Health inspection·July 31, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it was a reportable, but she did not know about it until she came back from vacation, and she reported it then. In a telephone interview on 07/31/24 at 02:45 pm CNA B stated, that day (01/02/24), Resident #1 was very anxious and in and out of bed. CNA B stated she and another CNA, CNA A, got the Hoyer (mechanical lift), and put him back to bed. CNA B stated CNA A seemed really tired and said she (CNA A) wanted to just leave the resident on the floor and not put him back in the bed because he was just going to get back out of bed, but CNA B said they could not do that and they put him back to bed. They changed him and gave report (reporting to the oncoming shift of each resident and how they were and any changes with residents). It was the end of their (CNA A and CNA B) shift. DON D called her (CNA B) later and asked CNA B what had happened. CNA B stated she was suspended for four days. CNA B stated they investigated and interviewed co-workers and residents about abuse from her or anyone else. CNA B said after four days, they called her and told her everything was good and she could come back to work. CNA B stated when she came back, CNA A was not there anymore. CNA B stated she did not know why CNA A made that report (allegations of verbal and physical abuse with Resident #1) on her because she (CNA B) would not hurt or abuse anyone. CNA B stated if she notices any changes on a resident, she reports to the nurse immediately and documents in the computer. CNA B stated if she finds a resident on the floor, she reports to the nurse and puts it in the computer. CNA B stated she reported Resident #1 being on the floor to LVN C, but she also is no longer working at the facility. Review of facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment dated 11/17 Reviewed/Revision 12/2023, revealed: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal laws. Procedure: 1.In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: - Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury - Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury 2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 2 of 3 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 07/31/2024 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 0609 including injuries of unknown source and misappropriation of resident property, are reported to: Level of Harm - Minimal harm or potential for actual harm a. The Administrator of the Facility b. The State Survey Agency Residents Affected - Few c. Adult Protective Services (as appropriate) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455625 If continuation sheet Page 3 of 3