Inspection·June 30, 2022

F 0812 3. Observation on 6/27/22 at 9:14 a.m. revealed the interior top of the microwave had dried food particles. Level of Harm - Minimal harm or potential for actual harm Observation on 6/28/22 at 1:37 p.m. revealed the interior top of the microwave had dried food particles. Residents Affected - Some Observation and interview on 6/28/22 at 1:38 p.m., after [NAME] B looked at the interior top of the microwave and used her finger to scrape off the dried particles, she stated the dried particles was food. [NAME] B stated the microwave was cleaned twice a day after breakfast and lunch. In an interview on 6/28/22 at 1:54 p.m., the FSS stated the microwave should be cleaned after each use, at the end of the shift by the cook or after a spill. In an interview on 6/28/22 at 2:18 p.m., the Administrator stated she would periodically conduct rounds in the kitchen to monitor their cleaning routines. In an interview on 6/29/22 at 3:30 p.m. the Administrator stated the facility had 3 residents who did not receive meals or snacks from the kitchen as they had orders for nothing by mouth. Record review of the Texas Food Establishment Rules (TFER) 2015, page 52, section §228.66(a)(1) and 228.66(a)(1)(d) revealed packaged and unpackaged food shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings. Record review of the TFER 2015, page 59, section §228.69(a)(1)(A)-(C) indicated food should be stored in a clean dry location where it is not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. Record review of the TFER 2015, page 72, section §228.75(g)(4)(B) revealed prepared food was to be marked with the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises or discarded. Record review of the TFER 2015, page107, section §228.113(3) indicated non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the TFER 2015, page109, section §228.114(c) indicated non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11 Food Storage revealed (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-602.13 Nonfood-Contact Surfaces, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, revealed (A) .food prepared and held in a food establishment for more than 24 hours shall be clearly marked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 2 of 4 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 675800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to indicate the date or day by which the food shall be consumed on the premises, sold or discarded when held at a temperature 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. And (B) .refrigerated, ready-to-eat time/temperature controlled for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24-hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations .and .(2) The day or date marked by the food establishment ay not exceed a manufacturer's used-by date if the manufacturer determined the use-by date based on food safety. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 3 of 4 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 675800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm . Residents Affected - Some Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters (Dumpster #1), in that: Dumpster #1 did not have a drain plug for 2 of 4 days. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 6/27/22 at 9:35 a.m. revealed 2 dumpsters, a reddish-brown dumpster (#1) and a tan dumpster (#2) were behind the facility and Dumpster #1 did not have a drain plug. Observation on 6/28/22 at 10:51 a.m. revealed Dumpster #1 did not have a drain plug. Observation and interview on 6/28/22 at 10:52 a.m. with the Maintenance Director revealed Dumpster #1 did not have a drain plug. The Maintenance Director stated he did not notice Dumpster #1 was missing the drain plug until just now. The Maintenance Director stated the dumpsters belonged to the city and thought Dumpster #1 was removed by the city for service a few weeks ago and brought back without the drain plug. In an interview on 6/28/22 at 2:42 p.m. the Housekeeping Director stated she had contacted the city about Dumpster #1 last week because it had some rust on the bottom, but she did not notice the drain plug was missing until today (6/28/22) when she checked the dumpster a few moments ago. In an interview on 6/28/22 at 2:18 p.m. the Administrator stated the dumpsters belonged to the city who would periodically change the dumpsters. In an interview on 6/28/22 at 4:46 p.m. the Administrator revealed the facility did not have a policy on dumpsters or garbage disposal. Record review of the Texas Food Establishment Rules (TFER) 2015, page 129, section §228.152(o) revealed drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place. Record review of the Food Code, U.S. Public Health Services, U.S. FDA, 2017, U.S. Department of H&HS, 5-501.110 Storing Refuse, Recyclables, and Returnables, revealed Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 4 of 4