Health inspection·November 13, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete allowed to touch a resident's feeding tube or to feed them via their feeding tube. She said that task belonged to nursing staff.In an interview on 11/10/25 at 4:18 pm, LVN D said Resident #1 had a feeding tube and was not allowed to eat or drink anything by mouth. He said if a CNA had any questions regarding his plan of care they would ask a charge nurse. He said CNAs were not allowed to touch a resident's feeding tube, he said that tasked belonged to nursing staff only.In an interview on 11/12/25 at 9:00 am, MDS/RN F, said it was her responsibility to ensure a resident's care plan (Kardex), and MDS were individualized and accurate. She said Resident #1 had a feeding tube and was not able to eat or drink anything by mouth. She said Resident #1's Kardex included a bedtime snack which was not an appropriate task for him because he had a feeding tube. She said the task of bedtime snack auto populated on all resident's Kardex, she said it was her responsibility to remove it for residents that were not allowed to have one. She said she failed to remove the task of bedtime snack for Resident #1 when she completed his most recent care plan. She was observed as she checked Resident #1's task of bedtime snack for the past 30 days and said the CNAs had documented NA for bedtime snack which indicated a snack was not given. MDS/RN F said there were no negative outcomes to Resident #1 having that task of a bedtime snack on his Kardex because he had not been given one. In an interview on 11/12/25 at 11:00, the DON said Resident #1 had been admitted with a feeding tube. She was observed as she checked Resident #1's Kardex and said a bedtime snack was a task that automatically populated but for him, it should have been removed because he was NPO. The DON said there were no negative outcomes to Resident #1 having his Kardex show a bedtime snack because he had not been given one. She said CNAs were trained to no give any food or drink to residents who were on continuous feed via a feeding tube and if they had any questions regarding a resident's plan of care to ask their charge nurse.Record review of the facility's Care Plans policy dated February 2017 and revised January 2024 reflected:Care Plans: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Event ID: Facility ID: 676441 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Alamo 1214 S. Alamo Road Alamo, TX 78516 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #2) reviewed for accuracy of records. The facility failed to ensure LVN C signed off Bisacodyl 10 mg PRN via rectal 1 dose on 10/03/25 after it was administered to Resident #2.This failure could place residents at risk of not receiving appropriate care through inadequate documentation resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. The Findings included: Record review of Resident #2's admission record dated 11/13/25 reflected a [AGE] year-old female with an admit date of 09/29/25 and an initial admission date of 09/15/25. Her relevant diagnoses included end stage renal disease (the final stage of chronic kidney disease, where the kidneys have severe damage and can no longer function well enough to sustain life), dependence on renal dialysis (patient has permanent kidney failure and relies on dialysis procedure or kidney transplant to sustain life), and constipation (having fewer than three bowel movements a week, with stools that are hard, dry, and difficult to pass). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of Resident #2's quarterly care plan dated 09/15/25 reflected a: Focus- I have chronic health conditions & comorbidities conditions that have affected my physical function and may affect my quality of life.constipation Interventions- in part included administer my medications, treatments, respiratory treatment/therapy, and diet as recommended by physician. Provide care as tolerated and needed. Record review of Resident #2's change in condition dated 10/03/25, authored by LVN D reflected: Situation: The change in condition, symptoms, or signs observed and evaluated is/are: constipation or impaction. Things that make the condition or symptom worse are: Resident complaining of constipation and wanting relief. This condition, symptom, or sign has occurred before: yes. Review and notify: primary care clinician notified: yes, date: 10/03/25, time: 11:00 am. Recommendations of Primary Clinicians: administer Bisacodyl PRN via rectal X 1 dose. Record review of Resident #2's eMAR for the month of October 2025 did not reflected an order for bisacodyl PRN via rectal x1 dose therefore, not signed off after being administered on10/03/25. Record review of Resident #2's Bowel Task report for 10/03/25 reflected she had a bowel movement at 1:43 pm. In an interview on 11/12/25 at 9:18 am, LVN D said on 10/03/25, RN E had informed him that Resident #2 had been flagged on their daily reports indicating she had not had a bowel movement in several days. He said he immediately sent CNA H to go check on Resident #2 and asked her if she felt she was constipated or had any discomfort. LVN D said CNA H had later gone back to him and told him that Resident #2 had requested medication for her constipation. LVN D said he called Resident #2's NP and he had prescribed a PRN 1 x medication (Bisacodyl/suppository) for relief. He said he instructed CNA H to accompany him to administer the suppository. LVN D said the medication Bisacodyl was successful and Resident #2 had a bowel movement minutes later. LVN D said as soon as Resident #2's NP ordered the Bisacodyl, he had completed an order and signed it off on her 10/2025 eMAR after it was administered. LVN D there were no negative outcomes to Resident #3 for not inputting an order for Bisacodyl and signing off on it after it was administered because he insisted he had done both. In an interview on 11/12/25 at 10:00 am, RN E said the facility received daily reports on residents that were flagged for not having a bowel movement in three days. RN E said on 10/03/25 while she reviewed those reports she noticed that Resident #2 had been flagged for not having a bowel movement in 3 days and discussed it with LVN D. RN E said as she reviewed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676441 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Alamo 1214 S. Alamo Road Alamo, TX 78516 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #2's eMAR that she did not see an order for the medication Bisacodyl and since there was no order, it did not populate on Resident #2's 10/2025 eMAR. RN E said the facility's protocol would have been that as soon as LVN D received the order for Bisacodyl, he should have inputted an order and then it would have automatically populated on Resident #2's eMAR. RN E said, since LVN D did not create an order for Bisacodyl, it was not populate on Resident #2's eMAR and not alerted to sign off on it. RN E said there were no negative outcomes to Resident #2 not having the medication Bisacodyl listed and signed off on her 10/2025 eMAR because she had confirmed with CNA H and LVN D that it had been administered. She said the medication had been written on Resident #2's Change in Condition. In an interview on 11/12/25 at 11:45 am, the DON said the facility's protocol for a nursing staff would have been that as soon as they receive an order to input it on the resident's electronic medical record. Once it was inputted as an order, it would populate on the resident's eMAR. After the nursing staff had administered the medication, it needed to be signed off on the eMAR. She said if the medication had been inputted and for some reason the nursing staff had forgotten to sign off on it, the system would have generated an alert. She said she had already discovered that on 10/03/25, LVN D had not inputted the medication Bisacodyl as an order and had not signed it off on Resident #2's eMAR. The DON said there were no negative outcomes to Resident #2 not having her medication Bisacodyl listed on her October 2025 eMAR and LVN D not signing off on it. She said the fact that what Resident #2's NP had ordered (Bisacodyl) had been documented on her Change in Condition report was sufficient. The DON said Resident #2's bowel movement task report indicated Resident #2 had a bowel movement on 10/03/25 after the administration of the Bisacodyl. Record review of the facility's Professional Standard of Care policy dated February 2017 and revised in January 2024 reflected: Compliance Guidelines: The community provides services that meet professional standard of quality and are provided by appropriately qualitied persons (e.g., licensed, certified).Compliance with Professional Standards of Care Nursing: Practices-D: When a licensed nurse takes a verbal or telephone order from a medical provider (MD/NP/PA), podiatrist, or dentist, the nurse should sign the order. Event ID: Facility ID: 676441 If continuation sheet Page 4 of 4