Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alamo Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Missing Documentation for Ordered Wound Care: A resident with a Stage 3 pressure ulcer, quadriplegia, polyneuropathy, and anxiety had a physician-ordered daily treatment for a right buttock wound. Review of the TAR showed multiple missed documentation entries for the wound care, and the DON stated that completed treatments should have been documented on the TAR or in progress notes.
A resident with COPD, HTN, and depression was observed in the designated smoking area with cigarettes and a lighter in his shirt pocket, and the Staffing Coordinator lit the cigarette with the lighter the resident carried. The resident was not wearing a smoking apron during the session, even though the smoking safety evaluation required supervision during smoking times and the care plan later included smoking apron use. Staff stated residents were not supposed to keep cigarettes or lighters on them, and the DON stated smoking should be care planned and residents should not have these items on their person.
A resident with aphasia, atrial fibrillation, dysphagia, and diabetes had a bottle of nasal mist spray and two bottles of lubricant eye drops left unattended on the bedside table without physician orders. In addition, an opened undated tuberculin vial was found in a medication refrigerator, and expired calcium and melatonin were found in a supply room; the LPN, RN, ADON, and DON all confirmed the medications were not stored as required.
A facility failed to follow infection control practices during wound care for a resident with a stage 3 pressure ulcer and during insulin administration for a resident with diabetes. A Wound Physician handled a soiled dressing and wound care tasks without changing gloves or performing hand hygiene, and also removed a phone from a pocket before treatment. An LPN placed insulin supplies on an over-the-bed table without a barrier and left the room after giving insulin without performing hand hygiene. The DON and staff acknowledged the expected hand hygiene and barrier practices.
An LPN at the facility failed to sign out 19 out of 25 medications after administration, resulting in a 76% medication error rate. Two residents, both cognitively intact, received their medications without proper documentation. The facility's policy requires immediate signing out of medications in the EMR, which was not followed. Interviews with the Regional Nurse Consultant and DON confirmed the requirement for immediate documentation.
The facility failed to provide necessary ADL assistance for bathing to two residents, both cognitively intact and dependent on staff for bathing. Despite documented preferences for whirlpool and bed baths, these were not provided on multiple occasions. The DON confirmed that daily bathing or documentation of refusals should occur, which was not adhered to.
A resident with Chronic Obstructive Pulmonary Disease was receiving oxygen therapy without a physician's order, and the facility failed to monitor and document the effectiveness of the oxygen. Observations showed improper storage of oxygen tubing, and interviews with staff confirmed the absence of an order and monitoring. This resulted in a deficiency in providing appropriate respiratory care.
A facility failed to maintain accurate medication records and reconcile controlled medications on the North Medication Cart. An LPN did not sign out narcotics after administration for three residents, leading to discrepancies between the narcotic inventory sheets and the actual remaining doses. The Regional Nurse Consultant confirmed that narcotics should be signed out in the narcotic book after administration.
A facility failed to discontinue a PRN order for Ativan after 14 days and did not provide documented rationale for its continued use. Additionally, the facility did not monitor a resident for bleeding and bruising related to Eliquis use and failed to discontinue Promethazine as ordered. The resident had severe cognitive impairment and multiple diagnoses, including dementia and anxiety.
A facility failed to securely store medications when a Heparin Flush syringe was left unattended in a resident's room. The facility's policy requires drugs to be stored securely, but an observation revealed the syringe on an over-the-bed table. Interviews with an LPN, an RN, and the DON confirmed that the medication should not have been left unattended.
A facility failed to ensure proper infection control practices when an LPN did not perform hand hygiene during medication administration, and two CNAs did not wear PPE or perform hand hygiene during a resident transfer under Enhanced Barrier Precautions. These actions were confirmed by observations and interviews with staff.
Missing Documentation for Ordered Wound Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after the facility failed to document wound care treatments for 1 of 2 sampled residents reviewed for pressure ulcers. The facility policy titled, Prevention of Pressure Ulcers/Injuries, stated that skin changes should be evaluated, reported, and documented. Resident #6 was admitted with diagnoses including Pressure Ulcer Stage 3, Quadriplegia, Polyneuropathy, and Anxiety, and the quarterly MDS indicated the resident was cognitively intact and assessed for a Stage 3 pressure ulcer. The physician's order dated 2/28/2026 directed treatment to the right buttock wound with cleansing, collagen powder, flagyl, alginate calcium with silver, skin prep to the peri-wound area, and a dry dressing, to be changed daily. Review of the TAR showed missing documentation that the treatment was completed on multiple dates in December 2025, February 2026, and March 2026. During interview, the DON reviewed the blank TAR entries and stated that if the treatment was completed, it should have been on the TAR or documented in the progress notes.
Smoking hazards not controlled for a resident
Penalty
Summary
The facility failed to identify and eliminate known and foreseeable accident hazards in the environment for a resident with smoking privileges. The resident was admitted with diagnoses including COPD, HTN, and depression, and the Smoking Safety Evaluation documented that supervision was required for all residents during designated smoking times, along with balance problems while sitting or standing. The baseline care plan did not include smoking, although the resident’s care plan later included smoking and use of a smoking apron. During observation in the designated smoking area, the Staffing Coordinator assisted residents while the resident kept a pack of cigarettes in his front shirt pocket and then pulled a lighter from the same pocket. The Staffing Coordinator lit the resident’s cigarette with the lighter the resident had brought in, and the resident was not wearing a smoking apron during the smoking session. The Staffing Coordinator stated that residents were not allowed to keep cigarettes and lighters on them and that these items were supposed to be locked up. The DON stated that the facility had no residents with independent smoking privileges, that smoking should be on the care plan, and that residents should not have cigarettes or lighters on their person. The DON also stated that if a smoking apron was care planned, residents should wear it, and refusals should be documented in the care plan. The report shows that the resident was observed smoking with cigarettes and a lighter on his person despite the facility’s smoking policy and the resident’s smoking safety evaluation.
Improper Medication Storage and Expired Medications
Penalty
Summary
Medications were not properly stored when a bottle of nasal mist spray and two bottles of lubricant eye drops were found unattended on the bedside table in Resident #52’s room. Resident #52 was admitted with diagnoses including aphasia, atrial fibrillation, dysphagia, and diabetes, and the quarterly MDS indicated the resident did not have a BIMS assessment because the resident was rarely or never understood. The current physician orders did not include orders for the nasal spray or eye drops. During observation and interview, the LPN confirmed the items were left unattended in the room, and the ADON and DON both stated the resident should not have those medications on the bedside table and that medications should be kept in a locked secure area. Medication storage rooms also contained improperly stored medications. In the South Hall medication room, an opened vial of tuberculin in the medication refrigerator was observed without an opened date. In the Central Supply Room, expired medications were found, including calcium 600 mg and multiple bottles of melatonin 3 mg with expiration dates of 11/2025 and 2/2026 and 3/2026. RN C confirmed the tuberculin vial should be dated when opened and that the expired medications should have been discarded. The DON stated medications should be discarded by the expiration date, charge nurses were responsible for checking medications in storage areas, and opened medication vials should be dated.
Infection Control Lapses During Wound Care and Insulin Administration
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during wound care for a resident with dysphagia, a stage 3 facility-acquired pressure ulcer, depression, quadriplegia, and anxiety. The resident was cognitively intact and dependent on staff for ADLs. During wound care, the Wound Physician performed hand hygiene and donned PPE, but then removed the soiled dressing, wiped the wound, and inserted a contaminated gloved finger into the wound bed without changing gloves or performing hand hygiene. The physician also removed a phone from a pocket before starting the treatment. LPN A later continued the wound care by applying Flagyl, collagen powder, and a dressing, then removed PPE, performed hand hygiene, and sanitized the over-the-bed table and cleanser bottles. The facility also failed to maintain infection control during insulin administration for another cognitively intact resident with hemiplegia, anxiety, diabetes mellitus, and depression who was receiving Lantus 70 units subcutaneously twice daily. During medication administration, an LPN prepared the insulin at the medication cart, entered the resident’s room, and placed the insulin syringe and alcohol pad on the over-the-bed table without a barrier. The LPN donned gloves, cleansed the resident’s abdomen with the alcohol pad, administered the insulin, discarded the syringe, removed gloves, and exited the room without performing hand hygiene. The LPN acknowledged that hand hygiene should have been performed after glove removal and that the insulin syringe and alcohol pad should have been placed on a barrier. The DON stated staff should perform hand hygiene before entering and exiting a resident’s room, before giving medications, after procedures, and after glove removal, and stated that double gloving does not replace hand hygiene. The Wound Physician stated that hand hygiene was not needed after removing a soiled dressing because of the multiple gloves worn and stated that double gloving should keep things as sterile as possible, despite the procedure not being sterile.
Medication Administration Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, as evidenced by a 76% error rate during a survey. This deficiency was identified when an LPN did not sign out 19 out of 25 medications after administering them to two residents. The facility's policy requires that the individual administering the medication must log into the resident's electronic medical record (EMR) and attach their signature after giving the medication. However, this procedure was not followed by the LPN during the medication administration for the two residents. Resident #30, who was cognitively intact with a BIMS score of 15, was administered multiple medications, including treatments for asthma, pain, and depression, without the LPN signing them out. Similarly, Resident #39, also cognitively intact with a BIMS score of 15, received medications for high blood pressure and clot prevention without proper documentation. Interviews with the Regional Nurse Consultant and the Director of Nursing confirmed that medications should be signed out immediately after administration, which was not adhered to in these instances.
Failure to Provide ADL Assistance for Bathing
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) related to showering for two residents. According to the facility's policy, residents who cannot perform ADLs independently should receive necessary services to maintain personal hygiene. However, Resident #39, who has cerebral vascular disease and mobility impairments, did not receive the preferred whirlpool baths or bed baths on multiple occasions in November 2024, despite being cognitively intact and requiring substantial to maximal assistance for bathing. Similarly, Resident #114, who is dependent on staff for bathing due to conditions such as spinal stenosis and congestive heart failure, also did not receive the preferred whirlpool baths or bed baths on several dates in November 2024. Both residents were cognitively intact, as indicated by their BIMS scores, and their preferences for bathing were documented but not adhered to. The Director of Nursing confirmed that residents should receive a bath daily or have refusals documented, which was not done in these cases.
Failure to Ensure Proper Oxygen Administration and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring an order for the continued use of oxygen and failing to monitor and document the effectiveness of the oxygen therapy. The facility's policy on oxygen administration requires a physician's order and documentation of the procedure, including the rate of oxygen flow and any assessment data. However, Resident #41, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, was observed receiving oxygen via nasal cannula at 3 liters without a physician's order. The resident's medical record did not contain an order for oxygen, and there was no documentation of monitoring the resident's oxygen saturation levels to ensure the correct amount of oxygen was being delivered. Observations revealed that the oxygen tubing was not stored properly, being left on the dresser and bed instead of in a bag. During an interview, an LPN confirmed the resident was receiving oxygen but was unaware of any order for it. The Director of Nursing also confirmed the absence of an order in the computer system and acknowledged that the resident's oxygen saturation was not monitored. This lack of adherence to the facility's policy and professional standards of practice resulted in a deficiency in providing appropriate respiratory care for the resident.
Medication Record Discrepancies on North Medication Cart
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled medications for one of its medication carts, specifically the North Medication Cart. The policy titled 'Administering Medications' from November 2017 requires that the individual administering medication must record it in the resident's medical record and attach their signature after administration. However, during an observation and interview, discrepancies were found in the narcotic inventory sheets and the actual remaining doses for three residents. For Resident #5, the narcotic inventory sheet indicated two doses of Tramadol were left, but only one tablet remained in the narcotic card. Similarly, for Resident #11, the inventory sheet showed three doses of Gabapentin left, while only two tablets were present. For Resident #24, the inventory sheet showed eight doses of Lorazepam left, but only seven tablets were found. Licensed Practical Nurse (LPN) B, who was responsible for administering these medications, confirmed during the interview that she did not sign out the medications when they were administered, which should have been done according to the facility's policy. The Regional Nurse Consultant also confirmed that narcotics should be signed out in the narcotic book after administration. This failure to accurately document and reconcile controlled medications indicates a lapse in following the established medication administration procedures, potentially affecting the safe management of narcotics within the facility.
Failure to Discontinue PRN Psychotropic Medication and Monitor Anticoagulant Use
Penalty
Summary
The facility failed to ensure a resident's medication regimen was free of unnecessary medications, specifically regarding the use of as-needed (PRN) psychotropic medications. The facility did not discontinue the PRN order for Ativan, an antianxiety medication, after 14 days as required by their policy. Additionally, there was no documented rationale for the continued use of this medication. The Director of Nursing (DON) confirmed the oversight and acknowledged the need for a policy review to address questions related to the PRN order for Ativan. Furthermore, the facility did not adequately monitor a resident for potential complications associated with the use of Eliquis, an anticoagulant. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and anxiety, was not monitored for bleeding and bruising every shift as required. Additionally, the facility failed to discontinue the medication Promethazine as ordered by the provider. These lapses in medication management and monitoring were confirmed by the DON during an interview.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to ensure medications were properly and securely stored, as evidenced by an unsecured Heparin Flush syringe left unattended in a resident's room. The facility's policy, dated May 2015, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner to prevent the possibility of mixing medications. However, during an observation on February 9, 2025, at 9:55 AM, it was noted that a Heparin Flush syringe was left on the over-the-bed table on the unoccupied side of the room of Resident #37, who no longer had a midline catheter. Interviews with LPN F and RN G confirmed that the medication should not have been left unattended. The Director of Nursing also confirmed on February 12, 2025, that medications should not be left unattended at the bedside.
Infection Control Lapses During Medication Administration and Resident Transfer
Penalty
Summary
The facility failed to adhere to proper infection control practices as outlined by the Centers for Disease Control (CDC) and the facility's own policies. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene before and after administering medications to residents, nor between donning and doffing gloves during medication administration. This was confirmed through observations and interviews with the LPN and the Director of Nursing (DON), who acknowledged the necessity of hand hygiene in these situations. Additionally, two Certified Nurse Assistants (CNAs) did not follow Enhanced Barrier Precautions when transferring a resident with a gastrostomy tube and a Foley catheter. The CNAs failed to wear gowns and did not perform hand hygiene before and after glove use. One CNA was observed entering another resident's room with the same gloves on, and both CNAs did not remove gloves or perform hand hygiene after handling potentially contaminated items. The Infection Control Preventionist confirmed these lapses in protocol, emphasizing the importance of gown and glove use, as well as hand hygiene, in preventing the spread of infections.
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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 Alamo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bells Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 4 | 0 |
| Avondale Health And Rehabilitation Center, Llc | 11.9 mi | ★★★★★ | 0 | 0 |
| W D Bill Manning Tennessee State Veterans Home | 12.2 mi | ★★★★★ | 0 | 0 |
| Haywood Post Acute | 15.7 mi | ★★★★★ | 0 | 0 |
| Northbrooke Post Acute | 16.3 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 July 2026) and official state health department websites.