Inspection Report Summary
The most recent inspection on December 20, 2025, identified a deficiency related to the failure to develop a baseline care plan addressing a resident’s diabetes within 48 hours of admission. Earlier inspections showed a pattern of deficiencies involving care planning, medication administration, resident dignity, documentation accuracy, and facility safety, including issues with infection control and food safety. Complaint investigations substantiated problems with medication timing and documentation, failure to notify representatives of condition changes, and inadequate supervision after incidents such as falls and elopement. Enforcement actions such as fines or license suspensions were not listed in the available reports, and most complaints were substantiated with corrective actions taken. The facility’s inspection history indicates ongoing challenges with care planning and documentation, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
280% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 20, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, specifically focusing on the development and implementation of baseline care plans for newly admitted residents.
Findings
The facility failed to develop a baseline care plan that included instructions for effective and person-centered care for one resident with diabetes mellitus. The admitting nurse did not check the diabetes mellitus box on the baseline care plan assessment, resulting in the omission of diabetes-related care interventions. No negative outcomes were reported due to this omission.
Deficiencies (1)
Failure to develop a baseline care plan that addressed Resident #1's diabetes mellitus within 48 hours of admission.
Report Facts
Residents reviewed for baseline care plans: 5
BIMS score: 12
Respite stay duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Admitting Nurse | Named in deficiency for failing to check the diabetes mellitus box on the baseline care plan assessment |
| MDS Coordinator | Interviewed regarding the baseline care plan deficiency and review process | |
| Interim DON | Interim Director of Nursing | Interviewed regarding corrective actions and review procedures following the deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 3, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to ensure resident participation in care planning, failure to notify representatives of significant changes in condition, and failure to maintain accurate clinical records for Resident #1.
Complaint Details
The complaint investigation focused on Resident #1, a female with COPD and Alzheimer's Disease, who was not involved in care plan meetings after March 2025, whose representative was not notified immediately of a significant oxygen saturation drop on 08/14/2025, and whose oxygen administration was not properly documented nine times in August 2025.
Findings
The facility failed to involve Resident #1 and her representative in care plan meetings, failed to notify the representative immediately of a significant change in Resident #1's condition, and failed to accurately document oxygen administration in clinical records. These deficiencies posed risks of inadequate care planning, delayed communication, and inaccurate medical records.
Deficiencies (3)
Failed to ensure residents participated in the care planning process with the resident and the resident's representative for 1 of 5 residents.
Failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative of significant changes in condition for 1 of 5 residents.
Failed to maintain clinical records that were complete and accurately documented, including failure to document oxygen use accurately for 1 of 5 residents.
Report Facts
Residents reviewed: 5
Oxygen documentation errors: 9
Oxygen saturation: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Assistant Director of Nursing | Interviewed regarding oxygen use documentation and notification of resident representative |
| DON | Director of Nursing | Interviewed regarding staff training on documentation and notification procedures |
| SW | Social Worker | Responsible for scheduling care plan meetings and interviewed about care plan meeting attendance |
| ADM | Administrator | Interviewed about care plan meetings and scheduling responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to complaints regarding pharmaceutical services and medical record maintenance at Alameda Oaks Nursing Center, specifically concerning medication administration errors and documentation failures for three residents.
Complaint Details
The complaint investigation found substantiated failures in medication administration timing, administration without orders, and incomplete documentation for Residents #1, #2, and #3. The facility staff did not follow facility policies and procedures, though no negative outcomes were reported for the residents.
Findings
The facility failed to provide timely pharmaceutical services, including administering medications at scheduled times and ensuring proper physician orders were in place. Additionally, the facility failed to maintain accurate and complete medical records for medication administration, risking errors in care and treatment for residents.
Deficiencies (2)
Failure to provide pharmaceutical services to meet the needs of each resident, including late administration of morphine and tramadol, and administration of tramadol without a physician order.
Failure to safeguard resident-identifiable information and maintain complete and accurate medical records, including failure to document administered medications on the medication administration record (MAR).
Report Facts
Residents reviewed for pharmaceutical services: 3
Residents reviewed for medical records accuracy: 3
Medication administration errors: 3
Dates of medication administration errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Failed to administer medications on time and administered medication late to Residents #1 and #3 | |
| LVN B | Administered medication without an order to Resident #2 | |
| LVN C | Failed to document medication administration on MAR for Resident #1 and Resident #2 | |
| LVN D | Failed to document medication administration on MAR for Resident #2 | |
| SDC | Failed to document medication administration on MAR for Resident #3 | |
| DON | Director of Nursing | Provided interviews regarding medication administration failures and facility policies |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, care planning, food safety, medical record accuracy, infection control, and other facility operations at Alameda Oaks Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to protect residents' personal and medical information, inadequate transfer notification procedures, incomplete and improperly implemented care plans, food safety violations, inaccurate medication administration records, and lapses in infection prevention and control practices.
Deficiencies (6)
Failed to ensure residents' personal and medical records privacy and confidentiality; medication cart laptop screen and paperwork left exposed.
Failed to provide and document written transfer notices to residents, representatives, and ombudsman in a language and manner they understand.
Failed to develop and implement a comprehensive person-centered care plan; Resident #70's call light was out of reach.
Failed to procure food from approved sources and maintain food safety standards including improper cleaning of dinnerware, damaged cooking utensils, unlabeled and expired food items, and improper freezer storage.
Failed to maintain accurate and complete medical records; Resident #00's medication administration records did not match narcotic sheets.
Failed to implement infection prevention and control program; improper wound care and hand hygiene observed with Resident #54.
Report Facts
Residents reviewed for rights: 10
Discharges: 55
Expired apple juice containers: 6
Plastic drinking glasses with residue: 24
Steam table wells: 4
Residents reviewed for care plans: 6
Residents reviewed for medical records: 7
Residents reviewed for infection control: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-D | Named in privacy violation for leaving medication cart laptop screen and paperwork exposed | |
| DON | Director of Nursing | Provided statements on privacy violations and medication record accuracy |
| ADON | Assistant Director of Nursing | Provided statements on privacy violations, medication record accuracy, and infection control |
| CNA B | Certified Nursing Assistant | Interviewed regarding call light accessibility for Resident #70 |
| LVN A | Licensed Vocational Nurse | Interviewed regarding call light accessibility for Resident #70 |
| DM | Dietary Manager | Interviewed regarding food safety violations |
| ADM | Administrator | Interviewed regarding transfer notifications and medication record accuracy |
| CNA-C | Certified Nursing Assistant | Observed and interviewed regarding infection control lapses with Resident #54 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 29, 2025
Visit Reason
The inspection was conducted based on complaints regarding dignity issues related to uncovered foley catheter bags and failure to timely report alleged abuse involving residents.
Complaint Details
The complaint involved dignity issues for Resident #2 related to uncovered foley catheter bags and an abuse allegation for Resident #1 where LVN B allegedly threw the resident into a wheelchair. The abuse allegation was not reported to local law enforcement within the required 24-hour timeframe. The allegation was investigated and found to have no evidence of physical abuse. The facility protocol was enacted after the complaint was made, and the alleged perpetrator was removed from the schedule pending investigation.
Findings
The facility failed to ensure residents were treated with dignity by leaving a foley catheter drainage bag uncovered, exposing urine to visitors and staff. Additionally, the facility failed to report an alleged physical abuse incident to local law enforcement within the required timeframe.
Deficiencies (2)
Failure to ensure residents were treated with respect and dignity by leaving a foley catheter drainage bag uncovered, exposing urine to visitors and staff.
Failure to timely report alleged abuse to local law enforcement within the required timeframe for one resident.
Report Facts
Residents reviewed for dignity issues: 5
Residents reviewed for abuse/neglect: 5
Urine volume in foley bag: 200
Urine volume in foley bag: 300
People observed in hallway: 4
People observed in hallway: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Interviewed regarding privacy bag placement and scope of practice |
| LVN C | Licensed Vocational Nurse | Interviewed regarding privacy bag placement and Resident #2's care |
| DON | Director of Nursing | Interviewed regarding facility expectations for privacy bags and abuse reporting protocols |
| LVN A | Licensed Vocational Nurse | Provided written statement regarding abuse allegation from Resident #1 |
| Administrator | Facility Administrator | Interviewed regarding abuse allegation investigation and reporting |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate treatment and care after a resident's fall and inadequate supervision leading to a resident exiting the facility.
Complaint Details
The complaint investigation revealed that Resident #1 sustained fractures from a fall on 08/29/24 that were not promptly evaluated by nursing staff, resulting in delayed treatment and eventual amputation. Two CNAs involved were terminated. Resident #2 was found sitting outside the front door unsupervised due to a door alarm not being set properly, but was returned safely. The facility implemented corrective actions including staff in-services and elopement drills.
Findings
The facility failed to ensure Resident #1 received timely nursing evaluation after an unwitnessed fall resulting in fractures and subsequent amputation, and failed to provide adequate supervision for Resident #2 who exited the facility through the front door. Corrective actions included termination of involved CNAs, staff re-education, and implementation of elopement protocols.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including failure to have a nurse evaluate Resident #1 after an unwitnessed fall resulting in fractures.
Failure to ensure adequate supervision to prevent accidents, specifically Resident #2 exiting the facility through the front door.
Report Facts
Residents reviewed for quality of care: 5
Residents reviewed for supervision: 3
Dates of noncompliance period: Noncompliance began on 08/29/24 and ended on 09/05/24.
Date of Resident #1 admission: Initial admission date 02/29/24, current admission date 09/16/24.
Date of Resident #2 admission: Original admission date 12/08/23.
BIMS score Resident #1: 2
BIMS score Resident #2: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Involved in failure to report Resident #1's fall and improper handling; terminated. |
| CNA B | Certified Nursing Assistant | Involved in failure to report Resident #1's fall and improper handling; terminated. |
| RN D | Registered Nurse | Received report of Resident #1's pain and called doctor for X-rays. |
| CNA C | Certified Nursing Assistant | Reported Resident #1's pain to nurse and assisted with care. |
| ADM | Administrator | Interviewed regarding incident and corrective actions. |
| DON | Director of Nursing | Interviewed regarding incident and staff knowledge. |
| NP | Nurse Practitioner | Provided clinical information about Resident #1's condition and treatment. |
| LVN G | Licensed Vocational Nurse | Conducted assessment of Resident #2 after elopement incident. |
| Receptionist | New receptionist involved in door alarm error leading to Resident #2 exiting facility. | |
| ADON | Assistant Director of Nursing | Interviewed about Resident #2's wandering and supervision. |
Inspection Report
Routine
Deficiencies: 8
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, and facility operations including medication administration, resident rights, respiratory care, food service safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), failure to maintain resident privacy, failure to follow physician orders for weight monitoring, failure to provide respiratory care as ordered, failure to secure medication carts, and multiple kitchen sanitation and maintenance issues including pest control and equipment maintenance.
Deficiencies (8)
Facility failed to provide Resident #300 an accessible call light that she could physically use.
Facility failed to ensure Resident #22's bedroom door was closed for privacy as requested.
Facility failed to ensure physician orders for monthly or weekly weights were followed for multiple residents (#4, #32, #23, #26, #22, #28, #18, #39).
Facility failed to ensure Resident #23's oxygen tubing was changed every night shift on Sunday as ordered.
Facility failed to store all drugs and biologicals in locked treatment cart; cart was left unlocked with drawers accessible.
Facility failed to maintain kitchen sanitation including dirty ice machine, unclean drinking glasses, eroded non-stick pans, dented pots and pans, ineffective pest control, personal items in prep areas, incomplete cleaning logs, and malfunctioning walk-in freezer and lighting.
Facility failed to maintain essential kitchen equipment including walk-in freezer with ice build-up and door not closing properly, dim lighting in walk-in refrigerator and freezer, dirty air intake and return vents, and non-functioning vent hood lights and exhaust fan.
Facility failed to maintain an effective pest control program; ants observed on prep table and can opener, rodent droppings and hole in baseboard near floor.
Report Facts
Residents reviewed for weight monitoring: 8
Weight loss percentage: -10.12
Weight loss percentage: -4.34
Weight gain percentage: 6.76
Weight gain percentage: 2.33
Weight gain percentage: 1.8
Weight gain percentage: 1.5
Weight loss percentage: -1.65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Mentioned in relation to unlocked medication cart and medication administration | |
| LVN F | Mentioned in relation to unlocked medication cart and resident bleeding incident | |
| DON | Director of Nursing | Interviewed regarding call light use, privacy, medication cart security, weight monitoring, and oxygen tubing |
| Administrator | Interviewed regarding resident call light use, weight monitoring, kitchen conditions, and facility operations | |
| RN C | Registered Nurse | Interviewed regarding Resident #300's call light use and care |
| CNA A | Certified Nursing Assistant | Interviewed regarding Resident #300's call light use and weight monitoring |
| RD | Registered Dietitian | Interviewed regarding weight monitoring and nutritional assessments |
| MS | Maintenance Supervisor | Interviewed regarding kitchen equipment maintenance and pest control |
| DM | Dietary Manager | Interviewed regarding kitchen maintenance and pest control |
| ADM | Administrator | Interviewed regarding kitchen conditions and facility operations |
| NP | Nurse Practitioner | Interviewed regarding Resident #39's weight loss and medical condition |
| Resident #39's doctor | Physician | Phone interview regarding Resident #39's weight loss and care |
| Assistant DM | Interviewed regarding kitchen sanitation and pest control | |
| Unit Manager | Interviewed regarding weight monitoring oversight |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement a comprehensive person-centered care plan for Resident #1, specifically concerning proper transfer instructions and resulting injuries.
Complaint Details
The complaint investigation focused on bruises found on Resident #1 due to improper transfers by hospice staff who were unaware of the two-person lift requirement. The facility acknowledged responsibility for educating hospice staff and noted difficulties coordinating care plans with the hospice agency.
Findings
The facility failed to ensure that care plans used by the hospice agency included two-person Hoyer lift transfer instructions for Resident #1, leading to injuries due to improper transfers by hospice staff. Interviews and record reviews revealed lack of coordination between facility and hospice care plans, inadequate training of hospice CNAs, and failure to communicate resident needs effectively.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and time frames.
Failure to ensure hospice care plans contained two-person Hoyer lift transfer instructions, resulting in resident injury.
Report Facts
Resident age: 96
BIMS score: 0
Dates of bruises observed: Bruises observed on 2023-08-28 and 2023-09-04
Date hospice care started: Hospice care started on 2021-03-01
Date of order to increase transfer to two people: Order received on 2023-09-06
Date of facility in-service training: Facility staff trained on 2023-08-28
Facility policy dates: Hospice policy dated 2023-11-23 and care plan policy dated 2022-12-05
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed multiple times regarding hospice care coordination and responsibility for resident care |
| ADON | Assistant Director of Nursing | Interviewed about training hospice CNAs and investigation of bruises |
| Hospice CNA | Interviewed about use of hospice care plan and lack of knowledge of two-person lift requirement | |
| Hospice nurse | Interviewed about hospice care plan development and resident care | |
| Hospice patient care manager | Interviewed about hospice care plan approval and coordination difficulties |
Inspection Report
Routine
Capacity: 146
Deficiencies: 7
Date: Apr 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, respiratory care, social services staffing, employee screening, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignity and advance directives, incomplete care plan revisions, inadequate respiratory care practices, lack of full-time qualified social worker for the licensed bed capacity, failure to conduct timely employee misconduct registry screenings, and unsafe environment due to an unsecured supply room.
Deficiencies (7)
Resident #51's catheter bag did not have a privacy cover while in a common area, violating the resident's right to dignity.
Resident #8's Do Not Resuscitate (DNR) form was executed incorrectly and invalid; Resident #38's out-of-hospital DNR was not reinstated upon readmission.
The facility failed to conduct current employee misconduct registry screenings for 14 of 19 staff reviewed.
Resident #15's care plan was not revised timely to reflect discontinuation of hemodialysis treatment.
Resident #38's nebulizer mask was unbagged and resting on bedside table, risking infection.
The facility did not employ a full-time qualified social worker as required for a facility with 146 beds.
The supply room door on the 300 hall was inoperable and could not be secured, exposing residents to potential hazards.
Report Facts
Licensed bed capacity: 146
Residents reviewed for dignity: 18
Residents reviewed for advance directives: 4
Staff reviewed for employment registry screenings: 19
Staff without current registry screenings: 14
Residents reviewed for respiratory care: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN O | Licensed Vocational Nurse | Interviewed regarding Resident #51's catheter bag privacy cover deficiency |
| DON | Director of Nursing | Interviewed regarding expectations for catheter privacy covers, advance directives, respiratory care, and supply room safety |
| SSD | Social Services Director | Interviewed regarding social worker qualifications and advance directive oversight |
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #38's code status and DNR order |
| SW | Social Worker | From sister facility, interviewed regarding supervision of SSD |
| HR Coordinator | Interviewed regarding employee misconduct registry screening process | |
| Administrator | Interviewed regarding staffing and social worker licensing | |
| LVN A | Licensed Vocational Nurse | Interviewed regarding nebulizer mask storage |
| CNA I | Certified Nursing Assistant | Interviewed regarding supply room door lock deficiency |
| Maintenance Director | Interviewed regarding repair of supply room door lock | |
| MDS/Care Plan Coordinator | Interviewed regarding care plan revision for Resident #15 |
Inspection Report
Routine
Capacity: 146
Deficiencies: 7
Date: Apr 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, respiratory care, social services staffing, employee background screenings, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' dignity, proper execution of advance directives, timely care plan revisions, appropriate respiratory care, employment registry screenings, full-time qualified social worker staffing, and maintaining a safe environment with secure supply rooms.
Deficiencies (7)
Resident #51's catheter bag did not have a privacy cover while in a common area, compromising dignity.
Resident #8's DNR was executed incorrectly and was invalid; Resident #38's OOH-DNR was not reinstated upon readmission.
Facility failed to conduct current employee misconduct registry screenings for 14 of 19 staff reviewed.
Resident #15's care plan was not revised timely to reflect discontinuation of hemodialysis treatment.
Resident #38's nebulizer mask was unbagged and resting on bedside table, risking infection.
Facility did not employ a full-time qualified social worker as required for a 146-bed facility.
Supply room door on 300 hall was inoperable and could not be secured, exposing residents to hazardous materials.
Report Facts
Residents reviewed for dignity: 18
Residents reviewed for advance directives: 4
Staff reviewed for employment registry screenings: 19
Licensed capacity: 146
Residents reviewed for respiratory care: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN O | Licensed Vocational Nurse | Interviewed regarding Resident #51's catheter bag privacy cover |
| DON | Director of Nursing | Interviewed regarding expectations for catheter privacy covers, advance directives, respiratory care, and supply room security |
| SSD | Social Services Director | Interviewed regarding social worker qualifications and advance directives oversight |
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #38's code status order after hospitalization |
| SW | Social Worker | From sister facility, available for consultation but not supervising SSD |
| HR Coordinator | Interviewed regarding missed employee misconduct registry screenings | |
| Administrator | Interviewed regarding staffing coordinator absence and social worker licensing | |
| LVN A | Licensed Vocational Nurse | Interviewed regarding unbagged nebulizer mask for Resident #38 |
| CNA I | Certified Nursing Assistant | Interviewed regarding inoperable supply room door lock |
| Maintenance Director | Interviewed regarding repair of supply room door lock | |
| MDS/Care Plan Coordinator | Interviewed regarding Resident #15's care plan revision oversight |
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