Weslaco Nursing And Rehabilitation Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

incident report about the skin tear, but she did not conduct a full head-to-toe assessment on the resident.

The MDSN stated she thought the charge nurse was going to conduct a full head-to-toe assessment on the resident. The MDSN stated it was important to do a full head-to-toe assessment on a resident after a new skin tear or wound was found to ensure there was not any other damage to the resident. In an interview with LVN B at 4:28 PM on 11/18/25, LVN B stated she was the charge nurse for Resident #2 on 10/22/25.

LVN B stated she remembered the MDSN told her about the skin tear on Resident #2 on 10/22/25. LVN B stated she thought the MDSN was just informing her about the skin tear, and not that it had just been found.

LVN B stated she thought the skin tear had been found on a previous shift. LVN B stated she did not perform a full head-to-toe skin assessment on Resident #2 on 10/22/25. LVN B stated it was important to do a full head-to-toe assessment on a resident after a new skin tear was found to ensure there were no other new wounds. In an interview with the DON at 5:28 PM on 11/18/25, the DON stated Resident #2 should have had a full head-to-toe skin assessment on 10/22/25 immediately after the new skin tear was found. The DON stated Resident #2 did receive treatment for her skin tear and it looked a lot better now than it did before. The DON stated it was important to conduct the assessment to see if new orders were needed and to examine the extent of the damage. Record review of the facility's policy Skin Assessment, dated 4/24/25, reflected the following policies: .7. Documentation of skin assessment:a. Include date and time of the assessment, your name, and position title.b. Documents observations.c. Document type of wound.d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).e.

Documents if resident refused assessment and why.f. Document other information as indicated or appropriate.

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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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Weslaco Nursing and Rehabilitation Center

422 E 18th St Weslaco, TX 78596

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 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold administration of Resident #1's nifedipine (blood pressure medication) when Resident #2's blood pressure was outside parameters on 10/01/25. This failure could place residents at risk for complications due to discomfort or their health being jeopardized.The findings include: Record review of Resident #1's face sheet, dated 10/13/25, reflected a [AGE] year-old female with an initial admission date of 07/10/23 and current admission date of 03/21/24. Resident #1's pertinent diagnosis included Essential Hypertension (high blood pressure with no known specific cause). Record review of Resident #1's Quarterly MDS assessment, dated 09/01/25, reflected a BIMS score of 12 which indicated moderate impairment. Record

review of Resident #1's comprehensive care plan, dated 11/13/25, reflected the problem [Resident #1] has hypertension initiated on 07/12/23 and revised on 02/25/24. An intervention listed for the problem included Give anti hypertensive medications as ordered. initiated on 07/12/23 and revised on 02/25/24. Record

review of Resident #1's order summary reflected an active order for Nifedipine Extended Release 90 mg Give 1 tablet by mouth one time a day for hypertension hold if SBP <100 or HR <60, notify nurse initiated

on 03/21/24. Record review of Resident #1's MAR from October 2025 reflected on 10/01/25 Resident #1's blood pressure was measured at 155/66 while her HR was measured at 56. Further review reflected nifedipine ER 90 mg was administered on 10/01/25 by LVN A after the heart rate was measured to be outside of ordered parameters. In an interview with LVN A at 11:48 AM on 11/13/25, LVN A stated before administering blood pressure medications she always measured the resident's blood pressure and heart rate. LVN A stated if the resident's heart rate or blood pressure was outside of the ordered parameters on

the medication she would hold the medication and inform the charge nurse. LVN A stated it was important to follow the doctor's orders because administering medication outside of the parameters may harm the resident. LVN A stated she did not remember specifically if she notified the nurse and got the okay to administer the nifedipine to Resident #1 on 10/01/25. In an interview with the DON at 12:06 PM on 11/13/25, the DON stated a resident's blood pressure and heart rate were measured before administering blood pressure medication. The DON stated if a resident's heart rate or blood pressure was outside parameters for a medication the nurse should hold the medication and notify the nurse or physician depending on the order. The DON stated the nifedipine should not have been administered to Resident #1

on 10/01/25 unless LVN A had been given the go ahead by the nurse or physician. The DON stated there was no documentation that LVN A had talked to the nurse or physician about nifedipine on 10/01/25. The DON stated it was important to follow doctor's orders on blood pressure medications to protect residents from negative effects like weakness, lethargy, and dizziness. Record review of the facility's policy Medication Administration, dated 10/24/22, reflected the following policies: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.14. Administer medication as ordered in accordance with manufacturer specifications.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet