Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect,
exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the
administrator of the facility and to other officials, including to the State Survey Agency in accordance with
State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Neglect,
The facility did not report an allegation of neglect per facility policy to the State Survey Agency (HHSC)
when Resident # 1 received an injury to the left lateral calf occurred.
This deficient practice could affect any resident and could contribute to further neglect.
The findings were:
Record review of Texas Unified Licensure Information Portal (TULIP) on 5/6/25 at 1:50 P.M. revealed no
self-reported incidents regarding allegations of Neglect were reported for Resident # 1 .
Record review of Resident # 1's face sheet dated 5/6/25 revealed an [AGE] year-old female admitted to the
facility on [DATE], readmitted [DATE] with the diagnosis that included: anxiety disorder (mental illness
characterized by feelings of uneasiness, worry, and fear) , Communication deficit (impairment in the ability
to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia
(loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes
with a person's daily life and activities).
Record review of the quarterly MDS assessment, 1/29/25, revealed a BIMS score of 3, which indicated
severe cognitive impairment. Section G revealed Resident #1 required extensive assistance with 2 persons
for transfers.
Record review of Resident #1's progress note, dated 3/7/25, revealed injury to left lower calf 10 cm X 1 cm
X 0.5 cm, sent to [local hospital] for evaluation and treatment.
Record review of Resident #1's care plan dated 3/7/25, revealed [Resident's name has a laceration to left
lateral calf] interventions: perform wound care as ordered.
Record review of resident #1's hospital discharge instructions, reviewed 5/5/25 at 10:30 AM, dated 3/7/25,
revealed that resident #1 received 13 stitches on the left lower calf.
(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 5
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
05/08/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview with CNA (A) on 5/6/25 at 10:20 AM revealed she transferred Resident # 1 from the wheelchair to
the bed with X 1 assist when the resident's left leg caught on the bed rail. She did not notice the injury to
Resident #1's left leg until Resident #1 was in bed, and this was when she notified LVN (B) .
Interview with LVN (R) on 5/6/25 at 10:52 AM revealed she was the nurse on duty on 3/7/25 when CNA (A)
notified her of the injury to Resident #1's left lower leg. She notified MD, who ordered Resident # 1 to be
sent to the local ER.
Interview with the MD on 5/6/25 at 1:34 PM revealed he was notified by LVN(R) on 3/7/24 regarding the
injury to the left lower leg of Resident # 1, and he ordered for Resident # 1 to be sent to the local ER for an
evaluation.
During an interview with the DON on May 6, 2025, at 11:15 AM, she shared LVN (R) had reached out to
her on March 14, 2025, about an injury to Resident #1's left lower leg. The DON also noted she promptly
informed the Administrator about this incident. In a follow-up interview with the DON on the same day at
11:30 AM, she emphasized it was the Administrator's role to report any neglect allegations to HHSC, which
was why she did not take the step to report the leg injury for Resident #1. Nonetheless, she conveyed she
felt strongly that any allegations of neglect should indeed be reported , to help those responsible
accountable for their actions if required.
Interview with the Administrator on 5/06/25 at 12:45 P.M. revealed he did not report the injury involving
Resident #1, as the incident was witnessed. However, upon reviewing the neglect guidelines from HHSC,
he acknowledged he should have reported the incident.
Record review of facility policy titled, Abuse, Neglect: , dated 9/9/24, , reflected, The Facility will report and
cooperate with any investigations concerning reports of abuse, neglect, exploitation, mistreatment of
residents, misappropriation of residents property and injuries of unknown source by the company's
employees as outlined in state law ( including to the state survey and certification agency ) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675800
If continuation sheet
Page 2 of 5
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
05/08/2025
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 0657
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the
interviews and record review, the facility failed to review and revise Resident Care Plans after each
assessment for 1 of 3 Residents (Resident # 1) whose records were reviewed for care plan revision/timing,
The [NAME] of Resident # 1 was not updated to reflect the required extensive assistance with 2 persons for
transfers via mechanical lift .
These deficient practices could affect any resident and contribute to the Residents not receiving the care
and services they need.
The findings included:
Record review of Resident # 1's face sheet dated 5/6/25 revealed an [AGE] year-old female admitted to the
facility on [DATE], readmitted [DATE] with the diagnosis that included: anxiety disorder (mental illness
characterized by feelings of uneasiness, worry, and fear), Communication deficit (impairment in the ability
to receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia
(loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes
with a person's daily life and activities).
Record review of the quarterly MDS assessment, 1/29/25, revealed a BIMS score of 3, which indicated
severe cognitive impairment. Section G revealed Resident #1 required extensive assistance with 2 persons
for transfers.
Record review of the [NAME] for resident # 1, dated 3/08/25, revealed a care plan with focus area [
resident's name is at risk for falls] interventions: staff X 2 to assist with transfers via mechanical lift.
Interview with CNA ( A ) on 5/5/25 at 11:15 AM revealed that on 3/7/25, when she transferred Resident # 1
from the wheelchair to bed, Resident #1's transfer status was X1 on the [NAME].
Interview on 5/07/2025 at 2:30 PM, the MDS nurse stated she had not updated the [NAME] for Resident #1
regarding transfer status, staff X 2 to assist with transfers via mechinical lift lift until 3/8/25, as it was missed
during audits. She emphasized failing to update these care plans/[NAME] might prevent staff from being
aware of Resident #1's transfer status, potentially injuring Resident #1. The MDS nurse stated it was her
responsibility to update the [NAME] to reflect the transfer status.
Interview on 5/7/2025 at 11:00 a.m., the DON stated the MDS nurse should have updated Resident #1's
[NAME] to reflect extensive assistance with 2 persons for transfers via mechinical lift as soon as the
Quarterly MDS assessment was completed 1/29/25. She added her ADON was responsible for overseeing
care plans, and she audited them at random as failure to update [NAME] timley could negatively affect
Residents.
Record review of the facility policy, titled Comprehensive Care Planning, undated, revealed . The resident
care plan will be reviewed after each admission, quarterly, annually, and/or a significant change in MDS
assessment, and revised based on the changing goals, preferences, and needs of the resident and in
response to current interventions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675800
If continuation sheet
Page 3 of 5
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
05/08/2025
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 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to ensure each resident received adequate
supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for
accident hazards and supervision,
On 03/07/2025, Resident #1 was transferred by CNA (A) using a standing pivot transfer x 1 staff instead of
a mechanical lift. During transfer, Resident #1 was injured, resulting in a laceration to the left lower calf
requiring 13 stitches.
The non-compliance was identified as past non-compliance. The PNC began on 3/7/25 and ended on
3/09/25. The facility had corrected the non-compliance before the survey began.
This failure could lead to injury or death to residents.
Findings included:
Record review of Resident # 1's face sheet dated 5/6/25 revealed an [AGE] year-old female admitted to the
facility on [DATE], readmitted [DATE] with the diagnoses that included: anxiety disorder (mental illness
characterized by feelings of uneasiness, worry, and fear. Communication deficit (impairment in the ability to
receive, send, process, and comprehend concepts of verbal, nonverbal communication), and dementia
(loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes
with a person's daily life and activities).
Record review of the quarterly MDS assessment, 1/29/25, revealed a BIMS score of 3, which indicated
severe cognitive impairment. Section G revealed Resident #1 required extensive assistance with 2 persons
for transfers.
Record review of the Care plan for resident # 1, dated 3/08/25, revealed a care plan with focus area [
resident's name is at risk for falls] interventions: staff X 2 to assist with transfers via mechinical lift .
Record review of the progress note for Resident # 1, dated 03/07/2025, revealed on 03/07/2025 at 12:45
PM, [CNA A] transferred [Resident #1] from the chair to the bed and left leg rubbed against bed frame.
[Resident #1] voiced that her leg hurt. Further review revealed Resident #1 was noted to have an
abnormality in the left lower leg, and the resident was transferred to the local hospital for treatment.
Record review confirmed that [Resident #1's] MDS assessment , dated 3/7/2025 was a staff X 2 to assist
with transfers via mechinical lift.
Record review of a progress note, dated 03/07/2025 at 12:45 PM, revealed, This nurse was called into the
residents' room by CNA (A), left lower extremity assessed, and [Resident #1] was able to state where the
pain was, and 911 was called.
Record review of Resident #1's hospital discharge records dated 3/7/25 revealed that Resident # 1 received
13 stitches to the left lower leg.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675800
If continuation sheet
Page 4 of 5
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
05/08/2025
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 0689
Level of Harm - Actual harm
Residents Affected - Few
During an Interview with the DON on 05/07/2025 at 1:25 PM, the DON stated CNA (A) should have
transferred Resident #1 using two staff members with a mechanical lift as per Resident #1's MDS
assessment. The DON also stated residents may be injured if CNAs do not follow the MDS assessment.
Interview with CNA (A) on 5/7/2025 at 9:58 AM revealed she transferred Resident #1 without using a
mechanical lift, opting for a single-person pivot transfer. She had previously used the lift but was unaware it
was indicated in the MDS assessment. As a result of the incident, she was suspended for one day and
retrained on locating the [NAME] /Care plan.
During a follow-up interview on 5/8/2025 at 8:02 AM , CNA (A) reported that Resident #1 complained of
pain in her left lower leg after the transfer, and blood was observed on the left lower calf.
Record review of the facility's policy titled, Hydraulic Lift, undated, revealed, The Resident will achieve safe
transfer to bed or chair via mechanical lift device.
The Administrator was notified on 05/08/2025 at 1:00 PM that a past non-compliance was identified due to
the above failure.
The facility implemented the following interventions before the survey entrance on 05/05/2025.
During an interview with the DON on 5/06/25 at 2:18 PM, the DON stated the facility implemented a system
for PRN (as needed) staff to review forms before their shift to identify each resident's care needs.
Record review of in-service training titled, How to use [NAME] in EMAR /Report change of condition to
charge nurse, dated 03/7/2025 to 03/09/2025, showed that 36 of 36 staff members, and 2 of 2 PRN staff
(as needed) completed the in-service training. Further, review revealed the in-service training addressed:
CNAs look at [NAME], mechinical lift's to be used if indicated for two-person assist, where to find POC
(Plan of Care), competencies, and demonstration of mechanical lift transfers.
Interviews with 12 staff members on 05/6/25 from 11:00 a.m. to 1:00 p.m. the following staff [CNA (B), CNA
(C), CNA (D), CNA (E), CNA (F), CNA (G), CNA (H), MA (I), CNA (J), CNA (K), CNA (L), CNA (M)]
confirmed completion of in services/training: Always Follow the POC (Plan of Care), the CNA's look at the
[NAME], mechanical lifts to be used if it is indicated 2 people assist,and where to find the POC (Plan of
Care. The Staff were able to verbalize understanding and information provided in the in-service/training.
Observation on 05/6/25 at 10:30 AM confirmed MA (N) and LVN (O) transferred Resident #2 using a
two-staff mechanical lift transfer.
Observation on 5/6/25 at 7:10 AM confirmed CNA (P) and LVN (Q) transferred Resident #3 using a
two-staff mechanical lift transfer.
The non-compliance was identified as past non-compliance. The PNC began on 3/7/25 and ended on
3/09/25. The facility had corrected the non-compliance before the survey began.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675800
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations 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.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the May 8, 2025 survey of LA VIDA SERENA NURSING AND REHABILITATION?
This was a inspection survey of LA VIDA SERENA NURSING AND REHABILITATION on May 8, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LA VIDA SERENA NURSING AND REHABILITATION on May 8, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
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.