Laredo West Nursing And Rehabilitation Center
Laredo West Nursing and Rehabilitation Center in Laredo, TX — inspection on August 14, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
4:14 pm, LVN J stated if a resident was sick or something happened, she checked vital signs, called the doctor or nurse practitioner and contacted the family. LVN J stated the information on who was contacted was documented in a progress note. LVN J stated she tried 2 or 3 times, left a voicemail, if possible, but only documented once that she tried however many times.
She stated if it was the end of her shift, and she was not able to contact family, she passed it on to the oncoming nurse to keep trying to contact them because the family needed to know how the resident was doing.In an interview on 08/14/25 at 4:37 pm, RN K stated if she could not get a hold of the family or RP when there was a change in resident condition, she made several attempts and documented in a progress note or risk management note how many times she tried. RN K stated it was important for the RP to be contacted so they knew what was going on with the resident and so they could okay any changes that needed to be made.A telephone interview was attempted with RN A on 08/14/25, however there was no answer, and the voicemail message stated he was out of the country. A message was left with a phone number for him to return the call, but he did not return the call.In an interview on 08/14/25 at 5:20 pm, Resident #1 was lying in bed with the television on. Resident #1 stated he was okay, and the staff was nice to him. Resident #1 did not recall the incident with the Lorazepam on 04/27/25. Resident #1 stated his guardian came to see him, sometimes.
Record review of the facility's Notification of Changes policy dated 10/24/22 reflected in part: Policy:The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Definitions:Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) or commence a new form of treatment to deal with a problem (for example. the use of any medical procedure, or therapy that has not been used on that resident before).
Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.
Circumstances requiring notification include:1.
Accidentsa.
Resulting in injury.b.
Potential to require physician intervention.2.
Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include:a.
Life-threatening conditions, orb.
Clinical complications.3.
Circumstances that require a need to alter treatment.This may include:a.
New treatment.b.
Discontinuation of current treatment due to:i.
Adverse consequences.
Additional considerations:2.
Residents incapable of making decisions:a.
The representative would make any decisions that have to be made.b.
The resident should still be told what is happening to him or her.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Laredo West Nursing and Rehabilitation Center
1200 Lane Laredo, TX 78043
SUMMARY STATEMENT OF DEFICIENCIES
psychiatric services due to his sudden change in behavior.
The provider investigation report stated, Negative outcomes/ Injury of Patient: No negative outcomes were noted for either resident.
There were no injuries identified related to this incident.
Residents did not voice nor indicate emotional distress as a result of the incident.
Both residents continue their normal daily routines.
Conclusion:
During an interview with the facility administrator, Resident #6 was able to verbalize what occurred during the incident. Resident #6 explains that he was planning to attend an activity in Wing A which started at 2 p.m. Resident #6 stated that Resident #7 was attempting to tell him something in the hallway, but he could not understand what Resident #7 was saying and asked him to repeat himself. Resident #6 states that he did raise his voice when he was unable to understand what Resident #7 was saying. Resident #6 explains that when he raises his voice, it does not mean he is upset. It was then that Resident #6 alleges that Resident #7 started to attempt to hit him. Resident #6 states he told Resident #7 to be careful because he was going to fall and to stop or otherwise, he was going to react. In an interview with the facility administrator, Resident #7 denied the incident occurred. Resident #7 denied hitting anyone.
The resident seemed upset about being asked questions related to the incident.
When asked what he would do if a situation arose and he became upset with another resident, he said he would leave.
The police officer responding to the incident interviewed only Resident #6. Resident #6 did not want to press charges. Resident #6 further explained to the officer that he was concerned that Resident #7 would fall because he was standing up from his wheelchair without assistance. In a subsequent interview, Resident #6 does not state any concerns or emotional distress from the incident.
Prior to the incident, Resident #6 was already receiving routine psychological services from Behavioral Healt
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Laredo West Nursing and Rehabilitation Center
1200 Lane Laredo, TX 78043
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
Coordinator.
The performance review documented on 05/28/25 stated no medication errors occurred this period and was signed by the DON.
There was also documentation of a one on one in-service was done by the ADON on 04/28/25 at 2:30pm.
The subject was Medication Administration Policy and Procedure, and the Return Demonstration Outcomes were: I have read Policy and Procedure for Medication Administration.
I will be getting a second license nurse to verify dosage administered with every Narcotic given for 4 weeks.
When in doubt, I will ask a co-worker, ADON, or DON for assistance in completing task. I will verify all information before documenting on PCC. I received a copy of the medication administration policy and procedure. It was signed by RN A and the ADON.
Record review of the facility's Medication Administration Incident Report dated 04/27/25 reflected the following:The incident was discovered by RN A (the off going nurse) and RN R (the oncoming nurse) on 04/27/25 at 10:24 pm.
The nurse was notified and gave a telephone order for Narcan to be administered immediately and neurologic checks and vital signs to be done every one hour for 24 hours on 04/27/25 at 10:55 pm.
The Employee's statement was handwritten and signed by RN A on 04/28/25 and stated, RN A gave scheduled medication- Lorazepam 0.5ml, but I accidentally gave 5ml.
Discovery of medication error was made during change of shift medication count.
The Management section was handwritten and signed by the DON on 04/28/25 and stated, RN A will have another nurse witness his medication administration (narcotics) for the next 30 days.
This form was also signed by the Admin on 04/28/25.
Record review of the facility's medication administration policy in-service dated 04/28/25 reflected that 25 of 26 RNs and LVNs attended the training.
Record review of the facility's Medication Administration Policy dated 10/24/22 reflected in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:3.
Identify resident by photo in the MAR (medication administration record).10.
Review MAR to identify medication to be administered.11.
Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.14.
Administer medication as ordered in accordance with manufacturer specifications.17.
Sign MAR after administered.
For those medications requiring vital signs, record the vital signs onto the MAR.18. If medication is a controlled substance, sign narcotic book.19.
Report and document any adverse side effects or refusals.20.
Correct any discrepancies and report to nurse manager.
Facility ID: