Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to promptly notify the residents' representatives immediately
of a fall that occurred for one (Resident #1) of two residents reviewed for resident rights.
The facility failed to immediately notify Resident #1's responsible party (RP) of a fall that occurred on
9/27/24.
This failure could place residents who had falls with injury at risk for not receiving appropriate care and
interventions.
The findings included:
Record review of Resident #1 face sheet dated 10/11/24 reflected an [AGE] year-old-female with an original
admission date of 4/27/24. Diagnoses included urinary tract infection, heart failure, diabetes type 2
(insufficient production of insulin in the body), and chronic kidney disease.
Record review of Resident #1's care plan dated 5/24/24 reflected Resident #1 was prescribed
medication/medications that lends to a risk for abnormal bleeding, easily bruised and/or skin issues/injury.
Resident # 1 had chronic health conditions & co-morbid conditions that have affected her physical function
and may further affect her quality of life.
Record review of Resident #1's MDS dated [DATE] reflected a BIM score of 5 (severe cognitive impairment)
and was dependant for toileting, transfers, dressing, and bathing.
In an interview with the ADM on 7/23/24 at 10:50 am. She stated there was no specific timeframe of when
the family needed to be notified as long as they were notified of the fall that day. The ADM stated the doctor
was aware Resident #1 rolled out of bed and did not order any x-rays and Resident #1 did not require to be
sent out to the hospital as Resident #1 was not complaining of pain and had full range of motion to the
extremities that were affected. The ADM stated LVN A did address Resident #1's small cut to the eyebrow
and put a bandage on it.
In a phone interview on 7/23/24 at 11:45 am LVN A stated Resident #1 had fallen on Sunday morning,
7/21/24. LVN A stated the day was really busy. LVN A stated during breakfast Resident #1 ate normal and
after the plates were picked up, CNA B went and told him that she found Resident #1 on the floor while
doing her rounds. LVN A stated he started to assess Resident #1 and noticed some swelling to her left
eyebrow and slight swelling to left knee. LVN A stated after the assessment, he notified the doctor and the
doctor stated to just treat the area and continue monitoring Resident #1 for any
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
676465
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
676465
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Las Alturas Nursing & Transitional Care
4301 North Bartlett Avenue
Laredo, TX 78041
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
changes in condition. LVN A stated the doctor stated Resident #1 did not need to be sent out to the hospital
and did not feel any other interventions were needed at that time. LVN A stated during that time, he was
taking care of another resident who was very ill and was nearing the end of life. LVN A stated he continued
to monitor Resident #1 and was not able to notify Resident #1's RP immediately but was going to. LVN A
stated Resident #1's family member came to visit Resident #1 approximately 4 hours after the fall and that
was when he informed Resident #1's family about what happened and how the doctor did not feel Resident
#1 needed to be sent out at that time. LVN A stated he offered to contact the doctor again to see if he
wanted to have Resident #1 sent out and the family refused. LVN A stated the family member called 911
themselves and Resident #1 was picked up by an ambulance and transferred to the hospital.
In a phone interview on 7/23/24 at 12:37 pm Resident #1's RP stated on Sunday 7/21/23, a family member
went to visit Resident #1 and saw Resident #1's face and called the RP and asked what was going on.
Resident #1's RP stated she spoke to LVN A on the phone and stated LVN A apologized to her and stated
that during the morning he went to check Resident #1's blood sugar and everything was fine and after that
CNA B stated she found Resident #1 on the floor after she had a fall trying to get out of bed. Resident #1's
RP stated it had been about 4 hours since Resident #1 fell to when they were informed and LVN A
apologized again and stated he had not had a chance to call to inform Resident #1's RP. Resident #1's RP
stated she understood LVN A was busy, but he could have taken one minute to call them. Resident #1's RP
stated the facility called for everything that was going on with Resident #1 and was upset they did not call
her right away about the fall.
In an interview on 10/11/24 at 11:07 am the ADM stated LVN A was working with the family of a resident
who was passing away and stated that everything happened so quick, but LVN A was going to
communicate with the family since Resident #1 was stable. The ADM stated in-service on notifications was
conducted with all staff.
In an interview on 10/11/24 at 12:37pm the DON stated what he remembered from that day was one of the
CNA's was doing their rounds and found Resident #1 on the floor and went and called LVN A. The DON
stated LVN A did an assessment and Resident #1 had a laceration on her forehead and swelling to her
knees. The DON stated LVN A notified the doctor and treated Resident #1 as ordered. The DON stated
approximately 10 to 15 minutes after Resident #'1s fall, LVN A had to tend to another resident who was
nearing the end of life and since Resident #1 was stable, the family was not notified immediately. The DON
stated it was not done with malicious intent as there was just circumstances that day and resident needs
were being prioritized. The DON stated everything was conducted in the best manner of the residents at
that time.
Record review of in-services dated 7/30/24 on falls, accident prevention, transfer safety, effective
communication, answering of call lights, reporting any change in condition, anticipate resident needs,
customer service, and abuse/neglect/exploitation.
Record review of facility's Fall Prevention policy dated 3/28/22 stated:
Post fall:
The resident is physically evaluated for injuries and medical attention is rendered as needed.
The physician and resident's representative are notified of the fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676465
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
676465
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Las Alturas Nursing & Transitional Care
4301 North Bartlett Avenue
Laredo, TX 78041
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
The resident is interviewed as appropriate to provide input on circumstances surrounding fall.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676465
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FAQ · About this visit
Common questions about this visit
What happened during the October 11, 2024 survey of Las Alturas Nursing & Transitional Care?
This was a inspection survey of Las Alturas Nursing & Transitional Care on October 11, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Las Alturas Nursing & Transitional Care on October 11, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.