Inspection Reports for
The Heights of Alamo
1214 S Alamo Rd, Alamo, TX 78516, United States, TX, 78516
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive person-centered care plans and maintenance of medical records for residents at The Heights of Alamo nursing home.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, including an inappropriate bedtime snack task despite the resident being NPO and fed via feeding tube. Additionally, the facility failed to maintain accurate medical records for Resident #2 by not properly documenting and signing off administration of Bisacodyl medication.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and actions, specifically for Resident #1 regarding feeding tube and bedtime snack.
Failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, specifically failure to sign off Bisacodyl administration for Resident #2.
Report Facts
Residents reviewed: 3
Date of survey completed: Nov 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Named in medication administration and documentation deficiency for Resident #2 and care plan oversight for Resident #1 |
| MDS/RN F | Registered Nurse | Responsible for ensuring individualized and accurate care plans, failed to remove inappropriate bedtime snack task for Resident #1 |
| RN E | Registered Nurse | Reviewed daily reports and eMAR, noted missing medication order and sign-off for Resident #2 |
| DON | Director of Nursing | Oversaw care plan and medication documentation processes, confirmed deficiencies and no negative outcomes |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, accurate assessments, care planning, infection control, respiratory care, catheter care, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure timely completion of Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms, inaccurate coding of dialysis in assessments, failure to update care plans after code status changes, improper catheter bag placement, incorrect oxygen administration settings, unclean juice nozzle in the kitchen, and lapses in infection prevention and control practices including inadequate hand hygiene and failure to use enhanced barrier precautions.
Deficiencies (7)
Failed to ensure timely completion of Out-of-Hospital Do Not Resuscitate (OOH-DNR) form for Resident #82.
Failed to ensure Resident #45 was coded in the MDS for Dialysis.
Failed to update Resident #9's comprehensive care plan after code status changed from full code to DNR.
Failed to prevent Resident #49's urinary catheter bag/tubing from touching the floor.
Failed to ensure correct oxygen administration settings for Residents #68 and #67.
Failed to ensure one of two juice nozzles in the kitchen was clean.
Failed to maintain infection prevention and control program including proper hand hygiene and use of enhanced barrier precautions for Residents #19 and #69.
Report Facts
Residents reviewed for OOH-DNR Order forms: 6
Residents reviewed for accuracy of assessments: 8
Residents whose care plans were reviewed: 24
Residents reviewed for infection control practices: 8
Oxygen liters per minute ordered for Resident #68: 2
Oxygen liters per minute observed for Resident #68: 4
Oxygen liters per minute ordered for Resident #67: 2
Oxygen liters per minute observed for Resident #67: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN J | Licensed Vocational Nurse | Nurse for Resident #68 who acknowledged oxygen setting was incorrectly set at 4 LPM. |
| LVN B | Licensed Vocational Nurse | Checked Resident #67's oxygen concentrator and noted it was set at 2.5 LPM instead of 2 LPM. |
| CNA A | Certified Nursing Assistant | Observed performing hand hygiene for less than 20 seconds prior to assisting with Resident #19's wound care. |
| WCN | Wound Care Nurse | Observed performing hand hygiene for less than 20 seconds prior to and after Resident #19's wound care. |
| LVN K | Licensed Vocational Nurse | Failed to wear PPE gown while providing gastrostomy site care for Resident #69. |
| DON | Director of Nursing | Provided multiple interviews regarding responsibilities for oxygen administration, care plan updates, and infection control. |
| ADON | Assistant Director of Nursing | Provided interviews regarding responsibilities for catheter care and oxygen administration. |
| MDS Coordinator | Minimum Data Set Coordinator | Responsible for verifying accuracy of assessments and care plans. |
| SW | Social Worker | Responsible for ensuring OOH-DNR forms and care plan updates. |
| CNA E | Certified Nursing Assistant | Interviewed about catheter bag placement and care. |
| CNA F | Certified Nursing Assistant | Interviewed about catheter bag placement and care. |
| ICP | Infection Control Practitioner | Provided interview regarding hand hygiene and infection control policies. |
| DM | Dietary Manager | Interviewed about kitchen sanitation and juice nozzle cleaning. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 5, 2025
Visit Reason
The inspection was conducted due to allegations of misappropriation of property and exploitation involving two residents' spending account cards, as well as concerns about abuse, neglect, and supervision related to resident safety.
Complaint Details
The complaint investigation was triggered by allegations that the Administrator Designee (AD) used Resident #1 and Resident #2's spending account cards without permission, purchasing snacks for other residents and personal items. Resident #1 and Resident #2's Responsible Parties (RPs) were not contacted for permission. The AD was terminated, and the BOM received a write-up. The facility failed to report the misuse of Resident #2's card to the State Survey Agency in a timely manner. Resident #3 suffered a fall from bed resulting in a fractured femur due to inadequate supervision.
Findings
The facility failed to ensure residents were free from misappropriation and exploitation of their spending account cards, resulting in unauthorized use and financial loss for two residents. Additionally, the facility failed to timely report abuse allegations involving one resident's spending account card and failed to provide adequate supervision to prevent a resident's fall resulting in a fracture.
Deficiencies (3)
Facility failed to ensure residents had the right to be free of misappropriation of property and exploitation involving spending account cards, resulting in unauthorized transactions and financial loss.
Facility failed to timely report alleged abuse and misappropriation involving Resident #2's spending account card to the State Survey Agency.
Facility failed to ensure adequate supervision to prevent Resident #3 from falling off the bed, resulting in a fractured right distal femur.
Report Facts
Financial loss Resident #1: 318.64
Financial loss Resident #2: 313.72
Unauthorized transactions: 4
Spending account monthly deposit: 50
Fall date: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Conducted investigation into spending card misuse, terminated AD, communicated with RPs |
| BOM | Business Office Manager | Gave AD permission to use spending cards without RP consent, failed to notify RPs, received disciplinary action |
| AD | Administrator Designee | Used residents' spending account cards without permission, terminated |
| RN D | Registered Nurse | Assessed Resident #3 after fall |
| LVN C | Licensed Vocational Nurse | Notified NP of Resident #3's x-ray results |
| NP E | Nurse Practitioner | Ordered x-ray and hospital evaluation for Resident #3 |
| CNA B | Certified Nursing Assistant | Was providing care when Resident #3 fell from bed |
| DON | Director of Nursing | Notified of Resident #3's fall, provided information on resident care needs |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
The document is an annual inspection report for The Heights of Alamo nursing home, documenting the results of the survey completed on April 11, 2024.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are both listed as unknown.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
The inspection was conducted as an annual survey of The Heights of Alamo nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating compliance with applicable standards.
Report
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