Laredo West Nursing: Family Not Notified of Drug Reaction - TX
That finding sits at the center of a complaint inspection conducted at the facility on August 14, 2025, by federal surveyors. The resident, identified in inspection records only as Resident #1, had a legal representative who, according to the facility's own policy, was supposed to be contacted any time there was an adverse drug reaction or a need to alter his treatment. Neither happened.
The nurse at the center of the lapse was identified as RN K in inspection records. She told surveyors she understood why contacting the responsible party mattered. The representative, she said, needed to know what was happening with the resident and needed to sign off on any changes to his care. She knew the rule. She described it accurately. The contact was never made.
Surveyors also tried to reach RN A, another nurse connected to the case. When they called on August 14, the phone rang through to voicemail. The recorded message said he was out of the country. Inspectors left a callback number. He did not call back.
The facility's own Notification of Changes policy, dated October 2022, is specific about when family members and legal representatives must be reached. Adverse drug reactions are on the list. So is any need to stop a treatment because of harmful consequences, or to start a new one. The policy also notes that residents who cannot make their own decisions are still entitled to be told what is happening to them, even as their representative steps in to make the formal choices.
Inspectors interviewed Resident #1 the evening of August 14, at 5:20 p.m. He was lying in bed with the television on. He said he was okay. He said the staff was nice to him. He did not remember the Lorazepam incident from April. He mentioned that his guardian came to visit him sometimes.
That detail landed quietly in the inspection record. His guardian came sometimes. Whether the guardian knew about the April drug reaction, or learned about it only later, or still does not know, the inspection report does not say.
What it does say is that RN K tried to reach the guardian, documented her attempts in a progress note or risk management note, and still the contact was not completed. The inspection record does not explain what happened between those attempts and the point at which surveyors determined the notification requirement had not been met.
The violation was classified as causing minimal harm or potential for actual harm, and described as affecting few residents. That language is standard CMS severity coding. It does not mean the gap was minor in practice. A resident on a sedative-class medication had a reaction significant enough that his treatment needed to change. The person legally responsible for his care decisions did not hear about it.
Lorazepam belongs to a class of drugs called benzodiazepines, used to treat anxiety and seizures but associated with falls, sedation, and respiratory depression, particularly in elderly patients. Nursing homes are required to use such medications carefully and to loop in family or legal representatives when something goes wrong.
The inspection report does not describe what the adverse reaction looked like, how Resident #1's treatment was altered afterward, or whether his condition changed in the weeks between the April incident and the August inspection. It does not name his guardian or describe any attempt by the facility to notify that person after the lapse was identified.
Resident #1, lying in bed on the evening the inspectors visited, said the staff was nice to him. He did not remember April.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laredo West Nursing and Rehabilitation Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Laredo West Nursing and Rehabilitation Center in Laredo, TX was cited for violations during a health inspection on August 14, 2025.
That finding sits at the center of a complaint inspection conducted at the facility on August 14, 2025, by federal surveyors.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.