Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laredo Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Down syndrome, myasthenia gravis, dementia, and severe functional dependence was identified as PASARR positive and approved for a customized wheelchair at the IDT meeting, but the NFSS specialized service was not initiated within the required timeframe. Interviews showed the wheelchair was not ordered after the IDT decision, the MDS nurse was responsible for PASARR referrals, and no backup person was assigned to ensure PASARR II services were completed.
A resident at risk for pressure injuries developed a new sacral skin issue that was reported to an LVN, who noted redness and dark discoloration but did not complete a full assessment or documentation of wound characteristics such as measurements, shape, and surrounding tissue, and did not obtain a photograph as outlined in facility policy. The next day, the area was documented as a new in-house–acquired Stage IV pressure ulcer with detailed measurements and surrounding erythema, and the MD and responsible party were notified. Interviews with the DON and wound care nurse confirmed that nursing staff are expected to assess, stage, and measure all new skin concerns and evaluate associated pain, highlighting that these required steps were not followed when the skin change was first identified.
A resident with multiple comorbidities and a stage 3 sacral pressure ulcer received wound care during which the WCN and a CNA failed to follow required hand hygiene practices. The WCN washed hands for less than the required 20 seconds before and after the procedure and did not perform hand hygiene between glove changes. The CNA also did not perform hand hygiene between glove changes while assisting with the wound care. Facility policy and CDC guidelines, as acknowledged by the ICP and DON, required hand hygiene for at least 20 seconds and after each glove removal, but these standards were not followed during the observed wound care.
Incomplete and inaccurate resident record documentation: RN C documented blood sugar values of 2 for two residents when fingersticks and insulin were refused, a resident’s post-fall neuro checks contained repeated vital signs instead of interval-specific readings, hydralazine holds were documented without the resident’s BP on the MAR, and an admission/readmission assessment contained inaccurate VS. The record review involved residents with diabetes, HTN, dementia, CHF, respiratory failure, atrial fibrillation, ESRD, and post-stroke conditions.
A resident with COPD, acute respiratory failure with hypoxia, and interstitial pulmonary disease was ordered continuous oxygen at 2 L/min via NC, but observation found the portable tank set at 2.5 L/min. The resident was sitting in a wheelchair without respiratory distress, and the LVN said she was unsure who changed the setting. The ADON and DON stated oxygen settings were checked during rounds and should match the physician order.
Medication Refrigerator Stored at Improper Temperature: Surveyors found the medication room refrigerator contained medications for several residents while two thermometers inside read 24 degrees Fahrenheit and 28 degrees Fahrenheit. ADON J had signed the temperature log as 37 degrees Fahrenheit earlier that day, and the DON later observed the low readings and adjusted the setting. The PC and DON stated medication refrigerators should be kept between 36 and 46 degrees Fahrenheit, and the DON stated the facility had no policy covering proper refrigerator storage temperature.
Failure to Follow Contact Precautions: A resident with bacteremia, ESBL resistance, and E. coli in blood and urine was on Contact Precautions with a gown required for room entry. A SW entered the room without the required PPE despite the posted sign, and later stated she realized afterward that the resident was under Contact Precautions. The IP and DON confirmed the precautions and the reason for them.
A CNA provided incontinent and bed mobility care alone to a resident with severe cognitive impairment and physical limitations, despite the care plan requiring two-person assistance. The resident fell from bed during the process, though no major injuries were sustained. Staff interviews confirmed that the care plan and facility policy mandated two-person assistance for this resident, which was not followed during the incident.
The facility failed to maintain effective infection control during incontinent care for three residents, as CNAs reused wipes and did not change gloves between dirty and clean tasks. Interviews revealed inconsistent training and supply access issues, contributing to improper practices. The DON acknowledged the risk of infections due to these deficiencies.
The facility failed to conduct timely care plan meetings for three residents, leading to a lack of necessary care and services. A resident with moderately impaired cognition had not had a care plan meeting since July, despite frequent hospital visits. Another resident with severely impaired cognitive skills had not had a meeting since August 2023, and a third resident had not had a meeting since July 2021. The oversight was confirmed by the MDS Nurse and Social Worker, who were unaware of the lapses.
Two residents in a facility did not receive appropriate respiratory care. One resident's oxygen was not continuously provided due to family and staff oversight, while another resident did not receive prescribed respiratory exercises, as the necessary equipment was missing. The facility's staff failed to update and adhere to physician orders, leading to a deficiency in care.
A facility experienced an 8% medication error rate when an RN failed to administer the correct dosages of sertraline and isosorbide dinitrate to a resident with vascular dementia and heart failure. The resident's care plan required precise medication administration to manage their conditions. The errors were identified during a medication pass observation.
A facility failed to accurately document the administration of vancomycin for a resident with Clostridium Difficile, leaving a blank entry in the MAR for one dose. Interviews with the DON and ADON indicated that the medication might not have been administered or documented, highlighting the importance of accurate record-keeping to prevent potential health risks.
Failure to Initiate PASARR II Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from the PASARR Level II determination for one resident and failed to initiate an NFSS within 20 business days after the services were agreed to in the IDT meeting. The resident was an older female with diagnoses including Down syndrome, muscle wasting, and myasthenia gravis. Her care plan identified her as PASARR positive with an intellectual disability or developmental disorder, and additional care plan information noted self-care deficits related to Down syndrome, myasthenia gravis, dementia, and muscle wasting and atrophy. Record review showed the resident’s MDS quarterly assessment documented severely impaired cognitive skills for daily decision making, dependence on staff for all ADLs, and that walking 10 feet was not attempted because of medical condition or safety concerns. The resident used a manual wheelchair and was dependent on staff for all effort to maneuver it. Progress notes also stated she required assistance with wheelchair mobility for safety and that skilled therapy remained necessary for cueing, strengthening, and improving propulsion techniques. The IDT meeting approved a customized wheelchair, but interview statements indicated the wheelchair was not ordered after the meeting and was not discovered as unaddressed until later. The MDS nurse stated she was responsible for ensuring PASARR forms and referrals were completed and said there was no backup person assigned to ensure PASARR II specialized services were completed and implemented. The DON stated the MDS nurse was responsible for referrals to the LIDDA and described the process for identifying residents with ID, MD, or related conditions for referral to the appropriate state-designated authority.
Failure to Properly Assess and Document New Sacral Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care and prevention in accordance with professional standards, the resident’s care plan, and the resident’s choices for one resident at risk for pressure injuries. Resident #1, an older woman admitted with a displaced intertrochanteric fracture of the right femur and orthopedic aftercare needs, was identified on a quarterly MDS as being at risk for developing pressure ulcers. On 02/01/26, an SBAR communication form documented that during routine rounds, a nurse aide notified LVN B of a skin issue on the resident’s sacrum, and LVN B noted redness and dark discoloration in that area. The facility’s skin and wound policy required that exceptions to normal skin integrity be documented in the EHR with details including type of skin injury, location, shape, ulcer edges, wound bed, measurements, and condition of surrounding tissues, and that a licensed nurse measure wounds in order of length, width, and depth. However, the report indicates that LVN B did not accurately assess and document the newly identified skin impairment on 02/01/26, including failing to record characteristics such as measurements, shape, or the condition of surrounding tissue, and the area was not photographed. The DON later stated that nursing staff are expected to assess all new skin concerns, including size and stage, and that based on the description of the discoloration, LVN B should have measured the area and evaluated whether it was blanchable. On 02/02/26, documentation showed that the sacral wound had progressed and was identified as a Stage IV pressure ulcer, described as a new in-house–acquired wound on the sacrum with specific measurements (length 7.38 cm, width 3.9 cm, depth 0 cm, area 19.11 cm²), no undermining or tunneling, no odor after cleansing, surrounding tissue with erythema, no edema, normal periwound temperature, and an intact dressing with no saturation. The wound was documented as painful “No,” and the MD and responsible party were notified. Additional interviews and observations related to another resident (Resident #2) showed routine repositioning and no observed skin concerns, and the WCN stated that all skin concerns should be assessed, measured, and evaluated for pain, underscoring that the required assessment and documentation steps were not followed for Resident #1’s initial sacral skin issue on 02/01/26.
Noncompliant Hand Hygiene During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene practices during wound care for one resident. The resident was an elderly female with Parkinson’s disease, chronic kidney disease, seizures, hypertension, severe cognitive impairment (BIMS score of 6), and was dependent for all ADLs. She had a care plan for a stage 3 pressure ulcer to the sacrum with interventions that included enhanced barrier precautions and measures to promote skin healing. Physician orders directed that the sacral wound be cleansed with wound cleanser or normal saline, patted dry, and treated with a collagen dressing secured with a dry or bordered dressing on a scheduled basis. During observed wound care, the Wound Care Nurse (WCN) performed hand hygiene for approximately 10 seconds before starting the procedure and approximately 17 seconds after completion, both times below the facility’s and CDC’s stated minimum of at least 20 seconds. The WCN did not perform hand hygiene between glove changes during the wound care procedure. CNA A, who assisted with the wound care, also did not perform hand hygiene between glove changes. In interviews, the WCN, CNA A, the Infection Control Preventionist (ICP), and the DON all stated that proper hand hygiene requires at least 20 seconds and that hand hygiene should be performed after each glove removal, and the facility’s hand hygiene policy and CDC guidelines similarly required hand hygiene between glove changes and after glove removal. These observations and statements demonstrated that staff actions during the resident’s wound care did not comply with the facility’s hand hygiene policy and established guidelines.
Incomplete and inaccurate resident record documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 4 residents reviewed. For Resident #1, RN C documented a blood sugar value of 2 on the MAR on multiple occasions even though the resident refused finger sticks and insulin, and other nurses in the record documented refusals by leaving the blood sugar field blank and marking refusal. Resident #1 had diagnoses including type 2 diabetes, hypertension, prior intracerebral and subarachnoid hemorrhages, and dementia, and her BIMS score was 0. For Resident #2, who had diagnoses including CHF, chronic respiratory failure, atrial fibrillation, pacemaker status, hypertension, and dementia, the record showed a fall on [DATE] followed by neuro checks. RN C and other nurses documented neuro checks, but the vital signs entered on the neuro check form were not updated for each interval and instead repeated earlier values. The record review showed multiple neuro check entries by RN C, LVN B, LVN G, LVN H, LVN D, and LVN F with vital signs that remained the same as earlier documented values rather than being recorded for each check. For Resident #6, who had diagnoses including hypertension, type 2 diabetes, hemiplegia/hemiparesis after cerebral infarction, bradycardia, pacemaker status, ESRD, aphasia, dysphagia, and gastrostomy status, RN C documented that hydralazine was held because blood pressure was outside parameters on multiple occasions, but the MAR did not contain the resident’s blood pressure for those dates. The record also lacked corresponding eMAR medication administration notes for most of the non-administration events. For Resident #14, who had diagnoses including cerebral ischemia, type 2 diabetes, hypertension, persistent atrial fibrillation, heart failure, and traumatic subdural hemorrhage with diffuse traumatic brain injury, LVN G documented inaccurate vital signs on the admission/readmission assessment, and RN C documented a blood sugar of 2 with refusal code 10 on the MAR on multiple occasions even though the resident refused fingersticks and insulin.
Oxygen Flow Rate Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #87 by not maintaining the ordered oxygen flow rate. Resident #87 was an [AGE]-year-old female admitted on 2/19/2026 with diagnoses including COPD, acute respiratory failure with hypoxia, and interstitial pulmonary diseases. Her quarterly MDS dated 2/26/2026 showed a BIMS score of 4, indicating severe cognitive impairment, and her active order as of 3/03/2026 directed continuous oxygen at 2 liters per nasal cannula every shift. Her care plan identified oxygen therapy related to chronic lung disease and directed staff to provide oxygen as ordered by the physician. During observation on 3/03/2026 at 10:56 AM, the resident’s portable oxygen tank was set at 2.5 liters per minute via nasal cannula instead of the ordered 2 liters per minute. The resident was sitting in her wheelchair and had no signs of respiratory distress at the time. In interview, the LVN stated she was not sure who had placed the resident on the portable tank at 2.5 liters, and said she had checked the concentrator at the beginning of her shift and it was set at 2 liters. The ADON and DON stated that oxygen settings were checked during rounds and that staff were expected to verify the prescribed rate, while the facility policies required oxygen to be administered as ordered by the physician and to obtain the ordered flow rate.
Medication Refrigerator Stored at Improper Temperature
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles when surveyors reviewed medications stored in 1 of 1 medication refrigerators in the medication storage room. Record review of the March 2026 medication room refrigerator temperature log showed the temperature was signed off by ADON J on 03/04/26 as 37 degrees Fahrenheit, and the refrigerator instructions stated adjustments should be made to correct temperatures not between 36 and 46 degrees Fahrenheit. During an observation of the medication room refrigerator at 4:05 PM on 03/04/26, surveyors found two thermometers inside the refrigerator with readings of 24 degrees Fahrenheit and 28 degrees Fahrenheit while various medications for several residents were stored inside. The DON observed these readings and adjusted the refrigerator setting to increase the temperature. In interviews, ADON J stated she had checked the refrigerator temperature earlier that morning and had never seen it outside the appropriate range, while the PC stated medication refrigerators should not be below 36 degrees Fahrenheit and that medications could become less effective if stored below that range for several hours. The DON stated the medications could lose potency if left outside the correct temperature range for too long and also stated the facility did not have a policy covering the appropriate storage temperature for medications.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for one resident under Contact Precautions. Resident #118 was admitted with diagnoses including bacteremia, ESBL resistance, and unspecified E. coli as the cause of diseases classified elsewhere. The resident’s record showed Contact Isolation Precautions ordered for E. coli ESBL in blood and urine, with instructions to ensure the infection site was contained prior to leaving the room and to keep the resident in the room for all care/services if the source could not be contained. During an observation, the social worker entered Resident #118’s room without donning the required PPE, specifically a gown, despite a Contact Precautions sign at the entrance indicating that a gown was required when entering the room. In interview, the social worker stated she entered because the resident was under hospice services and the family wanted to speak to her, and she realized afterward that the resident was under Contact Precautions. The Infection Preventionist and the DON both confirmed the resident was on Contact Precautions due to positive blood and urine cultures and stated that staff received PPE and handwashing education, with the DON noting that PPE was placed outside the room as an additional cue.
Failure to Provide Required Two-Person Assistance During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide the required two-person assistance during incontinent and bed mobility care for a resident with severe cognitive impairment and significant physical limitations. The resident, who had diagnoses including Parkinson's disease with dyskinesia, osteoporosis, and arthritis, was fully dependent on staff for all activities of daily living (ADLs) and had a care plan specifying two-person assistance for bed mobility, bathing, and toileting. Despite being aware of the care plan requirements, the CNA proceeded to provide care alone, citing concerns about the resident's dignity and the urgency of cleaning due to excessive soiling. During the incident, the CNA attempted to log roll the resident on an air mattress, which caused the resident to slide and fall from the bed. The CNA immediately checked on the resident and called for help. The resident was assessed and sent to the emergency room, where no major injuries were found. The CNA acknowledged in both verbal and written statements that she was aware of the two-person assist requirement but chose to act alone due to the situation at hand. Interviews with other CNAs and nursing staff confirmed that the standard procedure was to review the care plan at the start of each shift and to always use two-person assistance for this resident. Staff emphasized that deviating from the care plan could compromise resident safety. The incident was witnessed by a licensed vocational nurse (LVN), who responded to the call for help and confirmed that the CNA was alone with the resident at the time of the fall. The facility's policy required necessary assistance to maintain resident safety at all times, which was not followed in this case.
Inadequate Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper infection control practices observed during incontinent care for three residents. Certified Nursing Assistants (CNAs) D, E, B, and A were observed using improper techniques, such as not changing gloves or washing hands when moving from dirty to clean areas. They reused single wipes multiple times, contaminating their gloves and subsequently touching clean supplies and resident belongings with soiled gloves. These practices were consistent across multiple observations and involved direct contact with fecal matter, increasing the risk of cross-contamination and infection. Interviews with the CNAs revealed a lack of consistent training and adherence to proper infection control procedures. CNA D mentioned conserving wipes due to occasional low supply, while CNA E acknowledged the risk of contamination but stated she was not trained in the observed improper methods. CNA B and CNA A also demonstrated a lack of adherence to proper glove-changing protocols, with CNA A having only recently started working at the facility and learning from other CNAs without formal training. The Director of Nursing (DON) confirmed that improper peri or incontinent care could lead to infections and cross-contamination, especially given the residents' vulnerabilities. The facility's infection control policy outlines the responsibilities of the infection preventionist and the importance of staff education in preventing infections. However, record reviews indicated a high number of urinary tract infections in the preceding months, and previous in-services had addressed similar issues of improper care. Despite the availability of supplies, as confirmed by housekeeping and the administrator, the CNAs reported challenges in accessing them, leading to practices that compromised infection control standards.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for three residents, as evidenced by the lack of timely care plan meetings and updates. Resident #87, a male with moderately impaired cognition, had not had a care plan meeting since July 2024, despite the requirement for quarterly meetings or meetings following a change in condition. The MDS Nurse and Social Worker confirmed the oversight, noting that the resident had frequent hospital visits and communication with the responsible party, but no formal care plan meeting had been conducted since July. Similarly, Resident #61, with severely impaired cognitive skills, had not had a care plan meeting since August 2023, until a recent meeting in January 2025 regarding a transfer for rehab. The MDS Nurse was unaware of the lapse in care plan meetings. Resident #26, with moderately impaired cognition, had not had a care plan meeting since July 2021, which was acknowledged by the Social Worker and MDS Nurse, who could not find records of any subsequent meetings. The facility's failure to conduct regular care plan meetings as required could place residents at risk of not receiving the necessary care.
Failure to Provide Continuous Respiratory Care
Penalty
Summary
The facility failed to provide continuous oxygen therapy to Resident #44, who was diagnosed with heart failure, respiratory failure, and other conditions requiring continuous oxygen. During an observation, it was noted that Resident #44's oxygen concentrator was turned off, and the portable oxygen tank in her room was empty. The resident's family had taken her for a stroll without ensuring her oxygen was connected, and upon returning, the oxygen was not reconnected. The Licensed Vocational Nurse (LVN) acknowledged the oversight and mentioned the need for educating both the Certified Nursing Assistants (CNAs) and the family about the importance of maintaining oxygen therapy. Resident #13, who had a history of pneumonia and other health issues, was supposed to receive daily respiratory therapy, including the use of an incentive spirometer (IS) and oxygen as needed. However, during an observation, it was found that there was no oxygen or IS in her room, and the resident reported not using these since June 2024. Despite the Medication Administration Record (MAR) indicating that the IS treatment was administered, the device was not found in the resident's room, and the LVNs could not account for its whereabouts. The Director of Nursing (DON) admitted that the orders for respiratory care had been active for a year without being updated, and the Assistant Director of Nursing (ADON) had not revised them. The facility's policy on oxygen administration requires a physician's order for therapy, but the lack of adherence to these orders for both residents highlights a significant deficiency in providing necessary respiratory care. The DON acknowledged the responsibility of the nursing staff to educate families and ensure proper equipment use, but there was no evidence of training provided to staff or families regarding oxygen and respiratory equipment. This failure to provide appropriate respiratory care could have led to severe health consequences for the residents involved.
Medication Administration Errors Lead to 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate based on 2 errors out of 25 opportunities. This involved a resident who did not receive the correct dosage of prescribed medications. Specifically, RN B administered only one 25mg tablet of sertraline instead of the prescribed three 25mg tablets, and failed to administer a 20mg tablet of isosorbide dinitrate as ordered. These errors were identified during a medication pass observation. The resident involved was a female with diagnoses including vascular dementia, heart failure, and major depressive disorder, with a BIMS score indicating intact cognition. The resident's care plan emphasized the importance of administering medications as ordered to manage heart disease and potential side effects from psychotropic medications. Interviews with RN B, the DON, and the ADON highlighted the potential risks of not receiving the full dosage of medications, such as elevated blood pressure and symptoms of depression, although these risks were not directly observed in the report.
Incomplete Documentation of Antibiotic Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the administration of vancomycin, an antibiotic prescribed for enterocolitis due to Clostridium Difficile. On a specific date, the treatment administration record did not document the administration of the fourth dose of vancomycin, leaving a blank entry. This lack of documentation could lead to errors in medication administration and potentially worsen the resident's condition. The resident, a female with severe cognitive impairment, was at risk for infection due to her compromised medical condition. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the blank entry in the Medication Administration Record (MAR) could indicate that the medication was either not administered, refused by the resident, or not documented by the nurse. Both the DON and ADON emphasized the importance of documenting medication administration to ensure accurate medical records and to inform the physician if a dose is missed. The facility's policy requires that the electronic administration record be initialed after medication is administered, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Laredo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Las Alturas Nursing & Transitional Care | 1.4 mi | ★★★★★ | 13 | 0 |
| Laredo Medical Center | 1.5 mi | ★★★★★ | 1 | 0 |
| La Frontera Nursing & Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Laredo West Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 21 | 0 |
| Laredo South Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 1 | 0 |
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