Inspection Reports for Alta Vista Rehabilitation and Healthcare
510 Paredes Line Rd, Brownsville, TX 78521, United States, TX, 78521
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was conducted to assess the accuracy of resident assessments, specifically focusing on whether recent falls were properly coded in the Minimum Data Set (MDS) assessments for two residents.
Findings
The facility failed to ensure that the assessments accurately reflected the status of two residents who had falls; the falls were not properly coded in the MDS assessments. This failure could place residents at risk of improper care, although care plans and interventions were updated after each fall.
Deficiencies (2)
Failed to ensure Resident #1's fall was accurately coded in the MDS assessment.
Failed to ensure Resident #2's fall was accurately coded in the MDS assessment.
Report Facts
Residents reviewed for accuracy of assessments: 11
Residents affected: 2
Length of laceration: 3.5
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Documented Resident #1's fall and emergency transfer |
| LVN B | Licensed Vocational Nurse | Documented Resident #2's fall and care provided |
| MDS F | Reviewed MDS assessments and noted falls were not coded correctly | |
| DON | Director of Nursing | Interviewed regarding falls and care plan updates |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive person-centered care plans, respiratory care, nursing competency, and food safety in the facility.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for residents requiring oxygen therapy, ensure oxygen was administered at prescribed rates, demonstrate nursing competency in medication administration via feeding tube, and properly label and date food stored in residents' mini refrigerators.
Deficiencies (4)
Failed to develop and implement comprehensive person-centered care plans for residents requiring oxygen therapy.
Failed to ensure oxygen was administered at prescribed rates for residents receiving respiratory care.
Failed to demonstrate nursing competency by not checking G-tube residual prior to administering medication for a resident.
Failed to label and date food items stored in a resident's mini refrigerator.
Report Facts
Residents reviewed for comprehensive person-centered care plans: 24
Residents reviewed for respiratory care: 4
Oxygen flow rate prescribed for Resident #225: 4
Oxygen flow rate observed for Resident #225: 2.5
Oxygen flow rate prescribed for Resident #18: 2
Oxygen flow rate observed for Resident #18: 3
Oxygen flow rate prescribed for Resident #48: 4
Oxygen flow rate observed for Resident #48: 3.5
Tube feeding residual volume threshold: 150
Number of mini round containers with unlabeled food in Resident #39's refrigerator: 12
Number of residents with mini refrigerators: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to check G-tube residual prior to administering medication for Resident #48. |
| LVN B | Licensed Vocational Nurse | Responsible nurse for Resident #48; verified oxygen setting at 3.5 LPM instead of prescribed 4 LPM. |
| LVN C | Licensed Vocational Nurse | Observed checking oxygen settings and described charge nurse responsibilities for labeling outside food. |
| MDS/RN | Registered Nurse | Responsible for updating care plans including oxygen therapy; verified oxygen orders and care plan updates. |
| DON | Director of Nursing | Confirmed deficiencies in care plans and oxygen administration; conducted resident assessments; described staff training. |
| ADON | Assistant Director of Nursing | Described care planning responsibilities and staff training on oxygen administration. |
| Dietary Manager | Described procedures for handling outside food and labeling requirements. | |
| Business Office Coordinator | Conducted angel rounds; responsible for checking labeling of outside food in Resident #39's room. | |
| Administrator | Described facility policies on outside food handling and labeling. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report alleged verbal and physical abuse by one CNA against a resident.
Complaint Details
The complaint involved allegations made by one CNA about another CNA verbally and physically abusing Resident #1 on 01/02/24. The facility failed to report the allegation to the State Survey Agency within 24 hours as required. The Director of Nursing did not report the allegation while the administrator was on vacation. The administrator reported the allegation upon return. The CNA accused was suspended for four days and then reinstated. The Director of Nursing resigned shortly after the incident.
Findings
The facility failed to report allegations of verbal and physical abuse involving Resident #1 by a CNA within the required timeframe, placing residents at increased risk for unreported abuse and neglect. The investigation revealed that the Director of Nursing did not report the allegation while the administrator was on vacation, and the CNA accused was suspended but later reinstated.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents reviewed for abuse/neglect: 4
Suspension duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON D | Director of Nursing | Did not report the allegation of abuse to the State Survey Agency and resigned shortly after |
| CNA B | Certified Nursing Assistant | Accused of verbal and physical abuse, suspended for four days, later reinstated |
| CNA A | Certified Nursing Assistant | Made allegations of verbal and physical abuse against CNA B |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 22, 2023
Visit Reason
The inspection was conducted due to a complaint visit survey regarding failure to immediately inform the resident, the resident's physician, and the resident's representative of a significant change in Resident #1's condition, specifically an abnormal skin discoloration.
Complaint Details
The complaint investigation revealed that Resident #1 had an abnormal skin discoloration noted on 09/09/23 which was not properly communicated to the physician or family, nor was it documented appropriately. This led to delayed medical intervention for acute ischemia, resulting in hospitalization and risk of limb loss. The facility was cited for failure to notify, assess, document, and provide appropriate care, leading to an Immediate Jeopardy that was later removed after corrective actions.
Findings
The facility failed to notify the resident's physician and family in a timely manner about Resident #1's abnormal skin discoloration identified on 09/09/23, resulting in delayed treatment for acute ischemia and eventual hospitalization. The facility did not complete required change of condition documentation or communication protocols, leading to an Immediate Jeopardy that was removed after corrective actions were implemented.
Deficiencies (4)
Failure to immediately inform the resident, resident's doctor, and family member of significant change in Resident #1's condition (abnormal skin discoloration) and failure to notify the physician timely.
Failure to provide appropriate treatment and care according to orders and resident's preferences for Resident #1, including failure to document, monitor, and assess abnormal skin discoloration for approximately 39 hours.
Failure to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety, resulting in delayed recognition and response to Resident #1's condition.
Failure to maintain complete, accurate, and accessible medical records for Resident #1, specifically failure of RN A to document the change in condition of discoloration.
Report Facts
Hours of delayed assessment and documentation: 39
Date of survey completion: Sep 22, 2023
Date of Immediate Jeopardy identification: Sep 19, 2023
Date Immediate Jeopardy removed: Sep 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Failed to complete change of condition documentation, notify physician and family, and assess Resident #1's abnormal skin discoloration. |
| CNA G | Certified Nursing Assistant | Noticed and reported Resident #1's abnormal skin discoloration on 09/09/23. |
| LVN B | Licensed Vocational Nurse | Did not receive communication about Resident #1's discoloration and did not monitor or assess the condition. |
| LVN C | Licensed Vocational Nurse | Assessed Resident #1 on 09/10/23 after report of discoloration and initiated physician contact and family notification. |
| RN D | Registered Nurse | Returned Resident #1 from physician's office with orders for treatment. |
| Social Worker | Contacted Resident #1's family member on 09/12/23 to inform about physician's recommendation. | |
| Administrator | Informed of Immediate Jeopardy removal and termination of RN A. |
Inspection Report
Routine
Census: 85
Deficiencies: 3
Date: May 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to care planning, medication administration, infection control, and overall resident safety.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents with wound vac use and skin scratches. Medication errors were identified involving undiluted Potassium Chloride and improper administration of Chlorhexidine Gluconate via feeding tube. Additionally, hand hygiene practices were inadequate during incontinent care, posing infection risks.
Deficiencies (3)
Failed to develop and implement comprehensive care plans for residents with wound vac use and skin scratches.
Medication error: Potassium Chloride liquid administered without dilution and Chlorhexidine Gluconate administered via feeding tube without physician confirmation.
Failed to ensure proper handwashing for at least 20 seconds before and after incontinent care.
Report Facts
Residents observed during medication pass: 4
Census: 85
Medication errors: 2
Potassium Chloride administrations without dilution: 26
Chlorhexidine Gluconate administrations without physician confirmation: 55
Handwashing duration: 10
Handwashing duration: 16
Handwashing duration: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN H | Licensed Vocational Nurse | Administered Potassium Chloride undiluted and Chlorhexidine Gluconate without physician confirmation; reported medication errors to DON and physician |
| DON | Director of Nursing | Responsible for oversight of care plans and medication administration; acknowledged medication errors and in-service training |
| WCN C | Wound Care Nurse | Responsible for developing care plans for wound vac use; acknowledged oversight in care plan development |
| ADON D | Assistant Director of Nursing | Conducted in-services on handwashing; involved in medication order changes and oversight |
| CNA A | Certified Nursing Assistant | Performed incontinent care with inadequate handwashing |
| CNA B | Certified Nursing Assistant | Performed incontinent care with inadequate handwashing |
| LVN M | Licensed Vocational Nurse | Administered medications to Resident #70; aware of dilution requirements but did not question Chlorhexidine order |
| LVN N | Licensed Vocational Nurse | Administered medications to Resident #70; unaware of side effects of Chlorhexidine Gluconate |
| LVN O | Licensed Vocational Nurse | Administered Chlorhexidine Gluconate orally despite order for g-tube; unaware of medication error process |
| RN Q | Registered Nurse | Administered Chlorhexidine Gluconate orally; did not question order or notify supervisors |
| LVN P | Licensed Vocational Nurse | Administered medications; stated nurses should notify DON or ADON of medication errors |
| MD R | Physician | Attending physician for Resident #70; informed of medication errors; scheduled follow-up |
| RPH S | Pharmacist | Reviewed medications monthly; unable to provide information on Resident #70 orders at time of call |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 29, 2023
Visit Reason
The inspection was conducted as an annual survey of Alta Vista Rehabilitation and Healthcare to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 1
Date: Feb 4, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a comprehensive person-centered care plan for Resident #28.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to address Resident #28's behavior of removing undergarments and exposing himself outside his private room. This deficiency placed residents at risk of not receiving necessary care and services.
Deficiencies (1)
Failure to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet Resident #28's medical and nursing needs, specifically regarding his behavior of removing undergarments and exposing himself outside his room.
Report Facts
Residents reviewed for person-centered care plans: 8
Residents affected: 1
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Reported inappropriate behavior of Resident #28 exposing genitals | |
| RN A | Observed Resident #28 self-propelling wheelchair without undergarments and reported situation | |
| LVN C | Observed Resident #28 outside room without undergarments and reported behavior to DON | |
| Social Service | Discussed Resident #28's behavior and care planning responsibilities | |
| MDS RN D | Stated social worker responsible for care planning Resident #28's behaviors | |
| ADON B | Informed about Resident #28's behavior and interventions needed | |
| LVN F | Reported Resident #28 exposing genitals and discussed with DON | |
| DON | Director of Nursing | Acknowledged Resident #28's neurological deficiency and behavior; stated monitoring and intervention plans |
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