Inspection·August 27, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a major injury) on [DATE] was not reflected or coded in section J: health conditions - falls. No falls since previous quarterly MDS assessment noted.Record review of Resident #2's care plan dated [DATE] reflected [Resident #2] was at risk for falls related to Parkinson's disease, unsteady gait, history of falls, poor balance, and behavior of not calling for assistance by using the call light. Date initiated: [DATE]. [Resident #2] had a fracture to right wrist related to a fall and was at risk for pain, discomfort, and limited range of motion to right upper extremity. Date initiated: [DATE].Record review of Resident #2's progress note dated [DATE] at 12:36 AM reflected CNA responding to call light. Noted [Resident #2] on the floor in sitting position next to bed. CNA called this nurse to room. Upon entering room, noted [Resident #2] sitting next to bed on floor and urine on floor under resident. [Resident #2] stated he was attempting to go to the bathroom but lost his balance and slid off bed to floor. No hematomas or skin tears noted. [Resident #2] was able to move extremities X 4, however, stated right wrist hurts a little. Pain medication given at this time. [Resident #2] did not use call light to call for assistance. Roommate put on call light. Educated [Resident #2] on calling for help but [Resident #2] used poor judgement and was forgetful. Assisted back to bed and incontinent care was rendered. Documented by LVN B. On [DATE] at 10:40 AM, an attempted interview and observation with Resident #1, revealed he was not interviewable. Resident #1 did not answer baseline questions or questions related to the incident. Resident #1 laid in bed with the call light within reach. There were no safety concerns and the bed was at its lowest position. Resident #1 appeared with good personal hygiene, no injury, and not in distress.On [DATE] at 11:20 AM, an attempted telephone interview with LVN A, revealed he did not answer. A message was left requesting a callback. No callback was received. On [DATE] at 3:10 PM, in an interview with LVN B, she said she recalled the CNAs were rounding and called LVN B because Resident #2 was sitting on the right side of his bed and the wheelchair was on his left side. LVN B said, that day (did not recall date or time), Resident #2 stated he was going to the restroom, but did not get there in time and urinated. LVN B said Resident #2 said he slipped and he was sitting on the urine. LVN B said Resident #2 said his hand hurt so they got him back to bed and instructed him not to move his hand. LVN B said she propped and iced Resident #2's hand, called the MD, and the MD ordered x-rays. LVN B said Resident #2 had a history of falls as he did not like to ask for help and would say he could do things on his own. LVN B said Resident #2 had Parkinson's so he had tremors and they constantly re-educated him on using his call light, but he was also very forgetful and tried to get up without asking for help. LVN B said the bed was always in its lowest position before the fall, and LVN B said she did not recall what interventions were added afterwards. LVN B said when there was a fall, the DON updated the care plan. On [DATE] at 3:50 PM, in an interview MDS F, she said she reviewed the MDS assessments for Resident #1 and Resident #2 and the falls were not coded correctly for the residents' MDS assessments. MDS F said the fall on [DATE] for Resident #1 should have been coded yes on the following MDS assessment on [DATE] as section J1800 of the MDS assessment asked if the resident had any falls since the prior assessment. MDS F added Resident #2' s fall on [DATE] should have been coded yes on MDS assessment dated [DATE] as section J1800 asked if resident had any falls since prior assessment. MDS F said there was no negative outcome to the residents, and they would not be at risk of harm or injury as the falls were care planned and interventions were implemented after each incident for every fall. MDS F said it was still important for the MDS to be accurate. On [DATE] at 5:30 PM, in an interview with the DON, she said Resident #1 had a fall on [DATE] and he had no injury. The DON said Resident #2 had a fall on [DATE] which resulted in a fracture to his right wrist (serious injury). The DON said when a fall happened, she reviewed, and she was usually the one who wrote and updated the care plans. The DON said (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 08/27/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete if MDS assessments did not capture the fall, it did not affect the care because herself or the team would have updated the care plan and implemented interventions. The DON said not capturing the falls on the MDS assessments, did not affect the payment, but rather it would just not be coded correctly. Record review of the facility's Resident Assessment and Associated Processes policy dated 01/2022 reflected - Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. The comprehensive assessment includes the completion of the MDS as well as the Care Area Assessment process. An accurate comprehensive assessment will include special treatments and procedures. Record review of CMS's RAI Version 3.0 Manual dated 10/2024 reflected section J:J1700: Fall History on Admission/Entry or ReentryPlanning for Care: Determine the potential need for further assessment and intervention, including evaluation of the resident's need for rehabilitation or assistive devices. Evaluate the physical environment as well as staffing needs for residents who are at risk for falls. J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment - Has the resident had any falls since admission/entry/reentry or the prior assessment, whichever is more recent. Event ID: Facility ID: 455625 If continuation sheet Page 3 of 3