Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 West Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food storage and labeling standards were not followed in the kitchen. Eggs were stored on the top shelf of a refrigerator instead of the bottom shelf, hot dogs were left unlabeled and undated, a personal item was stored in a food refrigerator, smoked chicken salad was kept beyond 72 hours after opening, Eggo pancakes labeled to be kept frozen were stored in a refrigerator, and ice cream sandwiches in the freezer were not dated. The DA, DM, and RD all acknowledged the expected storage and dating practices, and the facility policy required proper labeling, dating, sealing, and timely disposal of leftovers.
A resident with DM, muscle wasting, intact cognition, and a history of CVA with impaired balance was observed in bed with his call light behind the bed frame and out of reach. RN D said he usually used the call light when he needed something, and the DON stated he was not able to call if he needed something. The facility policy required call lights at the bedside to allow residents to call for assistance.
Failure to Provide Appropriate Foot Care: A resident with severe cognitive impairment, hemiplegia, hemiparesis, and reduced mobility was found with a markedly overgrown, discolored, curled great toenail that had caused pain when caught in bed sheets. Staff, including CNA, LVN, WCN, ADON, and DON, acknowledged the toenail had been missed despite daily contact and weekly skin checks, and the resident had not been on the podiatry list for some time.
A resident with intact cognition and ADL assistance needs had a disposable razor left in his restroom, even though staff stated razors were not allowed in resident rooms and were supposed to be kept locked in the supply room. The resident said he would use the razor to shave, and staff could not say how long it had been there. The ADON and DON stated the facility was responsible for ensuring no sharps were kept in resident rooms and that there was no policy regarding resident safety or sharps.
Catheter bag left touching the floor. A resident with an indwelling catheter for neurogenic bladder was observed in bed with the catheter bag dragging on the floor, despite a care plan and MD order for catheter care every shift and positioning the bag and tubing below the bladder. RN E stated the bag should not touch the floor because it would not drain well and could pick up bacteria, and the DON stated it should be changed immediately if it touched the floor.
Unlabeled and Undated Enteral Feeding Supplies: Two residents with gastrostomy tubes had enteral feeding bags observed hanging on pumps without labels showing the resident name, formula, ordered rate, flush information, or start date/time. One resident’s enteral feed syringe used for meds and water flushes was also not dated. Staff interviews confirmed labeling and dating were expected, but the bags were not checked or changed out as required.
Oxygen care was not provided as ordered for two residents. One resident with pneumonia and respiratory failure was observed receiving O2 via NC at 2 LPM even though the order was for 3 LPM continuous, and nursing staff confirmed the setting should be checked each shift. Another resident with chronic respiratory failure with hypoxia was observed on O2 with the tubing touching the floor and no oxygen sign posted outside the room, despite staff stating all residents on oxygen needed a sign and the facility policy requiring oxygen warning signs.
Insulin Stored Without Open Date: A resident with DM and an order for Insulin Glargine had insulin on the med cart without an open date. An LVN stated insulin should be labeled with an open date so staff know when it expires, and the DON stated the open date is needed to track when the insulin was opened. The facility policy stated medications must have an expiration or beyond-use date clearly stated on the label or container.
Expired milk was found in a resident’s personal refrigerator during survey observation and record review. The resident had cerebral infarction and epilepsy, with moderately impaired cognition, and stated staff were supposed to inspect the refrigerator daily and check its contents. The Environmental Supervisor and DON said housekeeping staff were responsible for checking personal refrigerators for expired food, while the facility policy stated staff should clean the refrigerator weekly and discard foods out of compliance.
Incomplete and inaccurate resident documentation. The facility failed to accurately document a resident’s verbal aggression in the EMR and failed to maintain complete progress notes and dialysis communication sheets for another resident receiving HD. Staff described the first resident as refusing care and being verbally aggressive toward staff, while the second resident had ESRD, DM, and HF and refused scheduled HD, but the required documentation for several dialysis dates was missing.
Infection Control Lapses During Wound Care: During observed wound care for a resident with a sacral pressure ulcer and multiple comorbidities, an WCN pulled down the resident’s brief without placing a clean barrier between the brief and the resident’s buttocks. After completing the treatment, the WCN also did not wash her hands with soap and water before leaving the room. The DON stated the competency form required hand hygiene and use of a clean barrier during wound care.
Hospital Bed Not Functioning and Not Routinely Inspected: A resident admitted for short-term PT reported that his hospital bed’s knee and foot sections would not elevate, and staff observed the controller was not working. The resident also said the bed initially lacked needed rails, and an LVN noted mild ankle swelling. The ADON and Maintenance Director both confirmed the bed was not functioning, and the Maintenance Director stated he did not have a set inspection schedule for hospital beds; the DON said the facility had no policy regarding hospital beds.
Staff failed to maintain privacy for two residents during incontinent and wound care. In one case, a nurse left a resident with a Stage 4 sacral pressure ulcer exposed in bed, with her gown pulled up and brief removed, while the room door remained open and the privacy curtain only loosely pulled. In another case, two CNAs provided incontinent care to a dependent post-CVA resident with the room door closed but the privacy curtain open, allowing a visitor to enter while the resident was completely exposed. Staff later acknowledged they should have fully closed curtains and doors and covered the residents, and facility policy and resident rights documents required privacy during personal care and medical treatment.
Surveyors found that staff failed to follow proper infection control practices for two residents during wound and incontinent care. For a resident with a Stage 4 sacral pressure ulcer and diabetes, the WCN and a CNA used alcohol-based hand rub for only a few seconds and donned gloves while hands were still wet, and the WCN cleansed the wound with a single downward swipe rather than from the cleanest area outward as outlined in facility materials. For another resident with hemiplegia who was dependent for toileting, CNAs performed inadequate hand hygiene, including very short use of sanitizer and handwashing, and one CNA repeatedly re-entered a clean package of wipes with contaminated gloves and then returned the contaminated package to a clean supply cart. These actions did not comply with the facility’s hand hygiene policy requiring thorough coverage and rubbing until dry, nor with expected practices for maintaining separation of clean and contaminated supplies.
A resident with schizophrenia, heart failure, and severe cognitive impairment had a comprehensive MDS assessment completed, but the responsible LVN did not complete the required comprehensive care plan within 7 days as required by facility policy. Instead, the care plan was delayed and, when reviewed, only addressed limited issues such as code status, falls, incontinence, a rib fracture, and oxygen therapy, without the full scope of ADLs, medications, diet, treatments, goals, and interventions. The LVN reported she postponed completion because she was unsure if a change of condition assessment was needed after a recent fall, and the DON confirmed that the care plan in place was insufficient as a comprehensive care plan and should have been completed earlier.
A resident with Alzheimer’s disease, severe cognitive impairment, dysphagia, reduced mobility, and a stage 2 pressure ulcer repeatedly refused showers, meals, medications, wound care, and repositioning, as documented in multiple progress notes over several months. Staff, including hospice aides and nursing personnel, recorded frequent refusals of bathing, poor oral intake despite education and meal substitutions, multiple medication refusals, and resistance to wound care and side-lying positioning intended to promote ulcer healing. Although the resident had an ADL self-care deficit care plan, interviews with the ADON, RN, MDS nurse, and administrator confirmed that these ongoing refusals and noncompliance were never added to the comprehensive care plan with measurable objectives and timeframes, contrary to the facility’s Comprehensive Care Plans policy.
A resident with severe cognitive impairment and a history of alcohol dependence and alcoholic liver disease was found in his room with an alcohol-based hand sanitizer bottle on his bedside table after exhibiting unusual behavior, including stacking furniture at his door and stating he was intoxicated. The resident reportedly told an RN he had ingested hand sanitizer and other substances, although later monitoring did not confirm ingestion. The hand sanitizer, a potentially hazardous substance, was believed to have been obtained from a nurse’s station drawer, contrary to facility policy that such items be kept in a safe place accessible only to employees, resulting in a failure to ensure adequate supervision and control of accident hazards.
A resident with diabetes, impaired coordination, and muscle wasting who required extensive ADL assistance and had bowel and bladder incontinence received perineal care from a CNA who failed to change contaminated gloves and perform hand hygiene after touching the bed remote, the resident’s surroundings, and when moving from a clean perineal area to a soiled gluteal area. The CNA later acknowledged these lapses, and the DON confirmed that glove changes and hand hygiene were required in these situations. Review of facility policies showed that perineal care and hand hygiene procedures lacked specific guidance on when hand hygiene should be performed, despite CDC recommendations.
A resident with severe cognitive impairment and multiple health issues was involved in an incident where a staff member assisted her back into her wheelchair. A housekeeper witnessed the event but did not report it immediately to the administrator or state agency as required by policy, resulting in a delay in reporting an alleged abuse incident.
A resident was not protected from a significant medication error, reflecting a lapse in medication administration or management as required by regulations. The report does not provide further details about the circumstances or the resident's condition.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff did not promptly inform a resident, their doctor, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
Surveyors found that medication rooms and a medication cart were left unlocked, allowing unauthorized access to drugs and biologicals. Staff interviews revealed confusion about which medication rooms were in use and a lack of a clear policy for medication room security, despite existing policy for medication carts. These lapses occurred even after recent staff training on medication security.
A medication aide administered an antibiotic to a resident without reconciling a discrepancy between the physician's order and the pharmacy label, as required by facility policy. The aide noticed the difference in administration times but did not notify a nurse before giving the medication, resulting in the drug being given without proper verification.
Two residents with cognitive impairments were involved in a physical altercation after one entered the other's room and struck him, resulting in minor injuries to both. Despite one resident having a care plan with interventions for behavioral issues and 1:1 supervision, the altercation occurred, and documentation of injuries was incomplete.
A resident with mental health and intellectual disabilities did not receive timely PASRR specialized services after recommendations for a customized wheelchair and other supports were made. The facility failed to notify the PASRR Program Specialist when the resident refused the wheelchair, and staff were unaware of the need to document this change, resulting in incomplete records and a lack of required communication.
Two residents with gastrostomy status and significant nutritional needs had their enteral feeding bags unlabeled, lacking required information such as resident name, feeding type, rate, and initiation time. Staff interviews confirmed that labels often fell off and that without proper labeling, verification of correct feeding and rate against physician orders was not possible.
The facility failed to maintain accurate shower records for three residents, leading to discrepancies in documentation. A resident with Alzheimer's and other conditions had inconsistent shower records, while another with Osteomyelitis and End Stage Renal Disease required two-person assistance but had incomplete records. A third resident with Hypothyroidism and Alzheimer's also had inaccurate documentation, with staff misinterpreting codes, resulting in records not reflecting actual care.
A facility failed to report an incident where one resident punched another, leading to a fall and hip discomfort, to law enforcement within the required timeframe. Both residents had cognitive impairments, and the interim administrator did not report the incident, citing the residents' cognitive status and lack of willful intent. This failure to report could increase the risk of unreported abuse allegations.
A resident with Alzheimer's and dementia accessed a bottle of bleach due to a housekeeper's failure to secure cleaning chemicals. The resident was found with the bottle during a BINGO event, but no ingestion was confirmed. The housekeeper admitted to possibly leaving the cart unlocked due to an emotional situation, and an investigation confirmed all carts were otherwise secured.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during kitchen observations and record review. In refrigerator 1, a blue carton of 18 eggs was observed on the top shelf instead of the bottom shelf. In refrigerator 2, a Sysco plastic 2-gallon bag containing approximately 20 hot dogs was not labeled or dated, a grocery-type plastic bag containing a plastic container with an unknown substance was identified by the DA as a personal item, and an opened container of smoked chicken salad with a date of 3/31 written on top had not been discarded within 72 hours. In refrigerator 3, an original full box and a partial open box of Eggo frozen buttermilk pancakes were stored in the refrigerator even though the package stated to store frozen at 0 degrees. In the freezer, a white box containing approximately 10 ice cream sandwiches was not dated. During interviews, the DA stated the eggs had been purchased because the facility was out of eggs and were not placed on the correct shelf, the hot dogs should have been labeled and dated before being placed in the refrigerator, personal items should be stored in the employee refrigerator, and the chicken salad should have been discarded. The DA also stated the Eggo pancakes were regularly stored in the refrigerator because microwaving them from the freezer did not cook them evenly. The DM stated staff were expected to follow proper food storage processes, including labeling and dating all food, keeping personal items out of kitchen refrigerators, and discarding items in a timely manner. The RD stated in-services for proper storage of items were in process and that items with no label, expired items, or items opened for an unknown amount of time were expected to be thrown away. The facility's Food Storage Policy required refrigerated foods to be dated, labeled, and tightly sealed, leftovers to be used within 72 hours, and raw meats and eggs to be stored on the bottom shelf.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #95 had the call light within reach while in bed in his room. Resident #95 was a [AGE] year-old male with diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Muscle Wasting and Atrophy Multiple. His quarterly MDS assessment reflected a BIMS score of 14, indicating intact cognition, and his care plan noted ADL self-care performance deficits related to a history of CVA and impaired balance, with interventions stating he was totally dependent on 2 staff for transferring. During an observation, Resident #95's call light device was behind the bed frame and he was not able to reach it. RN D stated that Resident #95 usually used the call light when he needed something and that she always made sure residents had the call light within reach and reminded him to use it. The DON stated that if call lights were not within reach, residents might need help and could not get it, and that Resident #95 was not able to call if he needed something. The facility policy stated call lights should be at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance.
Failure to Provide Appropriate Foot Care
Penalty
Summary
Provide appropriate foot care was not ensured for a resident with chronic systolic heart failure, cognitive communication deficit, hemiplegia, hemiparesis, and reduced mobility. The resident's admission record reflected severe cognitive impairment with a BIMS score of 2, and he was dependent for personal hygiene. His care plan included checking nail cleanliness, length, and trimming nails as needed on bath day and as needed, with staff to report changes to the nurse. During observation, the resident was found lying in bed with his right foot uncovered and his right great toenail approximately 1.5 inches long, discolored, and curled. The resident stated that at times his bed sheet would get tangled with the long toenail and caused pain. He was unable to say whether he had notified staff about the toenail. A CNA assigned to the hall said she had daily contact with the resident but had not noticed the toenail, and an LVN later observed the toenail to be about 2 inches long, gray and yellow in color. The ADON observed the toenail and described it as about 5 cm long, off white, yellowish, with a little dark color. She stated the hospice CNAs had not informed the facility that the resident needed toenail trimming, but the facility remained responsible for ensuring proper foot care. She also stated staff had daily contact with the resident and several opportunities to notice the toenail, and that the resident had not been on the podiatrist list for a while. The WCN said she did weekly skin assessments but did not normally note long toenails unless they looked infected, and she agreed she should have informed the charge nurse to ensure the resident was placed on the podiatrist list. The DON stated the facility did not have a policy on foot care.
Razor Left in Resident Restroom
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for one resident when a disposable blue razor was found in the resident’s restroom. The resident’s record showed diagnoses including need for assistance with personal care, muscle weakness, and lack of coordination, and the quarterly MDS reflected a BIMS score of 14 with intact cognition. The care plan noted an ADL self-care performance deficit related to a left BKA, left upper limb amputation, and dementia, and also stated the resident preferred to perform his own personal hygiene and oral care. During observation, the resident was sitting on his bed and stated he could dress, groom, and shave on his own. With permission, the surveyor observed the restroom and saw a clear plastic cup containing one disposable blue razor and three small tubes of toothpaste on the sink. The resident said he would use the razor to shave and could not say how long it had been there. Staff interviews confirmed razors were not allowed in resident rooms, that razors were supposed to be kept locked in the supply room, and that CNAs were responsible for disposing of razors after shaving; however, staff had not noticed the razor in the restroom and could not say how long it had been there. The ADON and DON stated the facility was responsible for ensuring no sharps were kept in resident rooms and that the facility did not have a policy regarding resident safety or sharps.
Catheter bag left touching the floor
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure Resident #7, who had an indwelling catheter for neurogenic bladder, received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible. Resident #7's record showed a diagnosis of neuromuscular dysfunction of the bladder, an indwelling catheter care plan with interventions to keep the catheter bag and tubing below the bladder and away from the entrance room door, and an order for indwelling catheter care every shift and as needed. During an observation and interview, Resident #7's catheter bag was noted dragging on the floor while the resident was in bed. The resident was not able to verbalize. RN E stated the catheter bag should not be touching the floor and that if it was on the floor it would not drain well and could pick up bacteria from the floor. The DON later stated the bag and tubing should not be touching the floor, and if they were, they should be changed immediately. The DON also stated the negative outcome could be infection or the bag being ripped, and stated the facility did not have a policy for indwelling catheters.
Unlabeled and Undated Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure that enteral feeding administration supplies were labeled and dated for two residents receiving tube feeding. Resident #39 had diagnoses including vascular dementia, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, aphasia and dysphagia following cerebral infarction, and gastrostomy status. His care plan reflected that he required tube feeding and had a goal of being free of aspiration, but no interventions were listed. On 05/19/26, an observation showed his tube feed administration bag hanging on a pole and connected to a pump running at 20 ml/hr, but the bag was not labeled with his name, formula, ordered rate, water flush information, or the date and time the formula was started. Resident #11 had diagnoses including nontraumatic intracerebral hemorrhage in a subcortical hemisphere, muscle wasting and atrophy, type 2 diabetes mellitus, and gastrostomy status. His care plan stated he required a feeding tube due to dysphagia related to a stroke and that he was dependent on one staff member for tube feeding and water flushes. His orders included Glucerna 1.5 at 75 ml/hr for 20 hours via gastric tube and water flushes every 6 hours. On 05/20/26, an observation showed his tube feed administration bag hanging on a pole and connected to a pump running at 75 ml/hr, but the bag was not labeled with his name, formula, ordered rate, water flush information, or the date and time the formula was started. During interviews, LVN A stated it was important for enteral feeding bags or containers to be labeled to support infection control and ensure the formula was changed every day, and to identify the correct formula, rate, and water flush amounts. LVN G stated it was the responsibility of all nurses to ensure tube feeding supplies were changed and dated correctly. The DON stated labeling was important to identify the formula, flow rate, and date changed to prevent the tube feed from spoiling. RN D stated she did not check Resident #39's tube feed bag for labeling, did not turn the pump back on, and said it was the night nurse's responsibility to change out and label the bags. For Resident #11, the enteral feed syringe used for medication administration and water flushes was not dated.
Oxygen settings, tubing placement, and signage were not maintained for two residents
Penalty
Summary
Resident #29 had diagnoses including pneumonia and respiratory failure and was ordered oxygen at 3 LPM via nasal cannula continuously for hypoxia related to acute and chronic respiratory failure. On 05/19/26, the resident was observed lying in bed awake and receiving oxygen via nasal cannula, but the oxygen concentrator was set at 2 LPM instead of the ordered 3 LPM. The resident stated she required continuous oxygen and was not in distress at the time of observation. During the same observation, LVN G reviewed the electronic medical record and confirmed the oxygen order for 3 LPM effective 05/18/26, then checked the concentrator and found it set at 2 LPM. LVN G stated she had checked the resident's oxygen level earlier that morning but had not checked the oxygen setting at that time. She stated nursing staff were supposed to check the oxygen concentrator setting per shift and that staff received in-services on respiratory care, including oxygen settings. The ADON and DON also stated nursing staff were responsible for checking oxygen settings per shift and confirmed the resident's continuous oxygen order for 3 LPM. Resident #51 had chronic respiratory failure with hypoxia and an order for oxygen at 2-5 LPM as needed for shortness of breath. On 05/19/26, the resident was observed in bed wearing a nasal cannula and receiving oxygen at 2 LPM, with the oxygen tubing touching the floor without a protective sleeve. There was also no oxygen sign posted outside the resident's room. RN D stated staff were responsible for posting oxygen signs outside residents' rooms and that all residents on oxygen needed a sign. She also stated the tubing should not touch the floor because it could become contaminated and cause infection, and that the sign was important so others would know oxygen was in use for safety. The DON stated the admitting nurse was responsible for posting the oxygen sign and was not sure whether tubing touching the floor was against policy. The facility policy titled Oxygen Safety stated no smoking signs would be used to clearly identify oxygen is in use before connecting the oxygen supply and would remain in place until oxygen administration had been discontinued.
Insulin Stored Without Open Date
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles for one resident reviewed for medication labeling and storage. Resident #11, a male with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia, had an order for Insulin Glargine Solution 100 UNIT/ML, 20 units subcutaneously at bedtime for diabetes mellitus. During an observation of the A wing Hall Medication Cart with an LVN, the resident’s Insulin Glargine Solution 100 UNIT/ML did not have an open date. Record review showed the resident’s admission record, care plan, quarterly MDS assessment, and order summary all documented diabetes mellitus and insulin use. During interviews, an LVN stated insulin should be labeled with an open date and that the person who initially opened it was responsible for labeling it, so staff would know when it expired. The DON also stated Insulin Glargine should have an open date because medications have a life span and without an open date staff could not track when the insulin was opened. The facility’s Medication Storage and Disposal policy stated that medications received from the pharmacy will have an expiration or beyond use date clearly stated on the label or medication container.
Expired Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to maintain a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. During observation and record review, Resident #96’s personal refrigerator was found to contain a half-pint carton of 1% low-fat milk with an expiration date of 04/06/26. The resident’s refrigerator temperature log showed the refrigerator was last inspected on 05/17/26, and the expired milk was still present when the surveyor inspected the refrigerator on 05/19/26. Resident #96’s record reflected diagnoses of cerebral infarction and epilepsy, and his quarterly MDS showed a BIMS score of 10, indicating moderately impaired cognition. During interview, he stated he used the personal refrigerator to keep drinks and said staff were supposed to inspect it daily and check its contents. He also stated he was dependent on staff to place items in or remove items from the refrigerator. The Environmental Supervisor stated housekeeping staff were responsible for checking personal refrigerators daily for expired food, and the DON stated residents were allowed to have personal refrigerators and that housekeeping staff were responsible for checking temperature and expired food. The facility’s Resident Refrigerators policy stated staff shall clean the refrigerator weekly and discard foods that are out of compliance.
Incomplete and inaccurate resident documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for 2 residents by not keeping documentation complete and accurate. The report states that Resident #115, a long-term resident with dementia, cerebral infarction, absence of the left upper limb, and absence of the left leg below the knee, had a quarterly BIMS score of 12 and a care plan addressing a history of physical aggression. Staff interviews described him as refusing care, staying in his room, and being verbally aggressive toward staff by yelling, cursing, and screaming when approached or when staff entered his room. Multiple staff members stated that Resident #115’s verbal aggression was a known behavior and should have been documented in the electronic medical record, but the LVN said documentation had stopped because it was "a no win situation." The DON stated that staff had been regularly in-serviced on documentation and that daily occurrences should be documented accurately and consistently to paint a clear picture of the resident’s behavior. The DON also stated that not documenting the resident’s verbal behaviors could affect his MDS assessments. The facility also failed to maintain complete progress notes and dialysis communication sheets for Resident #130, a resident with ESRD, diabetes mellitus, and heart failure who was receiving hemodialysis on Tuesdays, Thursdays, and Saturdays. The record contained no dialysis communication sheet or refusal documentation for 3/31/26, 4/2/26, and 4/4/26, and no progress notes were found for those dates. A later MD note documented that the resident had refused hemodialysis since 3/28/26, had been educated about the need for dialysis, and was ultimately taken to the ER after continued refusal.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. During observed wound care for a resident with a sacral pressure ulcer, the wound care nurse unfastened the resident’s brief from one side and pulled it down, but did not place a barrier between the resident’s buttocks and the brief while providing care. The resident’s record showed diagnoses including nontraumatic intracerebral hemorrhage, muscle wasting and atrophy, type 2 diabetes mellitus, and gastrostomy status. His care plan identified a sacral pressure ulcer with a goal of healing and remaining free from infection, and his order summary included daily wound care to the sacrum. During the same wound care observation, the wound care nurse did not wash her hands with soap and water after completing the treatment and before exiting the room. In interview, the nurse stated she did not place a barrier because the wound did not touch the brief and her gloved hand did not touch the brief, but acknowledged a barrier should have been used in case contamination occurred. She also stated she did not wash her hands because she thought sanitizer was an option. The DON stated the competency check off form required hand hygiene before wound care and washing with soap and water after wound care, and that a clean barrier should be placed between the resident’s wound and brief.
Hospital Bed Not Functioning and Not Routinely Inspected
Penalty
Summary
The facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, resulting in a hospital bed that did not function properly for Resident #123. Resident #123 was admitted for short-term physical therapy and had diagnoses including hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, and rheumatoid arthritis. During observation, he was lying in bed with his head elevated at a 30-degree angle and stated he was upset because the knee and foot section of his hospital bed would not elevate. He also said he felt his feet were swollen because he could not elevate them. He reported that when he was first admitted, the bed did not have the rails he needed to help reposition himself, and the facility replaced the bed the following day. During the observation, Resident #123 pressed the hand controller button for the knee and foot section, but the sections did not elevate. An LVN then tried the controller and stated, "it's not working." The LVN assessed the resident's feet and ankles and noted the left ankle was a little swollen, while the right ankle was not swollen. The ADON also tried the controller and stated the bed was not working, and said she had not been advised the bed was not functioning properly. The Maintenance Director stated he was responsible for ensuring hospital beds were in working condition, but he did not have a set schedule for inspecting them and only checked beds for new admissions or when a bed was reported as not functioning. He also stated he had not received any work orders for Resident #123's bed. The DON stated the Maintenance Director was responsible for ensuring hospital beds were functioning and said the facility did not have a policy regarding hospital beds.
Failure to Maintain Resident Privacy During Incontinent and Wound Care
Penalty
Summary
The deficiency involved failures to provide personal privacy during incontinent and wound care for two residents. For the first resident, an elderly female with a history of a Stage 4 sacral pressure ulcer and diabetes, record review showed she was care planned for sacral pressure injury treatment. On the observed date and time, the wound care nurse left the resident’s room to obtain supplies with the privacy curtain only loosely pulled and the door completely open, while a CNA remained at the bedside. The resident was lying in bed with her gown pulled up to her breasts and her brief completely removed, leaving her body exposed. In subsequent interviews, the wound care nurse acknowledged she should have ensured the curtain was completely closed, the door was shut, and the resident was covered, and the CNA stated she should have covered the resident with a sheet or towel instead of leaving her exposed. The second resident was an elderly male with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, who was care planned as dependent for toileting hygiene due to an ADL self-care performance deficit. During an observed episode of incontinent care performed by two CNAs, the room door was closed but the privacy curtain was not pulled. While the resident was lying completely exposed in bed, a visitor entered the room. Both CNAs later stated they should have pulled the privacy curtain closed prior to providing care so the resident would not be exposed. The DON stated that CNAs and nurses knew they were supposed to provide dignity and privacy by closing privacy curtains and doors during care and covering areas of the body where no care was being provided. Facility policy on perineal care required staff to provide privacy by pulling the privacy curtain or closing the room door, and the facility’s Statement of Residents Rights affirmed residents’ rights to courtesy, respect, and privacy, including privacy while attending to personal needs and during medical treatment.
Failure to Follow Hand Hygiene and Wound Cleansing Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for two residents during wound care and incontinent care. For one resident, an older female with a Stage 4 sacral pressure ulcer and diabetes, the wound care nurse (WCN) did not follow proper hand hygiene technique while performing ordered wound care. The WCN repeatedly applied alcohol-based hand sanitizer, rubbed her hands for only 1–4 seconds, then attempted to don gloves while her hands were still wet. During the same wound care episode, the WCN cleansed the sacral wound by making a single downward swipe with saline-soaked gauze from above the wound to below it, rather than cleansing from the cleanest area to the dirtiest as described in the facility’s wound care education materials and as later stated by the WCN and DON. The same resident’s care also involved a CNA who did not perform hand hygiene correctly. During the wound care observation, this CNA used alcohol-based hand sanitizer for approximately 5–6 seconds and then applied clean gloves while her hands were still wet, indicating noncompliance with the facility’s hand hygiene policy that required rubbing sanitizer over all hand surfaces until dry, taking about 20 seconds. The resident’s records, including the physician’s order for wound cleansing with normal saline and application of Iodosorb gel, calcium alginate, and a super absorbent dressing three times per week, and the care plan for a Stage 4 sacral pressure injury, established the clinical context in which these improper practices occurred. For a second resident, an older male with hemiplegia and hemiparesis following a cerebral infarction and dependent for toileting hygiene, multiple CNAs failed to follow proper hand hygiene and clean/dirty supply handling during incontinent care. Two CNAs used alcohol-based hand sanitizer for only 3–4 seconds and attempted to don gloves while their hands were still wet, and one CNA washed her hands but scrubbed for only 6 seconds. During incontinent care, this CNA repeatedly touched and re-entered a clean package of wipes with contaminated gloves, then carried the now-contaminated package out of the resident’s room and placed it back on a clean supply cart. These observed actions conflicted with the facility’s hand hygiene policy and infection control expectations as later described by the DON and staff, and formed the basis of the cited infection control deficiency.
Failure to Complete Timely Comprehensive Care Plan After MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan within 7 days after completion of the comprehensive MDS assessment and to ensure it was reviewed and revised by the interdisciplinary team to reflect the resident’s current condition. A female resident with schizophrenia and heart failure was admitted on 03/05/26, and her comprehensive MDS assessment, dated 03/17/26, showed a BIMS score of 7, indicating severe cognitive impairment. Record review showed that as of 03/31/26, the resident’s care plan addressed only limited issues, including code status, sitting on the floor, a fall on 03/21/26, fall risk, bowel and bladder incontinence, a rib fracture related to a fall, and oxygen therapy. The care plan history indicated the next review date was 03/23/26, but the comprehensive care plan had not been fully developed by the required date. In interviews, the LVN responsible for care management stated that she completed initial MDS assessments within 14 days of admission and confirmed that the initial assessment for this resident was completed on 03/17/26. She acknowledged that the comprehensive care plan should have been completed within 7 days of that assessment, by 03/24/26, but she did not complete it until 03/31/26 because she was unsure whether a change of condition assessment was needed after the resident’s recent fall. She stated that delaying completion of the comprehensive care plan could result in nurses not being up to date on how to care for the resident. The DON stated that the comprehensive care plan should contain all necessary information for resident care, including ADLs, medications, diet, treatments, goals, and interventions, and confirmed that the care plan in place on the morning of 03/31/26 was insufficient as a comprehensive care plan and should have been completed by 03/24/26. Facility policy dated 10/24/22 required that the comprehensive care plan be developed within 7 days after completion of the comprehensive MDS assessment.
Failure to Care Plan Ongoing Refusals of Care and Noncompliance
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes addressing a resident’s repeated refusals of essential care. The resident was an elderly female with Alzheimer’s disease, dysphagia, muscle wasting and atrophy, and reduced mobility, admitted with a stage 2 pressure ulcer. Her MDS showed a BIMS score of 7, indicating severe cognitive impairment, and she required extensive assistance with ADLs including toileting, bathing, personal hygiene, and rolling in bed. Despite these needs, the existing care plan, initiated for ADL self-care performance deficit related to Alzheimer’s disease, did not include her ongoing refusals of eating, showering, wound care, medications, or her noncompliance with remaining positioned on her sides. Progress notes over several months documented multiple specific instances of refusal. The record showed repeated refusals of showers and bed baths despite attempts by hospice aides and nursing staff, with the resident becoming agitated when encouraged. Notes also reflected frequent refusals of meals and substitutes, with the resident sometimes eating less than 25% of meals or tightening her lips to avoid eating, and staff documenting education on the importance of nutrition. Staff also recorded that the resident’s responsible party reported a long-standing pattern of minimal breakfast intake. Additionally, there were multiple entries of the resident refusing medications on several dates, including refusals after repeated attempts. The documentation further showed that the resident refused wound care and repositioning intended to promote healing of her sacral pressure ulcer. Staff notes described having to beg the resident to allow dressing changes and peri care, with the resident limiting the time allowed for care, and refusing repositioning despite education about the impact on her bedsore. Interviews with the ADON, RN, MDS nurse, and administrator confirmed that the resident frequently refused to eat, shower, take medications, accept wound care, and remain on her sides, and that these behaviors and refusals were not incorporated into the care plan. Facility staff acknowledged that such refusals and noncompliance should have been care planned and that the facility’s own Comprehensive Care Plans policy required measurable objectives and timeframes based on identified needs, including documentation of alternative interventions as needed.
Failure to Prevent Cognitively Impaired Resident’s Access to Alcohol-Based Hand Sanitizer
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and control of accident hazards when a severely cognitively impaired resident obtained access to an alcohol-based hand rub. The resident was an adult male with multiple diagnoses including alcohol dependence with alcohol-induced mood disorder, alcohol dependence with unspecified alcohol-induced disorder, and alcoholic cirrhosis of the liver. His admission MDS showed a BIMS score of 4, indicating severe cognitive impairment, and he required partial/moderate assistance with ADLs. His care plan addressed mood problems related to alcohol dependence, including monitoring for self-harm, impaired judgment, and safety awareness, but did not document any history of consuming items he was not supposed to. On the date of the incident, an RN documented that the resident was found stacking furniture at his bedroom door, with an open bottle of hand sanitizer on his bedside table. The RN recorded that the resident stated, “Yes I'm F***** up,” and when asked where he obtained the hand sanitizer, the resident responded evasively. The facility’s provider investigation report stated that the administrator was notified that a bottle of hand sanitizer had been found in the resident’s room on the secured unit, that the bottle had been opened, and that the resident had vocalized to the nurse that he had ingested hand sanitizer and other items not located in his room. The report also noted that during subsequent monitoring there was never any indication that emergent services were warranted nor any confirmed indication that the resident consumed the hand sanitizer. Interviews with the DON and Administrator indicated that RN A had reported seeing a small bottle of hand sanitizer on the resident’s bedside table and that the resident had verbalized drinking multiple substances that were not kept within the facility. They stated that the resident should not have had access to the hand sanitizer as it was potentially a chemical hazard and that the hand sanitizer may have been retrieved from a drawer within the nurse’s station. At the time of the surveyor’s observation of the memory unit, all mobile hand sanitizers were locked within the nurse’s medication carts, and no hand sanitizer was observed in the resident’s room. The facility’s general housekeeping policy stated that potentially hazardous substances are to be kept in a safe place accessible only to employees, but the resident’s access to a non-fixed bottle of hand sanitizer in his room demonstrated a failure to prevent access to this potentially hazardous substance.
Failure to Perform Proper Hand Hygiene and Glove Changes During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during perineal care for one resident. The resident was an adult female with multiple diagnoses including type 2 diabetes mellitus, lack of coordination, and muscle wasting and atrophy, and required substantial/maximal assistance with ADLs. Her care plan identified bowel and bladder incontinence and directed that her perineal area be cleaned with each incontinence episode. During an observation, CNA A washed her hands and donned clean gloves, then used the bed remote, removed the resident’s blanket and gown, and retrieved cleansing wipes without changing gloves or performing hand hygiene before beginning perineal care. The observation further showed that CNA A cleaned the resident’s perineal area, rolled the front of the brief, then turned the resident to her right side and cleaned visible bowel movement without changing gloves or performing hand hygiene between these tasks. In a subsequent interview, CNA A acknowledged she should have changed gloves and performed hand hygiene after touching the bedside remote and the resident’s surroundings, and again when moving from a clean area to a dirty area. The DON stated that CNA A should have removed contaminated gloves after touching the resident’s immediate surroundings and when moving from cleaning the perineal area to the gluteal area, and that the facility followed CDC hand hygiene guidelines. Review of the facility’s perineal care and hand hygiene policies showed they did not specify when hand hygiene should be performed, despite CDC guidance that hands should be cleaned before touching a patient, before moving from a soiled to a clean body site on the same patient, after touching a patient or their surroundings, after contact with blood or body fluids, and immediately after glove removal.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported immediately to the administrator and to the state agency as required by facility policy. Specifically, an incident involving a female resident with severe cognitive impairment and multiple medical conditions was not reported within the required two-hour timeframe. The resident, who was dependent on staff for most activities of daily living and had a history of falls and behavioral disturbances, was involved in an incident where a staff member assisted her back into her wheelchair after she attempted to stand and walk unassisted. A housekeeper witnessed the staff member placing his hands on the resident's shoulders and chest to guide her back into her seat but did not perceive the action as forceful or harmful. However, the housekeeper did not report the incident immediately due to personal reasons and only informed her supervisor the following day. Other staff interviews indicated that the resident required frequent redirection and that the staff member involved was generally regarded as patient and kind. There was no immediate evidence of injury or distress observed in the resident following the incident. Despite facility policy requiring immediate reporting of abuse allegations, the delay in reporting the incident to the administrator and state agency constituted a deficiency. The facility's own policy mandated that such allegations be reported within two hours if abuse or serious bodily injury was involved, but this protocol was not followed in this case.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's well-being.
Failure to Secure Medication Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled according to professional standards. Specifically, the medication room on B-hall was found unlocked on two separate occasions, allowing surveyors to enter without a key and observe a basket of various medications inside. Additionally, a medication cart on A-hall was observed unlocked and unattended until an Assistant Director of Nursing (ADON) noticed and locked it. Interviews with staff revealed that some nurses had a habit of leaving carts unlocked, despite recent in-service training on the importance of securing medication storage areas. Staff members, including the ADON, Director of Nursing (DON), and charge nurses, expressed surprise at the presence of medications in the B-hall medication room, as they believed only the A-hall and D-hall medication rooms were in use. Further review indicated that the facility lacked a specific policy regarding the storage of medications in medication rooms, although there was a policy requiring medication carts to be locked at all times when not in use. Staff interviews confirmed that keys to medication rooms were sometimes given to medication aides without ensuring the rooms were relocked afterward. The DON and other staff acknowledged that any room or cart containing medications should be locked at all times to prevent unauthorized access, but lapses in practice were evident during the survey.
Failure to Reconcile Medication Orders and Pharmacy Labels Prior to Administration
Penalty
Summary
A deficiency occurred when a medication aide (MA A) failed to reconcile the instructions on a resident's blister pack of cefpodoxime with the physician's order before administering the medication. The physician's order specified that the resident should receive one 200 mg tablet of cefpodoxime by mouth once daily for prophylaxis, while the pharmacy label on the blister pack instructed administration at bedtime. Despite noticing the discrepancy between the medication administration record (MAR) and the blister pack label, MA A did not notify the nurse or take corrective action before administering the medication. The resident involved was a male with a history of follicular lymphoma, cirrhosis, and chronic leukocytosis, requiring reverse isolation and prophylactic antibiotic therapy. The resident's care plan included specific interventions for medication administration and infection monitoring. On the day of the incident, the medication aide administered the cefpodoxime in the morning, following the MAR, but did not address the conflicting instructions on the blister pack label as required by facility policy. Facility policy required staff to compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time before administration. Both the medication aide and the DON confirmed in interviews that discrepancies between the MAR and medication labels should be immediately reported to a nurse for resolution. The failure to follow this protocol resulted in the administration of medication without proper reconciliation of the physician's order and pharmacy label.
Failure to Protect Residents from Abuse During Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that two residents were protected from abuse, specifically in the context of a resident-to-resident altercation. One resident, a male with severe cognitive impairment and extensive needs for assistance with activities of daily living, was in his room when another male resident entered, asked about a taxi service, and then physically struck him in the face. The first resident retaliated by hitting back, subsequently tripping and falling during the altercation. Both residents sustained minor injuries, including a reddened area to the cheek and forehead for the first resident, and a 0.5 cm abrasion to the chin for the second resident. Prior to this incident, the first resident had no documented history of altercations or incidents, and his care plan did not address any risk of resident-to-resident aggression. The second resident, however, had a documented history of a previous verbal altercation with another resident, and his care plan included interventions such as behavioral health consults, redirection, 1:1 supervision, and being placed in a room alone due to not wanting a roommate. Despite these interventions, the second resident was able to enter the first resident's room and initiate a physical altercation. Documentation following the incident was incomplete, as skin evaluations did not provide detailed descriptions or locations of the injuries, and some progress notes lacked documentation of the wounds. Staff interviews confirmed the sequence of events, with a CNA responding to calls for help and finding the first resident on the floor and the second resident leaving the room. The facility's policy required prompt reporting and response to allegations of abuse, but the report focuses on the failure to prevent the altercation and ensure both residents were free from abuse.
Failure to Implement and Communicate PASRR Specialized Service Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report for a resident with diagnoses including schizophrenia, mild intellectual disabilities, and bipolar disorder with psychotic features. The resident was identified as PASRR positive and had specialized service recommendations, such as self-monitoring, assistance with ADLs, sensorimotor development, and independent living skills. The PASRR evaluation and PCSP meeting also recommended durable medical equipment, ongoing habilitation coordination, and a customized wheelchair. Despite these recommendations, the facility did not initiate the necessary PASRR specialized services within the required 20 business days following the IDT meeting where services were agreed upon. Documentation revealed that the resident refused the customized wheelchair, preferring her current one, but there was no evidence that this refusal or the change in service need was communicated to the HHSC PASRR Program Specialist. Progress notes lacked updates or notifications regarding the completion or discontinuation of specialized services for the resident during the relevant period. Interviews with facility staff, including MDS nurses, the COTA, and the administrator, confirmed a lack of awareness and follow-through regarding the need to notify the PASRR Program Specialist about the resident's refusal of the specialized wheelchair. Staff were unaware of the requirement to submit documentation indicating that the service was no longer needed, resulting in the appearance that the resident had not received the required services. Additionally, the facility did not have a PASRR policy available when requested.
Failure to Label Enteral Feeding Bags for Two Residents
Penalty
Summary
The facility failed to ensure that enteral feeding bags for two residents were properly labeled with required information, including the resident's name, feeding type, feeding rate, and the time and date the feeding was initiated. Observations revealed that both residents' enteral feeding bags were not labeled, and there were no labels found on the ground. Staff interviews confirmed that labels frequently fell off the feeding bags due to poor adhesion, and that the absence of labels prevented verification of the correct feeding and rate against physician orders. Both residents involved had significant medical conditions requiring enteral feeding, including gastrostomy status, severe protein-calorie malnutrition, dysphagia, and muscle wasting. Their care plans and physician orders specified the need for tube feeding at particular rates and formulas. Facility policies required verification of medication and feeding orders, but the lack of labeling on the feeding bags meant that staff could not confirm that the correct feeding was being administered as ordered.
Inaccurate Shower Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents regarding their shower documentation. Resident #1, diagnosed with Alzheimer's Disease, Dysphagia, Type 2 Diabetes Mellitus, Depressive disorder, Overweight, and Heart Failure, had discrepancies in shower records, with documentation indicating showers did not occur on several dates. The resident's care plan required monitoring and documentation of self-care deficits, but the records were inconsistent with the resident's statements that the facility provided his showers. Resident #3, with Osteomyelitis, End Stage Renal Disease, and Type 2 Diabetes Mellitus, required two-person assistance for showers three times a week. However, the documentation showed that showers did not occur on multiple occasions, and there was no progress note to explain these entries. The resident was also discharged to a medical clinic due to respiratory distress, fatigue, and chest pain, but the shower records remained incomplete and inaccurate. Resident #5, diagnosed with Hypothyroidism, Alzheimer's Disease, and abnormal gait, required extensive assistance for showers three times a week. The documentation indicated that showers did not occur on several dates, contradicting the family member's statement that the facility provided all care, including showers. Interviews with staff revealed confusion and misinterpretation of documentation codes, leading to inaccurate records that did not reflect the actual care provided.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving two residents to local law enforcement within the required timeframe. On the evening of February 7, 2025, a Certified Nursing Assistant (CNA) observed one resident punching another resident, who subsequently fell to the ground. The incident was documented by a Licensed Vocational Nurse (LVN), who noted that the resident who was punched experienced discomfort in his left hip and was sent to the emergency room for evaluation. Despite the documentation of the incident and the facility's policy requiring immediate reporting of such events, the local law enforcement was not notified within the 24-hour timeframe. The residents involved in the incident both had cognitive impairments. The resident who was punched had a history of cerebral infarction, subarachnoid hemorrhage, aphasia, and dysphagia, with a moderate cognitive impairment score. The resident who punched had a history of cerebral infarction, mood disorder, and dementia, with a severe cognitive impairment score. The facility's interim Director of Nursing (DON) and the administrator at the time did not report the incident to law enforcement, citing the cognitive impairments of the residents and the lack of willful intent as reasons for not doing so. The facility's policy on abuse, neglect, and exploitation requires that all alleged violations involving abuse be reported to the appropriate authorities, including law enforcement, within specified timeframes. However, the interim administrator interpreted the policy's language of "if applicable" to mean that reporting was not necessary in this case due to the residents' cognitive impairments and the families' requests not to press charges. This interpretation led to the failure to report the incident to law enforcement, which could potentially place all residents at increased risk for unreported allegations of abuse.
Failure to Securely Store Chemicals
Penalty
Summary
The facility failed to ensure that chemicals were securely stored, resulting in a resident gaining access to a bottle of bleach. Resident #1, who has Alzheimer's Disease and dementia, was found with a bottle of bleach in her hands while sitting in her wheelchair. The resident was solely dependent on staff for all activities of daily living and had a history of placing objects in her mouth. The incident occurred during a loteria BINGO event, and the resident was observed to be in the activity room without any items in her hands before the event started. However, after the event, she was found with the bleach bottle, which had its cap still on and no signs of spillage or ingestion were noted. The resident was promptly assessed and sent to the hospital for further evaluation, where no immediate concern of actual ingestion was documented. The housekeeper responsible for the chemicals admitted to bringing in an unapproved cleaning agent and speculated that she might have left her cart unlocked due to an emotional family situation. However, the timeline of events did not clearly explain how the resident obtained the bleach bottle. The Director of Nurses (DON) and the administration staff conducted an investigation and found that all housekeeping carts were secured under lock and key. The housekeeper's written statement confirmed that she might have been negligent in securing the chemicals due to her emotional state. The facility's policies and procedures clearly stated that all chemicals must be properly secured and out of residents' reach, and that only approved cleaning agents should be used. Despite these policies, the incident occurred, highlighting a lapse in adherence to safety protocols.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Laredo South Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Laredo Medical Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Las Alturas Nursing & Transitional Care | 1.6 mi | ★★★★★ | 13 | 0 |
| Laredo Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 8 | 0 |
| La Frontera Nursing & Rehabilitation | 3.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.