Health inspection·September 22, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as per protocol. RN A said she did not complete the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to incoming shift in the Resident #1's hall binder because she forgot. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. RN A said she thought she had called Resident #1's physician to ask for orders that addressed the disocloration on Resident #1. Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. CNA J said she was told that LVN B already knew about the discoloration on 09/11/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 2 of 24 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 09/22/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition. Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 3 of 24 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 09/22/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few informed the family member about the physician's recommendation so they could make a decision as soon as possible. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CNA G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment becsue she forgot. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. RN A said she had not called Resident #1's FM M. Interview on 09/14/23 at 2:29 pm with Resident #1's FM M revealed the facility had not contacted them on 09/09/23 when Resident #1 was noted with discoloration on her inner thigh. FM M said she was not contacted until 09/10/23 in the evening when it the nurse called her to inform her that Resident #1 now had dark purplish color on her left toes. Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified by facility staff whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 4 of 24 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 09/22/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. Record review of the facility policy in section Quality of Care, titled Significant Change in Condition, Response dated 12/2022 reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical and mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning reports. An Immediate Jeopardy was identified on 09/19/23. The Immediate Jeopardy template was provided to the facility Administrator on 09/19/23 at 6:10 pm. While the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m., the facility remained out of compliance pending approval of Plan of Correction.

F580 Notification of Change Plan of Removal September 19,2023 This plan of removal is written and submitted on behalf of in response to the citation and findings related to

F580 for failure to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychological well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. This deficient practice was identified during a complaint visit survey conducted on 9/15/2023. 9-19-2023 Per IJ template, facility failed to notify the residents physician when R#1 abnormal skin condition was identified on 09/09/23. Immediate Action 1. Medical Director on 9-19-23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 5 of 24 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 09/22/2023 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 0580 2. Residents #1, is no longer in the facility. Level of Harm - Immediate jeopardy to resident health or safety 3. IDT consisting of DON, MDS, Infection Preventionist, Director of Rehab, RN clinical resource to Audit all residents with skin condition, current care plan, Braden scores to identify high risk residents that may develop skin issues and verify notification to MD this will be completed on 9-19-2023. Residents Affected - Few 4.In-service/Education begun for Nurses and CNAs by DON on reporting all identified skin issues to the Director of Nursing immediately. In-service will be completed 9/20/23. Inservice/Education initiated with all staff on change of condition recognition, reporting and monitoring. 09/20/2023 Any employee not in facility will receive in service via phone, any employee who has not received in service will not be allowed to work until in service has been received. In-service will be general and resident specific. 5.All staff will complete competency on change of condition initiated 09/19/2023.This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 8.All residents will have a head-to-toe assessment completed on 9/19/23, any resident identified with skin issue will have MD notified immediately and orders put in place 9. QA meeting regarding items in the IJ template completed 09/19/2023. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources, Market Leader, and Clinical Market Leader, and included the plan of removal items and interventions. 10.The DON, ADON, QA Nurse, or Clinical Resource will verify staff competency by various change in condition scenarios with knowledge checks with a random 5 nurses per week x 2 weeks then, a random 5 nurses every 2 weeks x 2 months then a random 5 nurses per month on going. 11.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the POR included the following; Observations with the Wound Treatment Nurse/LVN on 09/16/23 revealed 6 residents identified with COC on the Skin. No further concerns were noted on these residents upon observation. Staff on interviewed from the shift of 6:00 am to 2:00 pm included six CNAs, two LVNs, one RN, one speech therapist, one ADON, and two med aides. Staff interviewed from the shift of 2:00 pm to 10:00 pm included eight CNAs, and two LVNS. Staff interviewed from the shift of 10:00 pm to 6:00 am included four CNA and three of three LVNS. All staff interviewed revealed they had been in-serviced on COC, Resident Rights, Quality of Care/Treatment, Nursing Services. Reporting, documenting, notifying and verifying the COC made. Staff interviews were conducted on 09/21/23 from 8:33 am to 3:39 pm. Reviewed In-service records dated 09/15/23, 09/16/23, 09/17/23, 09/18/23, 09/19/23 and 09/20/23 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 6 of 24 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 09/22/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few topics: Nursing Services, Changes of Condition, Quality of Care, Resident Rights, with Validation of Topics reviewed for each staff in-serviced. The in-services reflected that all staff was trained, including housekeeping, maintenance, dietary, pending staff out on leave and new staff that would start this weekend. Reviewed Head to Toe 100% skin audits were conducted on 09/16/23 and 09/27/32. Eleven residents were identified with a Change of Condition in the areas of thick, yellow toenails, 2 of them with fungus on their toenails. A COC was completed for those 11 residents. Doctors and RP were notified, progress notes, COC forms which included SBAR (s), physician orders for treatment (also podiatrist referrals),care plans were updated, and 24-hour reports were completed. Record review of 100 % of residents Skin Audit completed on 09/19/23 after the IJ was called and no residents were found to have a new COC. Reviewed Progress Notes Summary and entered in the 24-hour report available to staff. In-services received by staff from interviews: In-services included COC, Resident Rights, Nursing Services, Quality of Care/Treatment. COC topic included, reporting incidents to charge nurses, documenting in POC for CNAs and verifying by doing follow-ups on reported incidents. LVNs/RNs training included completing COC, notify MD,RP, DON, completing Progress Notes, linking report to the 24-hour report and carrying out orders from MD if needed. The Administrator was informed the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 7 of 24 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 09/22/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. Residents Affected - Few The facility failed to document, monitor, and assess Resident #1's abnormal skin discoloration for approximately 39 hours. Resident #1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated. The findings included; Record review of the admission record for Resident #1 dated 09/15/23 reflected Resident #1 was a [AGE] year-old female that was admitted to facility on 03/17/21 with the diagnosis of diabetes mellitus (sustained blood sugar levels), cognitive communication deficit (memory loss), need for assistance for personal care and hypertensive heart disease (complication of high blood pressure) without heart failure. Record review of the quarterly MDS dated [DATE] reflected Resident #1's cognitive status was severely impaired, required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use. Record review of the care plans dated 12/03/21 for Resident #1 reflected those resident needs included assistance with activities of daily living, transfer, toileting, and bed mobility. Interventions included required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. Interview on 09/19/23 at 1:15 pm with CNA G revealed she had worked on Resident#1's hall on 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as needed. RN A said she did not complete the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 8 of 24 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 09/22/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety incoming shift in the Resident #1's hall binder. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. RN A said she thought she had called Resident #1's physician to ask for orders that addressed the discoloration on Resident #1. Residents Affected - Few Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. CNA J said she was told that LVN B already knew about the discoloration on 09/11/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 9 of 24 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 09/22/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker informed the family member about the physician's recommendation so they could make a decision as soon as possible. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CAN G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. RN A said she had not called Resident #1's FM M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 10 of 24 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 09/22/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. Record review of the facility policy in section Quality of Care, titled Significant Change in Condition, Response dated 12/2022 reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical and mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 11 of 24 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 09/22/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few aware. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning reports. An Immediate Jeopardy was identified on 09/19/23. The Immediate Jeopardy template was provided to the facility Administrator on 09/19/23 at 6:10 pm. While the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m., the facility remained out of compliance pending approval of Plan of Correction. The following plan of removal submitted by the facility was accepted on 09/22/23 at 11:57 am:

F684 Quality of Care Plan of Removal September 19,2023 This plan of removal is written and submitted on behalf of in response to the citation and findings related to

F684 483.25 for failure to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychological well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. This deficient practice was identified during a complaint visit survey conducted on 9/15/2023.

F684 - Quality of Care Immediate actions 1. RN DON initiated in-services with nurses 09/19/23 at 6:15pm. Education for ALL facility staff consisted of timely identification and reporting Changes in Condition, Nursing Services, Resident Rights and Quality of Care. Ongoing education will be focused on the following areas: Identification and reporting of changes in condition to Primary Care Physician, Director of Nursing, Resident Representative/Designee and/or Medical Director Training to be provided addressing written communication to oncoming shift in the 24-hour written report. 2. Medical Director, notified of Immediate Jeopardy on 09/19/2023 at 6:37pm. Procedure implemented to prevent for a similar situation from reoccurring. The DON an ADON have immediately (9/19/2023) began to monitor all changes in condition daily on weekdays and weekends via review of electronic 24-hour report on PCC for all units, progress notes, new orders, new medication orders, change in condition assessments, hospital transfers and nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 12 of 24 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 09/22/2023 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 0684 documentation. Level of Harm - Immediate jeopardy to resident health or safety The daily monitoring by the Director of Nursing and the Assistant Director of Nursing began 9/19/2023 and will be ongoing. Residents Affected - Few Changes in condition will be reviewed daily and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designee to attend weekly clinical meetings to include review of residents with skin conditions, changes in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties as necessary. All residents will have a head-to-toe assessment completed on 9/19/2023, any resident identified with skin issue will have MD notified. Procedure for new staff Inservice Current staff will be in serviced by Administrative Nursing staff and sister facility DON's by 09/20/2023. New staff will be in serviced by DON or designee upon hire during orientation and prior to working the floor. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Training for the staff Director of Nursing/Assistant Director of Nursing/Designee will conduct training for the clinical staff. Any employee not in facility will receive Inservice via phone. Any employee who has not received the Inservice will not be allowed to work until in-service has been received. In-service will be general and resident specific. Monitoring Quality Assurance meeting regarding items in the IJ template completed 9/19/2023. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, Market Leader, and Clinical Market Leader, and included the plan of removal items and interventions. The Don, ADON, QA Nurse or Clinical Resource will verify staff competency by reviewing changes in condition and interventions, with knowledge checks with a random 5 nurses per week x 2 weeks then, a random 5 nurses every 2weeks x 2 months then a random 5 nurses every 2 weeks per month ongoing. Summary of IJ and corrective Action to be reviewed by QAPI Committee x 4 weeks or until substantial compliance established and continue monthly 90 days to ensure ongoing compliance. Monitoring of the POR included the following; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 13 of 24 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 09/22/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Observations with the Wound Treatment Nurse/LVN on 09/16/23 revealed 6 residents identified with COC on the Skin. No further concerns were noted on these residents upon observation. Staff interviewed from the shift of 6:00 am to 2:00 pm included six CNAs, two LVNs, one RN, one speech therapist, one ADON, and two med aides. Staff interviewed from the shift of 2:00 pm to 10:00 pm included eight CNAs, and two LVNS. Staff interviewed from the shift of 10:00 pm to 6:00 am included four CNA and three of three LVNS. All staff interviewed revealed they had been in-serviced on COC, Resident Rights, Quality of Care/Treatment, Nursing Services. Reporting, documenting, notifying, and verifying the COC made. Staff interviews were conducted onn 09/21/23 from 8:33 am to 3:39 pm. Reviewed In-service records dated 09/15/23, 09/16/23, 09/17/23, 09/18/23, 09/19/23 and 09/20/23 on topics: Nursing Services, Changes of Condition, Quality of Care, Resident Rights, with Validation of Topics reviewed for each staff in-serviced. The in-services reflected that all staff was trained, including housekeeping, maintenance, dietary, pending staff out on leave and new staff that would start this weekend. Reviewed Head to Toe 100% skin audits were conducted on 09/16/23 and 09/27/32. Eleven residents were identified with a Change of Condition in the areas of thick, yellow toenails, 2 of them with fungus on their toenails. A COC was completed for those 11 residents. Doctors and RP were notified, progress notes, COC forms which included SBAR (s), physician orders for treatment (also podiatrist referrals),care plans were updated, and 24-hour reports were completed. Record review of 100 % of residents Skin Audit completed on 09/19/23 after the IJ was called and no residents were found to have a new COC. Reviewed Progress Notes Summary and entered in the 24-hour report available to staff. In-services received by staff from interviews: In-services included COC, Resident Rights, Nursing Services, Quality of Care/Treatment. COC topic included, reporting incidents to charge nurses, documenting in POC for CNAs and verifying by doing follow-ups on reported incidents. LVNs/RNs training included completing COC, notify MD,RP, DON, completing Progress Notes, linking report to the 24-hour report, and carrying out orders from MD if needed. The Administrator was informed the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 14 of 24 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 09/22/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessments for one resident (Resident #1) of 5 residents reviewed for care. RN A's failure to document, monitor, and assess R#1's abnormal skin discoloration for approximately 39 hours resulted in R#1's transfer to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated. The findings included: Record review of the admission record for Resident #1 dated 09/15/23 reflected Resident #1 was a [AGE] year-old female that was admitted to facility on 03/17/21 with the diagnosis of diabetes mellitus (sustained blood sugar levels), cognitive communication deficit (memory loss), need for assistance for personal care and hypertensive heart disease (complication of high blood pressure) without heart failure. Record review of the quarterly MDS dated [DATE] reflected Resident #1's cognitive status was severely impaired, required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use. Record review of the care plans dated 12/03/21 for Resident #1 reflected those resident needs included assistance with activities of daily living, transfer, toileting, and bed mobility. Interventions included required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. Interview on 09/19/23 at 1:15 pm with CNA G revealed she had worked on Resident#1's hall on 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 15 of 24 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 09/22/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as needed. RN A said she did not complete the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to incoming shift in the Resident #1's hall binder. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 16 of 24 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 09/22/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition or in the 24-hour report. Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker informed the family member about the physician's recommendation. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CAN G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 17 of 24 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 09/22/2023 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 0726 that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Residents Affected - Few Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Interview on 09/19/23 at 5:32 pm with the Administrator revealed that RN A had been terminated. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. An Immediate Jeopardy was identified on 09/19/23. The Immediate Jeopardy template was provided to the facility Administrator on 09/19/23 at 6:10 pm. While the Immediate Jeopardy was removed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 18 of 24 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 09/22/2023 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 0726 09/22/23 at 11:57 a.m., the facility remained out of compliance pending approval of Plan of Correction. Level of Harm - Immediate jeopardy to resident health or safety

F726 Nursing Services Residents Affected - Few September 19, 2023 Plan of Removal This plan of removal is written and submitted on behalf of in response to the citation and findings related to

F726 for failure to ensure a nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident as determined by resident assessments and individual plans of care. This deficient practice was identified during complaint visit survey conducted on 09/15/2023.

F726 - Nursing Services Immediate Action 1. Medical Director notified of IJ on 9-19-23. 2. Residents #1, is no longer in the facility. 3. IDT consisting of DON, MDS, Infection Preventionist, Director of Rehab, RN clinical resource to Audit all residents with skin condition, current care plan, Braden scores to identify high risk residents that may develop skin issues and verify notification to MD this will be completed on 9-19-2023. An audit of all current skin assessments will be completed to ensure issues identified have been communicated to MD and orders are in place. 4. In-service/Education begun for Licensed Nurses by DON on reporting all identified changes in condition to the Director of Nursing immediately. In-service will be completed 9/20/23. Inservice/ Education initiated with all staff on assessment and immediate intervention upon identification of any changes of condition. This will be completed on 9-19-23. Any employee not in facility will receive inservice via phone, any employee who has not received the inservice will not be allowed to work until in service has been received. In-service will be general and resident specific. 5. All clinical staff will complete competency on proper and timely assessment initiated 09/20/2023.This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 6. All residents will have a head-to-toe assessment completed on 9/19/23, any resident identified with change of condition will have MD notified immediately and orders put in place 7. QA meeting regarding items in the IJ template completed 09/19/2023. Attendees included the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 19 of 24 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 09/22/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources, Market Leader, and Clinical Market Leader, and included the plan of removal items and interventions. 8. The DON, ADON, QA Nurse, or Clinical Resource will verify staff competency by reviewing skin assessments and interventions, with knowledge checks with a random 5 nurses per week x 2 weeks then, a random 5 nurses every 2 weeks x 2 months then a random 5 nurses per month on going. Residents Affected - Few 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the POR included the following. Observations with the Wound Treatment Nurse/LVN on 09/16/23 revealed 6 residents identified with COC on the Skin. No further concerns were noted on these residents upon observation. Staff on interviewed from the shift of 6:00 am to 2:00 pm included six CNAs, two LVNs, one RN, one speech therapist, one ADON, and two med aides. Staff interviewed from the shift of 2:00 pm to 10:00 pm included eight CNAs, and two LVNS. Staff interviewed from the shift of 10:00 pm to 6:00 am included four CNA and three of three LVNS. All staff interviewed revealed they had been in-serviced on COC, Resident Rights, Quality of Care/Treatment, Nursing Services. Reporting, documenting, notifying and verifying the COC made. Staff interviews were conducted on 09/21/23 from 8:33 am to 3:39 pm. Reviewed In-service records dated 09/15/23, 09/16/23, 09/17/23, 09/18/23, 09/19/23 and 09/20/23 on topics: Nursing Services, Changes of Condition, Quality of Care, Resident Rights, with Validation of Topics reviewed for each staff in-serviced. The in-services reflected that all staff was trained, including housekeeping, maintenance, dietary, pending staff out on leave and new staff that would start this weekend. Reviewed Head to Toe 100% skin audits were conducted on 09/16/23 and 09/27/32. Eleven residents were identified with a Change of Condition in the areas of thick, yellow toenails, 2 of them with fungus on their toenails. A COC was completed for those 11 residents. Doctors and RP were notified, progress notes, COC forms which included SBAR (s), physician orders for treatment (also podiatrist referrals),care plans were updated, and 24-hour reports were completed. Record review of 100 % of residents Skin Audit completed on 09/19/23 after the IJ was called and no residents were found to have a new COC. Reviewed Progress Notes Summary and entered in the 24-hour report available to staff. In-services received by staff from interviews: In-services included COC, Resident Rights, Nursing Services, Quality of Care/Treatment. COC topic included, reporting incidents to charge nurses, documenting in POC for CNAs and verifying by doing follow-ups on reported incidents. LVNs/RNs training included completing COC, notify MD,RP, DON, completing Progress Notes, linking report to the 24-hour report and carrying out orders from MD if needed. The Administrator was informed the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 20 of 24 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 09/22/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #1) reviewed for medical records . The facility failed to ensure RN A documented in the clinical records that Resident #1 had a change in condition of discoloration to the resident's inner thigh. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records. The findings include: Record review of the admission record for Resident #1 dated 09/15/23 reflected Resident #1 was a [AGE] year-old female that was admitted to facility on 03/17/21 with the diagnosis of diabetes mellitus (sustained blood sugar levels), cognitive communication deficit (memory loss), need for assistance for personal care and hypertensive heart disease (complication of high blood pressure) without heart failure. Record review of the quarterly MDS dated [DATE] reflected Resident #1's cognitive status was severely impaired, required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use. Record review of the care plans dated 12/03/21 for Resident #1 reflected those resident needs included assistance with activities of daily living, transfer, toileting, and bed mobility. Interventions included required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. Interview on 09/19/23 at 1:15 pm with CNA G revealed she had worked on Resident#1's hall on 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as per protocol. RN A said she had not completed the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to incoming shift in the Resident #1's hall binder because she forgot. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 21 of 24 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 09/22/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. RN A said she thought she had called Resident #1's physician to ask for orders that addressed the discoloration on Resident #1. Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. CNA J said she was told that LVN B already knew about the discoloration on 09/11/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition. Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 22 of 24 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 09/22/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker informed the family member about the physician's recommendation so they could make a decision as soon as possible. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CAN G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment because she forgot. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. RN A said she had not called Resident #1's FM M. Interview on 09/14/23 at 2:29 pm with Resident #1's FM M revealed the facility had not contacted them on 09/09/23 when Resident #1 was noted with discoloration on her inner thigh. FM M said she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 23 of 24 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 09/22/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not contacted until 09/10/23 in the evening when it the nurse called her to inform her that Resident #1 now had dark purplish color on her left toes. Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified by facility staff whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 24 of 24