Rio Grande City Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency, in accordance with State law through established procedures, for 1 of 3 residents (Resident #1) reviewed for freedom from abuse, neglect, and exploitation. CNA A failed to report an incident of abuse immediately to the Administrator. CNA A alleged she observed CNA B cover Resident #1's mouth with her hand to quiet Resident #1. [...]

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's interventions for her unwitnessed fall on 03/01/26 and 03/30/26 specified the location to which she was to be taken for activities. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the residents have the right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 3 residents (Resident #1) reviewed for consent for antipsychotic medications in that: Resident #1 was prescribed and administered Haldol (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. This failures could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 4 CNAs (CNA B) reviewed for competent nursing care. The facility failed to ensure CNA B communicated Resident #2's change of condition to the charge nurse on 12/01/25. This failure could place residents at risk of not having change in conditions assessed, decreased quality of life, and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure ADON-LVN A signed off the administration of Haldol injection solution 5 mg/ml (Haloperidol lactate) for Resident #1 on 11/06/25. This failure could place residents at risk of not receiving their medications as ordered by their physician.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one of three residents (Resident #58) reviewed for call lights. The facility failed to ensure Resident #58 had the call light within reach while in bed in his room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #12) of 1 resident reviewed for Advance Directives. The facility failed on [DATE] to ensure Resident # 12's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order form was completed. The OOH-DNR form did not have a date next to the physician's signature under the Physician's Statement section of the form. This failure could affect all residents who have implanted Advanced Directives and established their choice not to be resuscitated at risk of receiving Cardiopulmonary Resuscitation (CPR) against their wishes.

Inspectors wroteBased on interview and record review the facility failed notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understood and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents (Resident #85 and Resident #87) reviewed for transfer and discharge rights. The facility failed to notify the Ombudsman of Resident #85's discharge from the facility. 2. Resident #87 was discharged to the hospital on [DATE] without a notice to the LTC state ombudsman. These failures could place residents at risk of not receiving an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the residents goals and preferences for 1 of 2 residents (Resident #62) reviewed for intravenous fluids. The facility failed to ensure the dressing on Resident #62's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed on 09/08/2025. This failure could place residents at risk of not receiving the appropriate IV care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, all drugs and biologicals were stored locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 4 of 4 medication carts (Med-Cart A, Med-Cart B, Med-Cart C, and Med-Cart D) reviewed for labeling and storage.1. The facility failed to ensure medications were properly stored in the Med-Carts A, B and C on 9/9/2025 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 rooms (Room X) reviewed for infection control practices. The facility failed to ensure the sharps container was empty in room X. This failure could place residents at risk of communicable diseases.

Inspectors wroteBased on interviews and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 received adequate supervision to prevent accidents as Resident #1 was left unsupervised in the dining room and fell on [DATE], sustaining a 2.5 cm laceration with 3 staples. This failure could place residents at risk of injury and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately assess the resident's status for 1 of 5 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's fall risk evaluation on 10/04/24, baseline care plan on 10/04/24 and the MDS assessment on 10/14/24 accurately reflected her risk of falls. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #14, Resident #58, and Resident #65) of 7 residents whose records were reviewed for pharmacy services. 1. The facility failed to ensure Resident #14 was not prescribed Risperidone (an antipsychotic) without appropriate diagnosis for its use. 2. The facility failed to ensure Resident #58 was not prescribed Seroquel (an antipsychotic) without appropriate diagnosis for its use. 3. The facility failed to ensure Resident #65 was not prescribed Seroquel (an antipsychotic) without appropriate diagnosis for its use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #83) reviewed for respiratory care. The facility failed to ensure Resident #83 received oxygen at the prescribed rate. He received oxygen at a rate less than prescribed. This failure could place residents receiving oxygen at risk for respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that include measurable objectives and time frames to meet residents' physical needs for 2 (Resident #1 and #2) of 8 residents reviewed for comprehensive person-centered care plans. The facility failed to care plan Resident #1 and #2 the use of a raised perimeter mattress. The failure is affecting one male and one female resident, both use a raised perimeter mattress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for seven days of 7 days (06/11/2024, 06/12/2024, 06/13/2024, 06/14/2024, 06/15/2024, 06/16/2024, and 06/17/2024) reviewed for nurse staffing information. The facility failed to post and maintain the required nursing staffing information to include facility name, current date, current resident census, and total number and actual hours worked by licensed and unlicensed nursing staff for dates of June 11th through June 17th, 2024. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding facility regarding staffing schedule and facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 (Resident #138) of eight residents reviewed for call lights: Resident #138's call light was not placed within reach and provided with a soft ball device for ease of use by the resident. This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.