Rio Grande City Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rio Grande City Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 4, 2024

  Based 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. The findings included: Record review of Resident #1's face sheet dated 10/30/24 reflected an [AGE] year-old female with an original admitted [DATE]. […]

• No harm, potential for more than minimal, patternF758Aug 8, 2024

  41761 Based 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. […]

• No harm, potential for more than minimal, isolatedF609Jun 11, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF656May 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF552Nov 20, 2025

  Based 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. […]