She stated she would have to look up the side effects of this medication. An interview on 04/26/23 at 09:55 a.m. with the DON, stated LVN, G should not have given Chlorhexidine Gluconate without verifying the order with the physician prior to administering the medication. The DON also stated he did not know what the negative outcomes of this medication was. He stated he would have to look up the negative effects or consequences because he did not know what the side effects to Chlorhexidine Gluconate were. An interview on 05/10/23 at 10:40 with LVN H revealed she did look at the orders prior to administering Chlorhexidine Gluconate on 04/26/23 and continued to administer it via g-tube without notifying or questioning the physician or pharmacist because it was not a new order. LVN H stated the order said, rinse gums in all caps and was using that part of the order to administer the medication. LVN H stated Chlorhexidine Gluconate was administered oral with a toothbrush and the resident was to spit it out. LVN H stated that prior to the medication observation she had administered it correctly via the oral route, however on the day of medication observation the surveyor made her nervous. LVN H stated on 04/26/23 she did notify physician and DON of the medication error with Chlorhexidine Gluconate after she had administered the medication but did not document the error in the resident's progress notes. LVN H stated she did not know what the purpose of the Chlorhexidine Gluconate was for and was not familiar with the side effects. LVN H stated she had not brought up the discrepancy in the medication administration record to the DON, the pharmacist, or the physician prior to the medication error on 04/26/23 and that she had cared for Resident #70 since November when her g-tube was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 12 of 19 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 05/15/2023 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)

F 0760 placed. Level of Harm - Immediate jeopardy to resident health or safety An interview on 05/10/23 at 11:10 a.m. with LVN M revealed he had been a nurse for 27 years, working at the facility since 2009 and assigned to Hall 1for about 4 years. LVN M stated he was familiar with Resident #70 and had administered both Potassium Chloride and Chlorhexidine Gluconate to her. LVN M stated Potassium Chloride was diluted in 4-6 ounces of water. LVN M stated the bottle for Potassium Chloride had yellow labels marked on the bottle that stated, must dilute. He stated Potassium Chloride was a supplement used for hypokalemia with potential side effects such as irritation of the stomach, nausea, and vomiting. LVN M stated Chlorhexidine Gluconate was administered orally with a toothbrush. He stated Chlorhexidine Gluconate was used for gingivitis and potential side effects were irritation of the stomach, nausea, and vomiting. LVN M stated he had not questioned the order for Chlorhexidine Gluconate to the DON, the physician, or the pharmacist because the order stated, rinse gums in all capitalized letters. LVN M stated he would report medication errors to the DON, the physician, the resident's family, initiate a change of condition, document in the resident's progress notes and monitor the resident for 72 hours. Residents Affected - Some An interview on 05/10/23 at 11:30 a.m. with the DON revealed he was not aware Potassium Chloride was being administered undiluted to Resident #70 by LVN H. The DON stated LVN H was in-serviced on 04/26/23 and that a medication error report was completed on Potassium Chloride on the same day. The DON stated he also had no idea there was a discrepancy on the Chlorhexidine Gluconate order and could not say why it was not caught by other nurses administering it. The DON stated he could not say whether the nurses were looking at the order. The DON stated he was able to view the date and by whom the order for Chlorhexidine Gluconate was entered and discovered it was an order entry error. The DON stated Resident #70's orders changed from oral to g-tube, a route change, on 11/09/23 by the ADON who made an order entry error when changing the order. The DON stated the facility ensures staff are adequately trained to identify when medications are changed by performing the following: yearly check offs, trainings, and reviews performed by the pharmacy with recommended deficient practices. The DON stated the facility's record keeping system (point click care) flags changes in medications if it was an allergy, enteric coated, or if the medication was not allowed to be crushed; however, he stated Chlorhexidine is an anomaly, meaning that is a route not normally seen on that medication and that would not likely be flagged by the system. The DON stated he, the MDS nurse, and the ADON run a report in the morning on new orders, to make sure all orders are being put in correctly and discuss those new orders during morning meetings. The DON stated the report is not printed, it is only viewed on a big screen television in the conference room where everyone can view it and discuss those new orders, prior to executing them and initiating new care plans. The DON stated that when Chlorhexidine Gluconate was changed in the system, the person who changed the order should have, but did not verify the orders with the physician prior to the change. The DON also stated the nurses who administered this medication should have verified it prior to administration including the route. He stated that nurses communicate the orders during 24-hour report, therefore if there was a change to the order, the nurses would have been updated of that order during that time. The DON stated the facility distinguishes new orders from changed orders on their system because a new start date will reflect for each medication. He also stated charge nurses round every shift to ensure the new routes are observed by the staff, but that the facility does not keep a log for their rounds. In an interview on 05/10/23 at 12:00 p.m. with MD R revealed he was unaware of the medication error by LVN H of Potassium Chloride being administered to Resident #70 undiluted. MD R stated he assessed Resident #70 on 05/02/23 and at that time her potassium levels were 3.7. MD R stated he did not think this would affect the resident in the long run. MD R said he was informed of the medication error by LVN H of Chlorhexidine Gluconate being administered via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 13 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some g-tube on 04/26/23. MD R stated, the medication had been discontinued and although rare, may cause gastrointestinal irritation. MD R stated he had a scheduled follow up with Resident #70 in two (2) weeks. In an interview on 05/10/23 at 12:25 p.m. with LVN N revealed she had been a nurse for approximately five (5) years and employed at the facility since 07/23/18. LVN N stated she held a PRN position at the facility and worked in Hall 1 as needed. LVN N stated she worked nights and evenings and worked there the previous Sunday taking care of Resident #70. LVN N stated she had administered medications to Resident #70, including Chlorhexidine Gluconate. LVN N stated she administered Chlorhexidine Gluconate by mouth and was used to treat gingivitis. LVN N stated Resident #70 used to be able to take medications by mouth prior to being transitioned to g-tube, but she never administered this medication via g-tube. LVN N stated she did not know the side effects of Chlorhexidine Gluconate if ingested. She stated side effects including dry mouth and tongue staining. LVN N stated if a medication error occurred she would initiate a change in condition, monitor resident, check vital signs and mental status. In an interview on 05/10/23 at 12:35 p.m. with LVN O revealed he had been a nurse for approximately twelve (12) years and employed at the facility since 05/18/21. LVN O stated he had worked in Hall 1 for about 2 years and cared for Resident #70. LVN O stated he had administered medications to Resident #70 including Chlorhexidine Gluconate. LVN O stated he had administered Chlorhexidine Gluconate by mouth as an oral rinse and had resident spit out. He stated, it was never given via g-tube, although, the order entailed giving via g-tube, it specified oral. LVN O further stated, knowing it was mouth wash, I stuck to oral route and explained it was for gingivitis. LVN O stated he did not know the side effects of Chlorhexidine Gluconate if ingested but listed browning of teeth as a side effect. LVN O stated medication errors are documented and reported to the DON. He stated nurses are to follow the instruction of the DON, file an incident report, inform the physician and the resident representative, monitor the resident for side effects after ingestion of the medication. LVN O further went on to state he was unaware of the exact process to follow for medication error. In an interview on 05/11/23 at 10: 50 a.m. with RPH S revealed he reviewed all medications for residents at the facility monthly. RPH S stated he did recommendations to the facility or the physician via the facility staff through a written letter to clarify any discrepancy on any order(s). RPH S was unable to provide any other information on Resident #70 or the orders at the time of the call. No other attempts to return surveyor's calls were made. In an interview on 05/11/23 at 02:00 p.m. with MD R revealed he was not aware there was a discrepancy for the order Chlorhexidine Gluconate for Resident # 70 beginning 11/08/22. MD R stated he was notified of the medication error in April 2023. MD R stated, it would be a good idea to have a plan or project for the nurses at the facility to be more aware. MD R stated there should be a plan, to avoid these problems in the future. MD R stated, brainstorming a plan to prevent this from happening again because he, was concerned. MD R stated that any medication that could be given through the mouth could be given through the PEG (percutaneous endoscopic gastrostomy) tube and was not sure what medications could cause that type of negative consequences. MD R stated there were concerns and the facility needed to have a corrected plan of some sort in place to avoid for this to happen again. In an interview on 05/11/23 at 02:30 p.m. with LVN P revealed she had been a nurse for approximately four (4) years and employed with the facility since 12/15/20. LVN P stated she helped cover the floor on occasion and had administered medications including Potassium Chloride and Chlorhexidine Gluconate to Resident #70. LVN P stated nurses are always in a hurry and they use their common sense and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 14 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety we think everyone is going to be like that and apparently it is not like that. LVN P stated if she sees a discrepancy in a medication, she investigated the correct route and what the medication is for. LVN P stated she looked at progress notes and asked the DON or the ADON for clarification of the information. LVN P stated medication errors are caught on admission or when physicians send new orders. LVN P stated nurses should notify the DON or ADON or medication errors and documented right away. She stated that nurses are supposed to follow the protocol. Residents Affected - Some Interview on 05/11/23 at 02:45 p.m. with RN Q revealed she had been a nurse for approximately 30 years and been employed at the facility since 04/17/02. RN Q stated she helped cover Hall 1 and administered medications to Resident #70. RN Q stated she administered Chlorhexidine Gluconate with a toothbrush orally. RN Q stated she did not question the order for Chlorhexidine Gluconate because she was just covering and it slipped her mind. RNQ stated she knows it is a mouth administered medication. She stated she did not remember informing the ADON or the DON of the discrepancy. RN Q stated she is supposed to inform the ADON or the DON and the physician is supposed to be informed too. RN Q stated she is supposed to call the pharmacist and clarify the discrepancy with the physician. RN Q stated Chlorhexidine Gluconate is used to cleanse the mouth for oral candidiasis and if she does not know what the medication is for, she googles, calls the pharmacy or the doctor. RN Q stated, nurses have to read the EMAR (electronic medication administration record) and use their nursing judgment. RN Q stated negative consequences depend on the dosage; however, the resident must be observed and the error must be reported to the doctor at once. RN Q further stated nurses should, tell the DON of the error, monitor the resident, inform the resident representative. RN Q stated medication errors can be a negative consequence, every resident can have a different reaction to medications. Interview on 05/11/23 at 03:00 p.m. with ADON revealed she changed all the orders from oral to g-tube in November 2023. The ADON stated she informed the Nurse Practitioner who was rounding for MD R when Resident #70 had the G-tube inserted and needed her medications to be changed from oral to G-tube that Resident #70 needed her medications orders changed. ADON received a verbal ok from the Nurse Practitioner to change the orders from oral to G-tube. The ADON stated she proceeded to do a batch update conversion on their computer system that changed all medication orders from oral route to g-tube route. The ADON stated the physician was notified and he signed off on all orders after all updates are made. The ADON stated none of the nurses who administered Chlorhexidine Gluconate notified her there was a discrepancy in the order. The ADON stated staff do look at the orders but not one by one individually. The ADON stated nurses who questioned the ordered could have changed it without having to notify the physician. The ADON stated nurses did not have to call the physician and notify him because he would have replied, why are you calling me, just change it, common sense. The ADON stated she did not realize the discrepancy when administering the medication to Resident #70. The ADON stated she, cannot compare, judge or say and depends on the situation if it would have been a different medication with more serious consequences. The ADON stated, if nurses do not know what a medication is they have a PDR (physician's desk reference), can call the pharmacy or google the medication in question. In an interview on 05/11/23 at 03:15 p.m. with the DON revealed Chlorhexidine Gluconate was changed from oral to g-tube since November 2022. The DON stated there were approximately nine to eleven nurses including himself and the ADON who administered this medication to Resident #70 with an incorrect order between February 2023 through April 2023 when the medication error was observed. The DON stated nurses should have notified the physician. The DON stated the medication error should have been documented in a progress note. The DON also stated a progress note was needed to document the correction of route clarified by the nurse. The DON stated that none of the nurses who administered this medication questioned the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 15 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some order or notified him of the discrepancy. The DON stated he is unsure why the nurses did not question the order or notify him of this discrepancy. The DON stated he did not notice the order when he did his own medication pass for Resident #70. The DON stated when he saw the order he saw mouth wash and I know what I need to do. The DON stated he should have changed the order immediately upon identifying the discrepancy. He stated he should have questioned the staff to verify the route they had been giving the medication. The DON could not state how often the medication got restocked/refilled. He stated, this was an oversight, we all missed it. The DON further went on to state I see the clerical mistake, except nurses were giving it the right route. The DON stated, it would be speculation on his part if he stated it could have been a more serious medication and he would not be able to tell if there would be any negative consequences from that. In an interview on 05/11/23 at 03:25 p.m. with the Administrator revealed this discrepancy could have affected Resident #70 as well as other residents at the facility. The Administrator stated nurses must review the medications. The Administrator stated negative consequences depend on the medication that is being given. Record review of document provided by the DON, signed, and dated by LVN H on 06/21/22, titled, Skills competency checklist-Enteral Med Pass, quoted in part, Nurse verifies medication & strength with order as prescribed .medication errors are reported to supervisor. Record review of facility policy and procedures titled Medication Administration (no date), revealed Medication Administration-Oral: It is the policy of this facility to accurately prepare. Administer and document oral medications: Procedures: Preparing Liquid Medications: 3. Read medication card. 4. Read the label on the bottle as it is removed from the shelf and check label with medication card. 5. Read the label again prior to pouring the drug. 7. Read label before returning bottle to the shelf. 8. Verify with medication card as drug is placed on medication tray. Essential points: 8. If there is any question regarding dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage. Review of a facility policy titled Medication Administration via Feeding Tube dated 1/ 2022, quoted in part: A physician's order is required for the administration for the administration of any medication via feeding tube. Liquid dosage forms should be ordered if available . To ensure that medications administered via feeding tube are administered safely and accurately .Guidelines: 2 .The order must specify the medication, dose route (tube), frequency, and volume of water to be administered with the medication. The amount of water used to flush, mix, and administer the medication must be considered when calculating the total free water prescribed by the physician .Procedure: 1 .Confirm physician's order. Review of facility policy titled Pharmacy Services dated 08/2007 with a revision date 12/2019; 01/2022, quoted in part, It is the policy of this facility that medication errors and adverse drug reactions must be reported to the resident's attending physician .1. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. Review of facility policy titled Nursing Services, Physician Orders, dated 05/2021 with a reviewed date 08/2021; 08/2022, quoted in part, It is the policy of this facility that verbal/written/electronic orders for changes in medications including routes will be written upon receipt from Physician/Designee .orders for medications must include .right route of administration if other than oral. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 16 of 19 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 05/15/2023 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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of [NAME] Advisor, https://advisor.lww.com/lna/document.do?bid=6&did=1232821&searchTerm=potassium%20chloride&hits=potassium,chlori quoted in part, Potassium supplements .Administration .Give with meals and a full glass of water or other liquid to minimize GI (gastrointestinal irritation) . Adverse reactions .GI: nausea, vomiting, abdominal pain, diarrhea, flatulence .Nursing considerations . Patients at increased risk for GI lesions when taking oral potassium include those with scleroderma, diabetes, mitral valve replacement, cardiomegaly, or esophageal strictures, and older adults or patients who are immobile. Record review of https://www.drugs.com/mtm/chlorhexidine-gluconate-oral-rinse.html, Chlorhexidine Gluconate quoted in part, may cause serious allergic reaction that may be life-threatening . do not swallow the mouthwash .an overdose of chlorhexidine would occur only if the medicine were swallowed .overdose symptoms may include nausea, stomach pain, or the appearance of being drunk .can cause a rare but serious allergic reaction that may be life-threatening. Get emergency medical help if you have any of these signs of an allergic reaction: hives, severe skin rash, wheezing, difficulty breathing, cold sweats, feeling l[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 17 of 19 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 05/15/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #191) observed for incontinent care, in that: Residents Affected - Few CNA B did not perform handwashing for 20 seconds or more after before and after providing incontinent care for Resident #191. CNA A did not perform handwashing for 20 seconds or more after providing incontinent care for Resident #191. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #191's Face Sheet dated 04/27/23, documented a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included heart failure, hypertension (high blood pressure), and cerebral infarction (stroke), and a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) on left buttock. Record review of Resident #191's admission MDS dated [DATE] revealed MDS was not completed due to recent admission of Resident #191. During observation on 04/27/23 at 01:38 p.m., of incontinent care on Resident #191, with CNA A and CNA B performing the incontinent care. CNA A washed her hands for 25 seconds and put on gloves. CNA B washed hands for 10 seconds and put on gloves. CNA A pulled down covers and removed pillow from resident's knees and pillow from left side. CNA B removed pillow from right side. CNA B raised bed and lowered head of bed. CNA A removed tab from left side of adult brief. CNA B removed tab from right side of brief. CNA A removed gloves, used hand sanitizer, and put on clean gloves. Bruising to right side of abdomen, below belly button, toward hip. Greenish bruising. CNA B stated she did not know how the bruising occurred, but the nurse knew about the bruising. (Bruising noted on admission [DATE]) CNA A wiped from front to back with one wipe times six times. CNA A removed gloves, used hand sanitizer, and put on clean gloves. CNA B removed gloves, used hand sanitizer, and put on clean gloves. CNA B rolled resident to right side. CNA A wiped buttock using one wipe per swipe times 7 wipes. Small bowel movement. CNA A removed gloves, used hand sanitizer, and put on new gloves. CNA A placed new brief under resident's right side and assisted resident to roll to back. CNA A attached tab to left. CNA A rolled resident to left, CNA B attached tab on right. CNA A removed gloves, used hand sanitizer, and put on new gloves. CNA B removed gloves, used hand sanitizer, and put on new gloves. CNA A and CNA B repositioned resident up to head of bed. CNA A rolled resident to left side. CNA B placed clean mattress pad under resident. CNA B rolled resident to right side. CNA A pulled clean mattress pad to left. CNA A placed soiled linen in a bag and CNA B tied the bag closed. CNA B gathered trash in another bag. CNA A removed gloves, used hand sanitizer, and put on clean gloves. CNA B removed gloves, used hand sanitizer, and put on new gloves. CNA B rolled resident to right side and CNA A placed a pillow under left side. CNA A placed pillow between resident's knees. CNA rolled resident to left side and CNA B placed pillow under right side. CNA A covered resident. CNA B gathered trash and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 18 of 19 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 05/15/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm dirty linen. CNA B removed gloves, used hand sanitizer, and put on clean gloves. CNA A removed gloves, used hand sanitizer, and put on clean gloves. CNA A placed all bags into a bigger bag. CNA B removed gloves, used hand sanitizer. CNA A removed gloves, used hand sanitizer, and put on new gloves. CNA B left room disposing of soiled linen and trash. CNA B washed hands for 17 seconds. CNA A put new trash bag in trash can. CNA A removed gloves and washed hands for 16 seconds. Residents Affected - Few In an interview on 04/27/23 at 02:05 p.m., CNA A handwashing time is 30 seconds. CNA A stated she had washed her hands for less than 30 seconds. She stated she was sorry. CNA A stated infection could occur from not washing her hands for long enough. CNA A stated they are in-serviced on hand washing every two weeks. [NAME] the ADON does the in-services. In an interview on 04/27/23 at 02:09 p.m., CNA B stated 30 seconds was the time you had to wash your hands. CNA B stated she washed her hands for 30 seconds. CNA B stated if hands are not washed properly, you can cause an infection. In-services occur every month and a half or less. CNA B stated ADON D is the one who does the in-services. In an interview on 04/27/23 at 02:15 p.m., WCN C stated handwashing time is 30 seconds. WCN C stated, If you do not wash your hands for at least 30 seconds, you are not removing the majority of the bacteria and could cause and infection. WCN C said in-services for handwashing occur every six months by ADON D. In an interview on 04/27/23 at 02:38 p.m., DON stated CDC says handwashing should occur for 20 seconds, but at the facility, they say 30 seconds. DON stated infection could be passed to resident. DON stated in-services occur with spot checks throughout the month. DON stated ADON D is who does in-services. In an interview on 04/27/23 at 02:40 p.m., ADON D stated the CDC says 15-20 seconds is long enough to wash hands, but they tell them 30 seconds to make extra clean. ADON D stated germs are there even when hands are washed and they there's cross-contamination. ADON D stated she tries to in-service on handwashing monthly. ADON D stated January was the last time check off on handwashing. Review of Policy/Procedure - Nursing Clinical Subject: Handwashing (not dated) revealed: Policy: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Purpose: Hand washing is generally considered the most important single procedure for preventing nosocomial infections. Procedures: Handwashing 2. Rub hands in circular motion and rub between fingers for not less than twenty (20) seconds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 19 of 19