La Vida Serena Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 Resident Council group reviewed. The facility failed to follow up on concerns and requests expressed in Resident Council meetings June 2025 through November 2025. The facility failed to provide the Resident Council group with a response, actions, and rationale taken regarding their concerns. This failure placed residents at risk of not having their grievances followed up and addressed.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain a comprehensive Quality Assurance & Performance Improvement Program (QAPI) Plan, disclose records upon request, and have governance and leadership for 1 of 1 QAPI Program Plan reviewed. The facility failed to maintain an effective, comprehensive QAPI program and plan that addresses the full range of services the facility provides. The facility failed to ensure the QAPI Program uses performance indicator data, resident and staff input, and other information to identify and prioritize problems and opportunities. The facility failed to identify and prioritize quality deficiencies and utilize Resident and Family Council minutes, Grievance Review process, and Daily QA meetings (Morning QA stand up meeting) for improving resident outcomes. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 13 resident rooms (rooms 205, 206, 213) and 1of 1 hydration room and 1 of 1 laundry room reviewed for environmental concerns in that: 1-The facility failed to repair a bathroom ceiling vent that was dirty/rusty, replace a bathroom light bulb, repair a bedroom's broken window shade, repair a hydration room's ceiling, repair a laundry rooms ceiling vent and ceiling area, repair a laundry room's corner wall panel, clean a laundry room's corner wall area that had a film resembling mold, and replace laundry room floor tiles. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment [TT1] for 2 of 24 residents (Residents #28 and #44) reviewed for care plan. 1. The facility failed to develop and implement a care plan with a focus, goals, and interventions for Resident #28's needs for dialysis (a life-sustaining medical treatment that filters waste products and excess fluid from the blood when the kidneys fail.) 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents' environments remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 8 residents reviewed for anti-slip mats. Resident #9 was assessed as a fall risk with a history of falls from her wheelchair. Resident #9 was prescribed an anti-slip mat on the seat of her wheelchair and had gone missing for days. This failure could place residents at risk of falls and injuries.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure medical records were maintained completely, accurately documented, readily accessible, and systematically organized per professional standards for 2 of 8 residents (Residents #9 and #76) reviewed for accurate medical records. Resident #76's hospital discharge documents were stored in Resident #9's medical record. This failure could place residents at risk of harm by keeping inaccurate records.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #64) reviewed for assessments, in that: The facility failed to ensure Resident #64's Quarterly MDS assessment incorrectly documented the resident as not receiving hospice care. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 residents (Resident #34) reviewed for treatments and care related to enteral access devices. The facility failed to ensure medications were administered according to acceptable standards and practices related to enteral access devices when Resident #34's medications were not dissolved in water for administration with a flush between each medication administered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and #2) of 5 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1 was coded on his Quarterly MDS, dated [DATE] for a fall with major injury that occurred on 01/18/2024. 2. The facility failed to ensure Resident #2 was coded on her Quarterly MDS, dated [DATE] for a fall with major injury that occurred on 05/21/2024. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census. The facility did not post the required current nurse staffing information from 07/05/2024 to 07/11/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased 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: 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews the facility failed to develop, within 7 days after completion of the comprehensive assessment, a comprehensive care plan, prepared by an interdisciplinary team for 1 of 8 residents (Resident #18) reviewed for care plans, in that: The facility failed to complete a comprehensive care plan for Resident #18 needs for durable medical equipment, a prosthetic leg. This failure could place residents at risk for harm by not supporting their needs.

Inspectors wroteBased 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: 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.

Inspectors wroteBased 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.