Inspection·August 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/16/2023 at 11:00 AM the DON stated Resident #18 had his right leg amputated below the knee and was supported to walk with a prosthetic leg which was applied daily and as needed by nursing staff. The DON was informed that Resident #18's care plan did not address Resident #18's need for a prosthetic leg. The DON reviewed Resident #18's care plan and agreed there was no care instructions for staff to follow for care related to applying Resident #18's prosthesis. The DON stated the care plan should have had care instructions for staff to follow for care related to applying Resident #18's prosthesis. The DON stated she and her nurses were culpable for the lack of care support instructions and should have been reviewing the care plans for accuracy. During a joint interview on 08/16/2023 at 01:37 PM with MDS RN B and RN C, they were informed that Resident #18's care plan did not address Resident #18's need for a prosthetic leg. RN B and RN C reviewed Resident #18's care plan and agreed there were no care instructions for staff to follow for care related to applying Resident #18's prosthesis. RN B and RN C stated the care plan should have had care instructions for staff to follow for care related to applying Resident #18's prosthesis. RN B stated, It's my fault. I overlooked it and RN C stated she was also culpable for the lack of care instructions . Record review of the policy Comprehensive care Planning (no date), The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objective and timeframes to meet a resident's [NAME], nursing, and mental and psychological needs that are identified int eh comprehensive assessment. The services that are to be finished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 2 of 11 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 08/16/2023 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for 1 of 8 (Resident #2) residents reviewed in that: Residents Affected - Few Resident #2 did not receive assistance while eating when he was served his meal. This failure could place residents who require feeding assistance at risk of not receiving the necessary services to maintain good nutrition and decline in health. The findings were: Record review of Resident #2's admission Record dated 8/16/2023 revealed he was admitted to the facility on [DATE], re-admitted on [DATE] and his diagnoses included pain in left in right/left knee, muscle weakness, lack of coordination, peripheral vascular disease heart failure and diabetes (a metabolic disease, involving inappropriately elevated blood glucose levels) and cerebral palsy. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Section C Cognition BIMs was 5/15 (severely impaired) and Section G Functional Status bed mobility revealed the resident required extensive assistance with two-person assistance; for transfers the resident was total dependence with two-person assistance and with eating the resident required extensive assistance with one-person physical assistance. Record review of Resident #2's care plan dated 8/17/2023 revealed for Resident #2 in position due to cerebral palsy her Resident #2 request, encourage good nutrition and hydration, and Resident #2 was a risk for hygiene deficit, required extensive -total assist x2 with ADL's, showers, transfers due to neuromuscular impairment related to cerebral palsy interventions to assist with feeding as needed. Observation on 8/15/2023 at 10:06 AM in Resident # 2's room revealed he was served lunch and he was trying to open the butter container. He tried with his fingers and with his teeth with no success. There was no staff helping Resident #2 with eating his lunch. Observation of Resident #2 revealed he was one of the first residents to be served since his room was at the beginning of the hall . Interview on 8/15/2023 at 10:09 AM LVN H stated Resident # 2 required assistance with feeding at times and stated Resident #2 had a recent change. LVN H stated Resident #2 was one of the first residents to be served on the hall. Interview on 8/15/2023 at 10:11AM CNA I stated Resident #2 required assistance with meals. CNA I stated he had the serve the hall, then was going to come back and assist Resident #2 with feeding . Interview on at 8/16/2023 at 10:57 AM the DON stated she was not aware that Resident #2 did not receive help during meals. Interview on 8/16/2023 at 4 PM the ADM discussed occurrences with Resident #2, with no response. The Surveyor asked for a policy for residents receiving assistance during meal from staff. The ADM stated she had no policy for staff assisting residents during meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 3 of 11 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 08/16/2023 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 2 of 3 residents (Residents #20 and #48) reviewed for medication administration, in that: Residents Affected - Some 1. MA D attempted to administer to Resident #20, midodrine [a medication designed to raise a person's blood pressure] while Resident #20 was assessed with high blood pressure. Also, during the same attempt MA D attempted to concurrently administer midodrine [a drug to raise blood pressure] and antihypertensive medications [drugs designed to lower blood pressure]. 2. Resident #20 was administered midodrine incorrectly 6 times during the period from 08/01/2023 to 08/12/2023 by MA D and LVN F. 3. Resident #48 was administered midodrine incorrectly 23 times during the period from 08/01/2023 to 08/15/2023 by MA D, MA E, and LVN F. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included : 1. A record review of Resident #20's admission record dated 08/14/2023 revealed an admission date 02/06/2023 and diagnoses which included hypertensive [high blood pressure] heart and chronic kidney disease. A record review of Resident #20's annual MDS dated [DATE] revealed Resident #20 was an [AGE] year-old female admitted for long term care who was able to understand others and make her needs known. Resident #20 was assessed without mental cognition impairment as evidence by a BIMS score of 13 out of 15. Further review revealed Resident #20 received dialysis therapy. A record review of Resident #20's care plan dated 08/14/2023 revealed, [Resident #20] needs dialysis 3x a week r/t end stage renal disease .[Resident #20] will have no s/sx of complications from dialysis through the review date . Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately A record review of Resident #20's August 2023 physician's orders revealed the physician ordered for Resident #20 to receive midodrine 10mg three times a week, 1 hr. prior to dialysis if her blood pressure was lower than 110 systolic [the first number in a blood pressure reading; systolic/diastolic], Give 1 tablet by mouth one time a day every Tue, Thu, Sat related to end stage renal disease, administer medication one hour prior to dialysis if systolic BP is <110. During an observation and interview on 08/15/2023 at 09:00 AM revealed MA D prepared medications to administer to r esident #20. MA D assessed resident #20's blood pressure as 156/58 with a pulse of 57 and alerted LVN G to reassess Resident #20. LVN G assessed Resident #20 with a blood pressure of 137/62 and a pulse of 70. MA D proceeded to dispense Resident #20's morning medications which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 4 of 11 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 08/16/2023 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some included midodrine with an order if the blood pressure was greater than 110 do not give the midodrine. MA D also had dispensed 3 medications prescribed for high blood pressure concurrently MA D dispensed all the medications into a pill cup and gathered a cup of water and attempted to administer the medications when the surveyor actively interrupted the attempt to administer the medications and asked MA D if she intended to administer the medications. MA D stated yes. The surveyor again interrupted the medication administration and asked for MA D to please review the order for midodrine. MA D reviewed the order and removed the midodrine and placed the midodrine in another pill cup and stated she would administer the midodrine later; approximately 1 hour prior to Resident #20's dialysis appointment. MA D then administered the remaining medications to Resident #20 . During an interview on 08/15/2023 at 09:20 AM LVN G stated she was the charge nurse for Resident #20. The surveyor gave LVN G a report of the medication error where MA D tried to administer midodrine concurrently with blood pressure medications prescribed to lower high blood pressure. LVN G stated MA D should not have attempted to administer the midodrine due to the blood pressure assessment for Resident #20 was too high for the midodrine to be administered. LVN G stated she would address MA D . During an interview on 08/15/2023 at 09:34 AM the DON received a report from the surveyor of the medication error where MA D tried to administer midodrine concurrently with blood pressure medications prescribed to lower high blood pressure. The DON stated MA D should not have attempted to administer the midodrine due to the blood pressure assessment for Resident #20 was too high for the midodrine to be administered. The DON stated she would address MA D. The DON stated the risk for harm to Resident #20 was possible heart injury. 2. A record review of Resident #20's August 2023 medication administration record and blood pressure records revealed Resident #20 was administered midodrine outside of physicians ordered parameter, give .if blood pressure is less than 110, 4 times. MA D administered the midodrine outside of physicians ordered parameter as follows: On 08/01/2023 Resident #20 was assessed in the morning, with a blood pressure of 128/63 and was administered the midodrine. On 08/03/2023 Resident #20 was assessed in the morning, with a blood pressure of 134/64 and was administered the midodrine. On 08/08/2023 Resident #20 was assessed in the morning, with a blood pressure of 132/64 and was administered the midodrine. On 08/10/2023 Resident #20 was assessed in the morning, with a blood pressure of 129/64 and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 5 of 11 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 08/16/2023 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)

F 0760 administered the midodrine. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #20's August 2023 medication administration record and blood pressure records revealed Resident #20 was administered midodrine outside of physicians ordered parameter, give .if blood pressure is less than 110, 1 time. LVN F administered the midodrine outside of physicians ordered parameter as follows: Residents Affected - Some On 08/12/2023 Resident #20 was assessed in the morning, with a blood pressure of 148/70 and was administered the midodrine. 3. A record review of Resident #48's admission record dated 08/15/2023 revealed an admission date of 05/22/2023 with diagnosis which included hypotension [low blood pressure]. A record review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 was a [AGE] year-old male admitted for long term care. A record review of Resident #48's care plan dated 08/14/2023 revealed, [Resident #48] has potential fluid deficit .[Resident #48] will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor . Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage the resident to drink fluids of choice. A record review of Resident #48's August 2023 physician's orders revealed the physician ordered for Resident #48 to receive midodrine 5mg three times a week, midodrine .Oral Tablet 5mg Give 1 tablet by mouth three times a day for Hypotension Administer if SBP <100 [less than 100]; Hold medication if SBP >100 [is greater than 100; the first number in a blood pressure]. A record review of Resident #48's August 2023 medication administration record and blood pressure records revealed Resident #48 was administered midodrine outside of physician's ordered parameters, give .if blood pressure is less than 100, 4 times. MA D administered the midodrine outside of physician's ordered parameter as follows: -On 08/01/2023 Resident #48 was assessed with a blood pressure of 122/70 and was administered the midodrine at 01:00 PM. -On 08/08/2023 Resident #48 was assessed with a blood pressure of 124/68 and was administered the midodrine at 01:00 PM. -On 08/11/2023 Resident #48 was assessed with a blood pressure of 112/77 and was administered the midodrine at 01:00 PM. On 08/14/2023 Resident #48 was assessed with a blood pressure of 111/67 and was administered the midodrine at 01:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 6 of 11 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 08/16/2023 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #48's August 2023 medication administration record and blood pressure records revealed Resident #48 was administered midodrine outside of physician's ordered parameters, give .if blood pressure is less than 100, 13 times. MA E administered the midodrine outside of physician's ordered parameter as follows: -On 08/01/2023 Resident #48 was assessed with a blood pressure of 128/70 and was administered the midodrine at 08:00 PM. -On 08/02/2023 Resident #48 was assessed with a blood pressure of 138/68 and was administered the midodrine at 08:00 PM. -On 08/03/2023 Resident #48 was assessed with a blood pressure of 130/68 and was administered the midodrine at 08:00 PM. -On 08/04/2023 Resident #48 was assessed with a blood pressure of 138/68 and was administered the midodrine at 08:00 PM. -On 08/05/2023 Resident #48 was assessed with a blood pressure of 118/60 and was administered the midodrine at 08:00 PM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 108/62 and was administered the midodrine at 08:00 PM. -On 08/07/2023 Resident #48 was assessed with a blood pressure of 132/70 and was administered the midodrine at 08:00 PM. -On 08/08/2023 Resident #48 was assessed with a blood pressure of 128/66 and was administered the midodrine at 08:00 PM. -On 08/09/2023 Resident #48 was assessed with a blood pressure of 110/66 and was administered the midodrine at 08:00 PM. -On 08/10/2023 Resident #48 was assessed with a blood pressure of 128/70 and was administered the midodrine at 08:00 PM. On 08/11/2023 Resident #48 was assessed with a blood pressure of 128/70 and was administered the midodrine at 08:00 PM. -On 08/12/2023 Resident #48 was assessed with a blood pressure of 119/70 and was administered the midodrine at 08:00 PM. -On 08/13/2023 Resident #48 was assessed with a blood pressure of 133/78 and was administered the midodrine at 08:00 PM. A record review of Resident #48's August 2023 medication administration record and blood pressure records revealed Resident #48 was administered midodrine outside of physicians ordered parameter, give .if blood pressure is less than 100, 6 times. LVN F administered the midodrine outside of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 7 of 11 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 08/16/2023 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)

F 0760 physicians ordered parameter as follows: Level of Harm - Minimal harm or potential for actual harm -On 08/05/2023 Resident #48 was assessed with a blood pressure of 112/70 and was administered the midodrine at 08:00 AM. Residents Affected - Some -On 08/05/2023 Resident #48 was assessed with a blood pressure of 126/64 and was administered the midodrine at 01:00 PM. -On 08/05/2023 Resident #48 was assessed with a blood pressure of 118/60 and was administered the midodrine at 08:00 PM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 104/62 and was administered the midodrine at 08:00 AM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 110/64 and was administered the midodrine at 01:00 PM. -On 08/06/2023 Resident #48 was assessed with a blood pressure of 108/62 and was administered the midodrine at 08:00 PM. During an interview on 08/16/2023 at 03:02 PM MA E stated he had been in-serviced by the DON on the drug midodrine to include proper administration. MA E stated the less than symbol and the greater than symbol confused him and would now be written out and not used. MA E stated he had been administering the midodrine to residents in error and was regretful he did not seek out clarification on the less than greater than symbols. During an interview on 08/15/2023 at 05:01 PM the Medical Director stated he had not received reports that Residents #20 and #48 had received their midodrine outside of parameters for the month August 2023. The Medical Director received a report from the surveyor that Resident #20 had been receiving antihypertensive and hypotensive medications concurrently. The Medical Director stated Resident #20 should not have been administered the antihypertensive and hypotensive medications concurrently. The Medical Director stated he was not aware Resident #48 was also administered midodrine out of parameters multiple times in August 2023. The Medical Director stated he should have received reports from nursing staff that the midodrine was given while the residents were hypertensive. The Medical Director stated the risk to residents receiving concurrent hypertensive medications with hypotensive medications and receiving hypotensive medications while having hypertension could potentially at worst cause a resident a neurological event such as a stroke. A record review of the facility's Adverse Consequences and Medication Errors dated February 2023, revealed, Policy Heading: The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. Policy Interpretation and Implementation .Medications Errors 1. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 8 of 11 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 08/16/2023 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that residents received a therapeutic diet as prescribed by the physician for 1 of 8 residents (Resident #20) reviewed in that: Resident #20 was prescribed a low sodium diet and was provided a regular diet which did not meet her dietary needs. This failure could affect residents who are prescribed a low sodium diet and could result in complications with high blood pressure and kidney disease. The findings include: Record review of Resident #20's Face Sheet dated 8/14/2023 reflected an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including: pulmonary hypertension (high blood pressure), end stage renal disease (final stage of kidney disease where kidneys cannot function on their own), and fluid overload (condition where the liquid portion of the blood is too high ). Record review of Resident #20's MDS dated [DATE] reflected a BIMS of 13, indicating the resident was cognitively intact. The residents MDS did not reflect a Therapeutic diet for the resident. Record review of Resident #20's Dialysis Physician's Order dated 8/1/2023 reflected an order for Low Salt Diet. Record review of Nursing Progress Notes dated 8/1/2023 reflected a note reflecting the resident Returned from dialysis with orders for low salt diet. Record review of Nursing - Dietary Communication Form dated 8/1/2023 reflected a new order for a low sodium diet. Record review of Resident #20's tray ticket dated 8/14/2023 reflected no indication of a low salt diet. Record review of Resident #20's Care Plan dated 7/26/2023 did not reflect a therapeutic diet. Observation and interview on 8/14/2023 at 12:50 PM of the lunch service revealed a meal tray intended for Resident #20 containing a packet of salt on the tray for the resident to use on her food as needed. Resident #20 stated she did not know why she was provided salt, as her ankles were swollen due to water retention and her doctor at the dialysis clinic had informed her that she should maintain a low sodium diet. The resident stated her ankles felt tight at times when they were swollen and made her uncomfortable. Interview on 8/16/2023 at 9:34 AM, the DM stated that if a resident received new dietary orders, a nurse would create a communications slip and provide it to the DM either by physically handing it to her or putting it in her mailbox outside of her office. The DM stated she was able to review orders in the resident's EMR and that any changes would be reviewed in meetings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 9 of 11 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 08/16/2023 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 8/16/2023 at 10:57 AM, the DON stated that her expectations for nursing staff was to review orders, create Nursing - Dietary Communication Forms, and provide them to the DM, informing the kitchen of the new dietary order. The DON stated that nursing staff was instructed to double check meals and compare the meals to orders and meal slips. Interview on 8/16/2023 at 3:12 PM, LVN G stated if a resident had an order for a change in their diet, LVN G would turn in a Nursing - Dietary Communication Form to the Dietary Manager to ensure the residents' ordered diet was followed by the kitchen. LVN G stated she had provided the Dietary department with the low sodium diet order the day the order was received. Interview on 8/16/2023 at 3:35 PM, the Administrator stated her expectations were for dietary staff to make any changes based on physicians' orders communicated to them by nursing. Record review of the facility policy, undated, titled Diet Orders/Diet Manual reflected The Dietary Service Department is to be informed of any of the changes listed below in a timely manner: . Change of Diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 10 of 11 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 08/16/2023 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public for 3 of 13 (201,202, 205) rooms in the 200 hall in that: Resident rooms 201, 202, 205 had broken window blinds. This could affect residents on the 200 hall and could result in low self-esteem and a lack of privacy. The findings were: 1.Observation on 8/15/2023 at 4:10 PM in resident room [ROOM NUMBER] revealed his window blinds had 5 slats that were broken and could see outside while the window blinds were closed. Interview on 8/15/2023 at 4:11 PM the resident in room [ROOM NUMBER] stated the window blinds had been broken for a while and he did report to Maintenance Supervisor. Observation on 08/16/2023 at 2:20 PM in resident room [ROOM NUMBER] revealed his window blinds had 5 slats that were broken and could see outside while the window blinds were closed. 2. Observation on 8/15/2023 at 4:12 PM in resident room [ROOM NUMBER] revealed the window blinds had 2 slats that were broken . Interview on 8/15/2023 at 4:13 PM the resident in room [ROOM NUMBER] stated he did report the window blinds were broken to staff (unknown). 3. Observation on 8/15/2023 at 4:41PM in resident room [ROOM NUMBER] revealed the window slates were broken. The resident not interviewable. Interview in 8/15/2023 at 4:45 PM with the ADM stated she was not aware the window blinds were broken. A policy was requested. Interview on 8/16/2023 at 1:57 PM the Maintenance Supervisor stated rooms 201,202, 205 had broken window blind slats. The Maintenance Supervisor stated the broken window blinds were not reported to him . Interview on 08/16/23 at 2:16PM the ADM stated the broken window slates on the blinds were not reported to her and would check on TELLS .(communication for environmental concerns in the facility) A policy was requested but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675800 If continuation sheet Page 11 of 11