Inspection·August 3, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement written policies and procedures that Prohibit and prevent abuse for 1 of 5 Residents (Resident #1) whose record were revived for abuse. Residents Affected - Few The facility failed to report an allegation of abuse involving Resident #1 within 2 hours per HHSC regulation. This deficient practice could affect any resident and contribute to further abuse. The findings were: Review of Resident #1's admission, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses including UTI (A urinary tract infection is an infection that affects part of the urinary tract.), Major Depressive Disorder (clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Anxiety Disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event). Review of Resident #1's quarterly MDS assessment dated , [DATE], revealed his BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of incident report, dated [DATE], documented at 04:03 AM by RN A revealed Resident #1 was noted with 2 large bumps to right side of his forehead. Resident #1 reported he was hit on the head by an English speaking male and it happened earlier in the day at4 PM per RN A. Review of Provider Investigation Report, dated [DATE] and written by the ADM, revealed the allegation of abuse involving Resident #1 was reported to the ADM on [DATE] at 8 AM. Observation and attempted interview on [DATE] at 1:45 PM revealed Resident #1 was lying down in bed fully dressed. Attempted interview revealed Resident #1 was confused and in-coherent. He was not interviewable. Interview on [DATE] at 3:20 PM with the ADM revealed she was the abuse coordinator and she reported all allegations of abuse/neglect. She stated Resident #1 was very confused and his story changed about how he got the red marks/bumps on his forehead. She stated she was not sure who exactly told her about Resident #1's injuries but thought it was the morning nurse who told her at about 8 AM. She stated she reported it to HHSC soon afterwards. The ADM reviewed RN A's statement, dated [DATE], documented at 04:03 AM by RN A, which stated she noted the 2 bumps and red marks on Resident #1 during (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 6 Event ID: 675800 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 08/03/2023 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)