Health inspection·July 31, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 4 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report allegations made by one CNA about another CNA of verbal and physical resident abuse. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1's admission Record dated 07/31/24, revealed a [AGE] year-old male, admitted to facility on 12/22/23, and discharged on 01/10/24 to home. Resident #1's diagnoses included: Sepsis (a life-threatening emergency that happens when the body's immune system has an extreme response to an infection causing organ dysfunction. The body's reaction causes damage to its own tissues and organs, and it can lead to shock, multiple organ failure and sometimes death, especially if not recognized early and treated promptly), need for assistance with personal care, and mild cognitive impairment of uncertain or unknown origin. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 08, indicating moderate impaired cognition. Record review of Resident Interviews for Abuse on 01/04/24 revealed Resident #1 denied any abuse from CNA A or CNA B during the provider investigation. No other resident or staff member alleged abuse by CNA B. Record review of Provider Investigation Report, page 7, dated 01/09/24, revealed the incident took place on 01/02/24 at 07:30 a.m. The intake was dated 01/04/24, for when the incident took place and was reported by DON D. In an interview on 07/31/24 at 12:15 pm the Administrator stated that she was on vacation when CNA A stated CNA B abused Resident #1 on 01/02/24. The administrator said DON D, who was here at the time, did not report the allegation of abuse to State, but she (administrator) did as soon as she came back. The administrator stated DON D resigned shortly after that. The administrator stated she knew Page 1 of 3 455625 455625 07/31/2024 Alta Vista Rehabilitation and Healthcare 510 Paredes Line Rd Brownsville, TX 78521

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, 455625 Page 2 of 3 455625 07/31/2024 Alta Vista Rehabilitation and Healthcare 510 Paredes Line Rd Brownsville, TX 78521

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) 455625 Page 3 of 3