Rio Grande City Nursing And Rehabilitation Center

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

towards her and that he had threatened to slap her. She said she immediately called Resident #1's NP, but didn't get an answer, so she left a message. ADON A said while she was in the morning meeting, Resident #1's NP returned her call and gave a new order for a Haldol injection. ADON A said she had quickly left the meeting to go administer the Haldol injection to Resident #1. She said prior to administering the injection,

she had called Resident #1's RP for consent, which RP gave verbal consent. ADON A said after she administered Resident #1 the Haldol injection she returned to the morning meeting. She said after the morning meeting, she had emailed Resident #1's RP a consent form for her to sign. ADON A was observed as she reviewed Resident #1's electronic medical record and said she must have forgotten to document that Resident #1's RP had given verbal consent on the progress note she authored on 11/06/25 at 9:58 am.

ADON A said after she reviewed Resident #1's electronic medical record the signed consent form for Haldol had not been received/uploaded. ADON A said Resident #1's RP had not returned the signed consent form for Haldol. She was observed as she looked for the email, she had sent Resident #1's RP on 12/01/25 and said she was only able to retrieve the email but did not see an attachment (consent form).

ADON A said part of her responsibility as an ADON was to audit new psychotropic orders as they come in to ensure the resident or their RP had given consent prior to being administered. She said she was not sure how or why she had missed Resident #1's RP had not sent back the signed consent form for Haldol. ADON said there were no negative outcome to Resident #1's RP not signing a consent form for the administration of Haldol because RP had verbally consented via phoneIn an interview and observation on 11/19/25 at 1:29 pm, the DON said the facility's protocol for psychotropic drugs was to obtain a verbal consent prior to

the drug being administered. She said after the psychotropic drug was administered, the nursing staff would be responsible to obtain a written consent from the resident or their RP. The DON was observed as

she reviewed Resident #1's electronic medical record and said ADON A had forgotten to document his RP had given verbal consent. She said she believed ADON A had obtained verbal consent for the Haldol injection prior to being administered. She said Resident #1's RP had voiced several times and she would agree to the treatment the facility recommended. The DON said it was her responsibility to ensure a written consent form was obtain for all psychotropic drugs. She said she was not sure why she had missed the consent form for Haldol was not in Resident #1's electronic medical record. The DON said there were no negative outcome to Resident #1 not having a signed consent form for Haldol. Record review of the facility's Use of Psychotropic Medication(s) policy dated 03/05/25 reflected: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used to discipline or staff convenience, which would deem it a chemical restraint. Policy Explanation and Compliance Guidelines: 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risk and benefits of the proposed care, the treatment alternatives or other options and the preferred options to accept or decline in a format that facility deems to use (e.g., written consent form, narrative note, etc.).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Grande City Nursing and Rehabilitation Center

2530 Central Palm Dr Rio Grande City, TX 78582

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she got to the shower room she no longer complained of pain CNA B said if PA had not rounded earlier in

the morning, she would have notified Resident #2's charge nurse, that she had complained of pain to her right side. CNA B said she had been in-serviced on reporting change of condition to the charge nurse regularly but in this case she had assumed Resident #2 had informed her PA when he visited her earlier that morning. In an observation and interview on 11/18/25 at 9:30 am, Resident #2 was observed lying in bed awake. She said she had not been abused by anyone in the facility. She said if anyone abused her, she would notify her nurse immediately. In an interview on 11/18/25 at 10:40 am, LVN E said on 10/01/25 at around 6:00 am, she had accompanied Resident #2's PA for his weekly visit. LVN E said Resident #2 had not complained of any pain and had not mentioned anyone had hit her during the visit. LVN E said during noon hour, Resident #2 was sitting in her wheelchair in the dining room when she saw NP F in the hallway and she called him. LVN E said Resident #2 made an allegation of abuse to NP F. She said NP F immediately notified her and both went in to do a head -to-toe assessment. She said no bruising, swelling, discolorations were found. LVN E said Resident #2 denied being hit by anyone in the facility. She said after

the head-to-toe assessment, an investigation was initiated and the allegation of abuse was unfounded. LVN E said she was not told by CNA B that Resident #2 had voiced pain to her right side when being transferred to the shower chair. LVN E said if CNA B had reported to her that Resident #2 had pain, she would have gone to see her and done a pain assessment. She said CNA B was supposed to stop what she was doing and reported to the charge nurse that Resident #2 had voiced pain to her right hip. LVN E said CNAs are regularly in-serviced on topic of reporting change in conditions to the charge nurse. LVN E said she had also notified Resident #2's RP. LVN E said there were no negative outcomes to Resident #2 not having her right side pain assessed at 7:30 am because she had been assessed at 12:15 pm and nothing abnormal was found. In a telephone interview on 11/18/25 at 11:55 am, NP F said on 10/01/25 while he was walking down the hall in the females secured unit, he was called by Resident #2 and told him she had pain to her right side and chest wall. He said Resident #2 had alleged a staff member had struck her and was in pain.

NP F said during his assessment, Resident #2 did not notice any swelling or any discolorations on her right side but did have tenderness. He said he ordered a chest x-ray, which the results were negative. He said Resident #2 was a very sensitive patient and suffered from chronic advancing dementia. He said Resident #2 changed her story several times and first had said a staff member had hit her and then said her pain started when she was being repositioned. NP F said Resident #2's lab results showed she had a urinary tract infection in which he ordered antibiotics. NP F said Resident #2 suffered from thrombocytopenia (a medical condition characterized by a low platelet count in the blood, which symptoms include easy bruising) and she had been hit she would have bruised easily. In an interview on 11/18/25 at 2:19 pm, the DON said

on 10/01/25, Resident #2 had voiced to NP F that someone in the facility had hit her on her right side by her rib cage. She said NP F immediately reported the allegation of abuse to the state and an investigation was initiated. The DON said after their investigation, the allegation of abuse had been unfounded. The DON said CNAs were supposed to stop what they are doing if a resident complained of pain and immediately notify their charge nurse. She said CNAs were regularly in-serviced on the topic of reporting changes. The DON said there were no negative outcomes to Resident #2 not having her pain reported to her charge nurse because her PA had come earlier in the morning and complaints of pain were reported to him, scheduled pain medication was administered to Resident #2 at 8:00 am, the head-to-toe assessment done by LVN E showed visible trauma. The DON said the facility did not have a policy related to reporting change

in conditions.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Grande City Nursing and Rehabilitation Center

2530 Central Palm Dr Rio Grande City, TX 78582

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

said there was no negative outcome to Resident #1 not having his Haldol injection solution 5 mg/ml (Haloperidol lactate) signed off on his electronic medical record because ADON-LVN had made a progress note that indicated the medication was administered that was acceptable. Record review of the facility's Medication Administration policy dated 10/24/22 reflected: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standard of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines:17. Sign MAR after administered.

Event ID:

Facility ID:

If continuation sheet