Rio Grande Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF690Nov 6, 2025

  Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#2) of seven residents reviewed for foley catheter care and catheter assessments out of eleven sample residents.Specifically, the facility failed to ensure staff were appropriately trained in the care needs of a resident with quadriplegia and effectively monitoring Resident #2, who had an indwelling foley catheter for signs and symptoms of urinary retention. This resulted in the resident being transferred to the hospital where she was admitted to the hospital's intensive care unit for a higher level of care. […]

• Actual harm, isolatedF600Nov 6, 2025

  Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#10) of three residents reviewed for abuse out of 11 sample residents.Resident #10 was admitted on [DATE] with diagnoses of autistic disorder, dementia and depression.Resident #11 was admitted on [DATE] with diagnoses of dementia and schizophrenia (mental illness).On 9/7/25, Resident #10 entered the facility from outside. Resident #11 approached Resident #10 and pushed him to the floor. Resident #10 complained of left leg pain and was transferred to the hospital where he was diagnosed with a femur fracture that required surgical repair. Specifically, the facility failed to protect Resident #10 from physical abuse by Resident #11.Findings include:I. […]

• Actual harm, isolatedF684Nov 6, 2025

  Based on , observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for two (#1 and #2) of five residents reviewed for wound care and weekly skin assessments out of 11 sample residents.Resident #1 was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #1 had a diagnosis of heart failure, multiple sclerosis, dementia and diabetes. Resident #1 had a history of hemorrhoids and was receiving as needed topical medication. Upon admission to the hospital on [DATE], it was discovered that Resident #1 had a perianal abscess which required surgery and intravenous (IV) antibiotics. […]

• Actual harm, isolatedF600Feb 1, 2021

  Based on record review and interview, the facility failed to prevent neglect for one (#4) of three residents reviewed for injuries of nine sample residents. During Resident #4's rehabilitation stay, the resident suffered a hip dislocation of unknown origin. Resident #4 was admitted to the facility on [DATE] for rehabilitation after surgery to his left hip. He had severe cognitive impairment and required extensive two-person assistance for care. Eighteen days later he was transferred to the hospital with the same hip having been dislocated. The facility stated the hip became dislocated due to his movement while in bed. The hospital records documented the cause of the dislocation was unknown. Hospital records further documented the resident had a pressure injury on his left heel. […]

• No harm, potential for more than minimal, widespreadF812Apr 22, 2026

  Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to:-Ensure staff did not touch ready-to-eat food with their bare hands; -Ensure staff performed proper hand hygiene during meal service;-Ensure expired food was discarded;-Ensure equipment was in good repair; and,-Ensure artificial nails and jewelry were not worn. Findings include: I. Failure to ensure staff used proper hand hygiene and did not touch ready-to-eat foods with bare hands during meal service.A. […]