Inspection·September 10, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm including how the system works and ensuring resident access to the call light. All residents will be educated on how to call for help by using the resident call system.5. Staff will ensure the call light is within reach of resident and secured as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 2 of 10 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 09/10/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings include:Record review of Resident # 12's electronic face sheet, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included Vascular Dementia with mild anxiety, Hypertension (high blood pressure), Hyperlipidemia (high level of fats in the blood), and Acute Kidney Failure. Resident #12's Code Status was Do Not Resuscitate (DNR). Record review of Resident #12's Minimum Data Set (MDS) assessment, dated [DATE], reflected she scored a 05 on her BIMS, which indicated severe cognitive impairment.Record review of Resident #12's, undated, Care Plan report revealed Resident is a DNR, Resident has Medical Power of Attorney and Statutory Durable Power of Attorney, date initiated: [DATE]Record review of Resident #12's physician order, dated [DATE], revealed DNR. Record review of Resident #12's OOH-DNR form, dated [DATE], revealed the form was signed in section B Declaration by legal guardian, agent or proxy on behalf of the adult person who is Incompetent or otherwise incapable of communication: I am the: agent in a Medical Power of Attorney. The OOH-DNR revealed under section Physician's Statement: I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professional acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation the physician's signature, License number, and there was no date. Record review of Resident #12's OOH-DNR form, updated on [DATE], revealed a date of [DATE] was added next to the physician's signature under section Physician's Statement. Interview on [DATE] at 5:45 PM, Social Services said she started her training in December and was not familiar with Resident # 12's OOH-DNR form. She said it was her understanding there was no effective date for DNR forms. She said upon admission she reviewed code status with newly admitted residents and their families. If they chose to have a DNR status she would obtain the necessary signatures and then notify the physician of pending forms to be signed. She said she notified nursing when signatures were obtained from the Resident, legal representative, and witnesses. The first form was uploaded on to PCC and then uploaded the second time with the physician's signature. Social Services said she performed care plan meetings every 3 months and updated code status.Interview on [DATE] at 3:35 PM, the DON said Admissions and Social Services did the DNRs, and they got 2 people to sign and then send off the form to the physician for signature. Social Services notified nursing of DNR signed by the initial parties, not MD, and put into PCC system.Interview on [DATE] at 3:35 PM, the Administrator said when families requested DNR status they uploaded the family signed DNR. The DNR was re-uploaded with the physician signature. She said they had recurring audits that were done monthly and quarterly.Record review of the facility's policy titled Resident's Rights Regarding Treatment and Advance Directives, dated [DATE], revealed the following: Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 3 of 10 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 09/10/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm care.Record review of the Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order-Texas Department Of State Health Services revised [DATE], revealed the following: The original or a copy of a fully and properly completed OOH-DNR Order of the presence of an OOH-DNR device on a person is sufficient evidence of the professionals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 4 of 10 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 09/10/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 . Findings included: 1. Record review of Resident #85's face sheet reflected a [AGE] year-old male who was admitted on [DATE] and discharged on 08/22/25. Resident #85 had diagnoses which included, chronic kidney disease stage 4 (a serious condition where the kidneys are functioning at a significantly reduced level), end stage renal failure (a condition where the kidneys have permanently lost most of their ability to function), Type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), atherosclerotic heart disease caused by plaque buildup in arterial walls), heart failure (occurs when the heart muscle weakens and cannot pump blood effectively enough to meet the body's needs), peripheral vascular disease (a condition that affects the blood vessels outside of the heart, typically in the legs) and anemia (a condition characterized by low levels of red blood cells). Record review of Resident #85's admission MDS assessment, dated 07/16/25, reflected a BIMS score of 10, which indicated the resident was moderately cognitive impaired. Record review of Resident #85's Transfer/Discharge Notice, dated 08/22/25, reflected the reason for transfer was for an emergency transfer to an Acute Care setting. Record review of Resident #85's progress notes, dated 08/22/25, reflected resident had a change in condition in which the doctor gave the order to have resident sent out to the hospital. In an Email communication on 09/09/25 at 3:04 PM, the ombudsman revealed since she started visiting the facility in April of 2025, she had not received any discharge notices from the facility. In an interview on 09/09/25 at 11:55 AM, the Social Worker stated she did not notify the ombudsman of the discharge. The Social Worker stated she was not aware she had to notify the ombudsman when a resident was discharged . She stated she was under the impression she only had to notify the ombudsman if there was something wrong with a resident such as an open APS case. In an interview on 09/09/25 at 4:30 PM, the Administrator stated not reporting the discharge for Resident #85 to the ombudsman was miscommunication. The Administrator stated the Social Worker communicated frequently with the ombudsman regarding APS cases or discharge follow ups, however the actual sending notice for discharges or transfers was not done. The administrator stated notices were to be sent out at least monthly. The Administrator stated the Social Worker, through the admissions team, was sending out the notices when in fact they were not being sent out. The Administrator stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 5 of 10 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 09/10/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharge and transfer logs were being done and kept on file. (Discharge and transfer logs were provided during the interview.) The Administrator stated going forward, the Social Worker was aware to send notification to the ombudsman for all discharges and transfers. 2. Record review of Resident #87's admission Record, dated 09/10/25, reflected an [AGE] year-old male with an admission date of 08/05/25. Resident #87's had diagnoses which included Encounter for Surgical Aftercare Following Surgery on the Skin & Subcutaneous Tissue (layer of loose tissue beneath skin) (Primary Diagnosis), Acquired Absence of Right Leg Above Knee, Type 2 Diabetes Mellitus (chronic condition where body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels) with Hyperglycemia (condition where there is an abnormally high level of glucose [sugar] in the blood), and Permanent Atrial Fibrillation (hearth rhythm disorder where upper chambers of the heart beat irregularly & rapidly). Record review of Resident #87's, quarterly, dated 08/12/25, revealed a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #87's, quarterly, dated 08/12/25, revealed a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #87's Transfer/Discharge summary, dated [DATE], reflected Resident #87 had a discharge date of 08/28/25 to home. Record review of an email communication dated 09/09/25 at 3:04 PM, the Ombudsman revealed since she started visiting the facility in April of 2025, she had not received any discharge notices from the facility. In an interview on 09/09/25 at 4:12 PM, the Social Worker stated she was not aware she needed to notify the Ombudsman when a resident was discharged from the facility. She said she worked under the supervision of the social service corporate consultant and was given duties to do but notifying the ombudsman was not a duty she had been told to do. In an interview on 09/09/25 at 5:27 PM, the Administrator stated the Admissions team was sending a report log of all the discharged residents for the month to ombudsman prior to the hiring of the current Social worker. She said the current Social Worker should have been doing it but was not sure if she had been doing it since she was fairly new and she didn't know if she was sending it out or not. She said she would make sure she began notifying the ombudsman Record review of the facility's policy Transfer and Discharge (including AMA) dated 3/5/25, reflected: “…10. Emergency Transfers to Acute Care h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 6 of 10 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 09/10/2025 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings include: Record review of Resident #62's admission record, dated 06/04/25, revealed an [AGE] year-old female. Resident #62 had diagnoses which included Colle's' fracture of right radius (type of wrist fracture that occurs when the distal radius the lower end of the radius bone in the forearm] breaks and bends backward), other fractures of lower end of right radius, unspecified protein-calorie malnutrition, major depressive disorder, and dysphagia (difficulty swallowing food or liquids). Record review of Resident #62's care plan, dated 4/7/23, revealed: The resident has a potential UTI: Administer antibiotic as per physician orders Record review of Resident #62's quarterly MDS assessment, dated 7/31/25, revealed Resident #62's BIMS score was a 9, which indicated moderate cognitively impaired cognition. Section O - Special Treatments, Procedures, and Programs revealed Resident #62 was receiving IV medications. Record review of Resident #62's Order Summary Report, dated 9/8/2025, revealed Resident #62 had an order for Ertapenem Sodium Injection Solution Reconstituted (Ertapenem Sodium) Use 1 application intravenously one time a day for Extended-Spectrum Beta-Lactamases (ESBL) for 10 Days Administer 500milligrams. Start date 9/3/2025. During an observation on 9/8/25 at 10:05 a.m. revealed Resident #62 was in his room lying in bed. He had a peripheral intravenous lock covered with transparent dressing with no date and no initials on her left hand. There were no signs or symptoms of infection or infiltration noted at the IV site. During an interview on 09/8/25 at 10:40 a.m., LVN E stated he was the nurse for Resident #62. He stated the nurse who initiated the IV was responsible for labeling the dressing with the date of placement and initials. LVN E stated it was important to label the IV site to know when the IV was placed or the last time it was changed. He stated if the IV was not changed within the ordered time, then it could cause an infection. He stated the last time he checked the resident's IV site was this morning, at the beginning of his shift. LVN E stated the IV site should be checked at every shift. The site was checked for any signs of infection, the date and signature on the dressing, and check that the saline lock cap was in place. He stated he could not recall when the last training was that he received on IV administration. LVN N stated the resident had a peripheral IV lock on her left hand covered with a transparent dressing that was not labeled or dated. In an interview on 09/10/25 at 3:15 a.m., the DON stated she did not know why the dressing label had not been dated and initialed. The DON stated the nurse who inserted the IV should have dated and initialed the dressing that was over the IV site. The DON searched through orders on their computer system to verify who placed the IV, however, she was not able to find the progress note which indicated placement. The DON stated labeling the insertion site dressing was taught in nursing school and every nurse should have known to label it. She stated the negative outcome of not labeling the dressing was it could go over the recommended standard time of every 72 hours and could cause infection. She stated IV administration class was done annually and as needed. During an interview on 9/10/25 at 4:00 p.m., the DON stated she was not able to find a policy on IV's. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 7 of 10 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 09/10/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based 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. The facility failed to ensure expired medications were not stored on Med-Cart D.These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication and not receiving prescribed medications as ordered, placing the facility at risk of drug diversion. The findings included:1. Observation on 9/9/2025 at 9:25 AM of the medication cart A with LVN A, 2 pills were found in the drawer of the medication cart. LVN A retrieved the unidentified pills from the drawer and handed them to the RN/ADON D.Observation on 9/9/2025 at 9:30 AM of the medication cart B with LVN A, 1 pill was found in the drawer of the medication cart. LVN A retrieved the unidentified pill from the drawer and handed it to the RN/ADON D.Observation on 9/9/2025 at 9:34 AM of the medication cart C with RN B, 3 pills were found in the drawer of the medication cart. RN B retrieved the unidentified pills from the drawer and discarded them in the waste basket. 2. Observation on 9/9/2025 at 9:50 PM of the medication cart D with LVN C, revealed an approximately 1/4 full vial of Insulin Aspart (a medication used to control high blood sugar in adults with diabetes) 25% which had expired on 9/8/2025. The label on the vial had an open date of 8/11/25.Interview on 9/9/2025 at 9:50 AM with LVN A, stated that expired insulin loses its strength and if given, blood sugar may not lower and not do its job. She said that all nurses are responsible for assuring medications are used within their time frame. LVN A said that the expired insulin was not administered to Resident # 3 because her blood sugar level was not within the parameters to receive the insulin.Interview on 9/9/2025 at 9:54 AM with RN/ADON D, stated that she received unidentified pills from LVN A and unidentified pills were discarded by RN/ADON D. RN/ADON stated that in-services were done with nurses on pharmacy services and medication storage. She said she in-serviced LVN C on expired insulin and the expired insulin was replaced and dated. RN/ADON D said that if insulin was administered it would not be effective and blood sugar may increase.Interview on 9/9/2025 at 10:05 AM with the DON, stated that in-services were started on medication storage, maintaining clean carts, and expired medication. She said management and nurses were and will continue checking carts daily to make sure insulins are up to date. The DON said she did not know if the insulin's shelf life (the length of time the product remains suitable for its intended use, maintaining its safety, quality and effectiveness) is determined within the period of 28 days. She said Resident #3's blood sugar levels were consistently being monitored.Interview on 9/10/2025 at 3:35 PM with the Administrator, stated that she communicates daily with DON regarding clinical matters. She said that she provides nursing staff reminders and request feedback, and re-education. The DON said that she takes care of what happens during the day. She said that the pharmacy consultant checks the medication carts monthly and removes expired medication and nurses keep up with the medication carts.Record review of the facility's Medication Administration policy, implemented on 10/01/2019 revealed the purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications.Record review of Novo (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 8 of 10 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 09/10/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Nordisk Pharma, Inc. Patient Information Leaflet (PIL) for Insulin Aspart 10 mL multiple dose vial, revised on 2/2023 revealed that storage conditions for an In-use (opened) vial are 28 days (refrigerated/room temperature). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 9 of 10 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 09/10/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. The findings include: During an observation on 09/8/25 at 10:00 a.m. revealed Room X's sharp container was overfilled, and needles were sticking out of the container. During an interview on 9/8/25 at 10:32 a.m., LVN E stated nurses were responsible for changing the sharp containers when the sharp container was two thirds full. LVN E stated staff could poke themselves when trying to dispose of a needle. LVN E stated the residents in room X were not ambulatory. During an interview on 9/10/25 at 3:10 p.m., the DON stated nurses were responsible for changing the sharp containers. The DON stated nurses could poke themselves with the needles sticking out the sharp containers. The DON stated she would start making rounds to make sure sharp containers were not full and would assign a person to ensure sharp containers were not overfilled. During an interview on 9/10/25 at 3:35 p.m., the Administrator stated she did not have a policy on sharp containers. Record Review of Infection Prevention and Control Program with an implemented date 5/13/23 revealed This facility has established and maintains an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of a communicable diseases and infections as per accepted national standards and guidelines. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676119 If continuation sheet Page 10 of 10