Inspection·June 20, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: 1.Record review of Resident #1's electronic facility face sheet dated 6/18/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke), Muscle weakness, Dementia (group of thinking and social symptoms that interferes with daily functioning), Alzheimers (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Heart Failure, Hypertension (high blood pressure), and Depression. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he scored a 04 on his BIMS which indicated he was severely cognitively impaired. Record review of Resident #1's care plan dated 5/14/24 revealed risk for falls related to wandering. Interventions steps did not include any information regarding a raised perimeter mattress. Observation on 6/18/24 at 2:20pm Resident #1 was lying down, asleep on a raised perimeter mattress. During an interview on 6/18/24 at 2:37pm, ADON A stated that Resident #1 has a raised perimeter mattress as a fall intervention. She stated ADON B was the person who was responsible to care plan the fall interventions. The charge nurse and herself help with interventions as well to see what suits well for the resident. She stated it was important for the interventions to be care planned so staff knows the fall interventions, and the resident won't have falls in the future. When asked ADON A stated, she was not sure of the negative outcome of interventions not being care planned. During an interview on 6/18/24 at 3:31pm, ADON B stated that Resident #1's fall interventions were a raise perimeter mattress, bed in low, and fall mat. She only does care planning for incidents with (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676119 Printed: 05/15/2026 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 676119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 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)