Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Heights Of Atascosa during CMS and state inspections, most recent first.
Kitchen Food Safety and Sanitation Deficiencies: A cook was observed without a beard guard and a kitchen aide without a hair restraint, required temp logs for the refrigerator, freezer, and dishwasher were not signed off, and multiple food items were found undated or improperly labeled. The kitchen floor drain beneath the rear prep counter also contained standing water and debris, and the Dietary Supervisor and Maintenance Director confirmed the sanitation concerns.
MDS Assessment Did Not Reflect Diuretic Use: A resident with HF, heart disease, HTN, and kidney disease had an MDS that listed several medications and severe cognitive impairment, but did not include prescribed diuretic therapy. The MAR showed the resident was receiving Furosemide as ordered, and the care plan documented heart disease but not the diuretic use. The MDS LVN, DON, and Administrator stated the MDS should accurately reflect the resident’s orders and care.
Care Plan Did Not Reflect Antiplatelet Medication Use: A resident with dementia, epilepsy, hyperlipidemia, HTN, and stroke had an MDS that documented antiplatelet medication use and an order for Cilostazol, but the care plan did not note the antiplatelet medication. The MDS LVN stated the drug was coded as an antiplatelet because of its effect, and the DON stated antiplatelet meds should be included on the care plan so staff know what the resident is on and care plans remain accurate.
The facility failed to keep the controlled substance reconciliation log fully signed for the H nurse cart. During cart observation, one signature was missing from the shift-change count log, and the LVN and DON both stated the log should be signed at each shift change when the controlled medication count is completed. The facility policy also required narcotic count logs to be reconciled at the beginning and end of each shift exchange.
A resident with a history of severe mental illness made repeated allegations of sexual abuse, which were documented by nursing staff and reported internally to the DON and Administrator. However, the facility did not report these allegations to the state agency, as required by policy, because leadership determined the claims were delusional and unsubstantiated. No self-reports were submitted to the state regarding these incidents.
Two residents, one with hemiplegia and moderate cognitive deficit and another with a history of stroke and amputation, were found with their call lights out of reach. Staff interviews confirmed the importance of call light accessibility, but the issue was not identified or addressed at the time, contrary to facility policy.
A resident's right to privacy was not maintained when a broken window blind in her room allowed people outside to see inside, especially during personal care and while changing clothes. Staff interviews confirmed the issue and acknowledged the potential for privacy concerns, with the facility's policy requiring protection of resident privacy and confidentiality.
A resident with intact cognition and requiring assistance for daily living was unable to fully cover her window due to a broken blind, resulting in privacy concerns as people outside could see into her room. Staff interviews confirmed the issue, and facility policy emphasizes the right to privacy and confidentiality during care.
Two residents with significant medical histories and fall risks did not have their call lights within reach as required by their care plans. Observations found one call light wedged between the bed rail and mattress and another on the floor, with both residents unable to access them. Nursing staff and the DON confirmed the importance of following care plans and keeping call lights accessible for resident safety.
Surveyors found that the kitchen's deep fryer and its baskets were not cleaned after use, with visible crumbs and grease remaining after two meals had been served. Staff interviews confirmed the fryer should have been cleaned after each use, and facility policy requires daily cleaning of all food-contact equipment. The deficiency was observed and acknowledged by staff, but the fryer remained uncleaned throughout the survey period.
Nursing staff did not document the changing of oxygen tubing and nasal cannula for a resident with multiple medical conditions, leaving scheduled entries blank on the treatment administration record despite the changes being performed and labeled. Both the ADON and DON confirmed the omission of documentation, resulting in incomplete medical records.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to procure, store, prepare, distribute, and serve food in accordance with professional standards in one kitchen. During observation, the cook was seen without a beard guard and the kitchen aide was observed without a hair restraint. In interview, the Dietary Supervisor confirmed that beard guards and hair restraints were required whenever dietary staff handled food, and stated that hair contamination could present a sanitation concern. Training and certificates for dietary staff were reviewed and were up to date and in compliance with regulations. The facility also failed to sign off on temperature logs for the refrigerators, freezers, and dishwasher in the prep area, and failed to properly label and date multiple food items including sugar free syrup, prepared salads, tea, water, thickener, ground beef, cheese, chicken, pancakes, pizza crust, and hamburger patties. The Dietary Supervisor confirmed that temperatures were expected to be documented by the employee who opened in the morning and that food was expected to be dated when received and when opened, with items removed from original packaging sealed and labeled. In addition, the kitchen floor drain beneath the rear preparation counter contained standing water and debris, and the Maintenance Director stated debris had accumulated on the drain covers and restricted drainage.
MDS Assessment Did Not Reflect Diuretic Use
Penalty
Summary
The facility failed to ensure that Resident #5’s assessment accurately reflected the resident’s status by omitting the use of a diuretic medication on the MDS. Resident #5 was an [AGE]-year-old female admitted with diagnoses including heart failure, heart disease, hypertension, and kidney disease. The MDS assessment documented a BIMS score of 5, indicating severe cognitive impairment, and listed the use of antianxiety, antibiotic, antiplatelet, and anticonvulsant medications, but did not include diuretic use. Record review showed that Resident #5 had an order for Furosemide 20 mg by mouth daily related to heart failure, and the June 2026 MAR showed the medication was administered during the lookback period from 6/09/2026 through 6/15/2026. The care plan initiated on 6/09/2026 documented heart disease but did not document the resident’s use of diuretic medication. During interviews, the MDS LVN stated she was responsible for ensuring the accuracy of the MDS and that missing information could affect the care plan and resident care. The DON stated the MDS assessments were expected to be accurate and reflect the orders, and the Administrator stated the facility used the RAI manual as its policy for MDS assessments.
Care Plan Did Not Reflect Antiplatelet Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that reflected all assessed needs, including the resident’s antiplatelet medication use. Resident #61 was an [AGE] year-old male with diagnoses including dementia, epilepsy, hyperlipidemia, hypertension, and stroke. His MDS assessment documented a BIMS score of 12, indicating moderate cognitive impairment, and recorded the use of antidepressant, anticoagulant, opioid, antiplatelet, and anticonvulsant medications. The resident’s order summary included Cilostazol 100 mg by mouth twice daily, ordered on 3/14/2025. Record review showed the resident’s care plan, initiated on 5/11/2023, did not document that he was treated with an antiplatelet medication. During interview, the MDS LVN stated Cilostazol was coded on the MDS as an antiplatelet medication because it had an antiplatelet effect. The DON stated antiplatelet medications should be on the care plan so staff would know what the resident was on, and stated the expectation was for care plans to be accurate because they guide how care is provided to the resident. The facility policy titled Care Plan Development, Review, and Update Policy stated the purpose of the care plan was to ensure each resident receives an individualized, person-centered care plan that reflects assessed needs, goals, preferences, risks, and strengths.
Missing Controlled Medication Reconciliation Signature
Penalty
Summary
The facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 carts reviewed, the H nurse cart. During observation of the cart with LVN A, one signature was missing from the controlled medication reconciliation log for the shift change count. LVN A stated the reconciliation log should be signed when the controlled medication count was performed at shift change, and the DON stated the log should be signed at every shift change because the receiving staff member was taking responsibility of the cart. Record review of the facility policy titled Narcotic Medications: Controlled Drugs - Fentanyl Patch Disposal stated that narcotic count records/logs were to be reconciled at the beginning of and at the end of each shift exchange.
Failure to Timely Report Allegations of Abuse Due to Resident's Psychiatric History
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, and mistreatment were reported immediately, but no later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, the facility did not report an allegation of sexual abuse made by a resident with a history of bipolar disorder and schizoaffective disorder. The resident, who had a legal guardian, made repeated statements to nursing staff over several months indicating she believed she was being raped by an unknown male, sometimes describing the perpetrator as transforming into other people or using technology to harm her. Nursing progress notes documented multiple instances where the resident expressed fears and allegations of sexual abuse, including claims of being raped by an unknown male, being impregnated, and requests for help. Staff interviews revealed that these allegations were consistently reported up the chain to the DON and Administrator, but were not reported to the state. Staff and leadership attributed the resident's statements to her psychiatric diagnoses, describing them as delusions or hallucinations, and determined internally that the allegations were unsubstantiated. Despite the facility's policy requiring immediate reporting of all alleged or suspected abuse to the state agency, the DON and Administrators decided not to report the allegations, citing the resident's history of delusions and the lack of evidence or named individuals matching the allegations. The facility's records confirmed that no self-reports were made to the state regarding these allegations during the relevant period.
Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, as observed and confirmed through interviews and record reviews. One resident with a history of hemiplegia following a stroke, vascular dementia, and moderate cognitive deficit was found sitting in bed with the call light dangling on the left side, wedged between the bed rail and mattress. The resident confirmed the call light was on his side of the bed. Another resident, who had a history of stroke, above-the-knee amputation, and intact cognition, was observed sitting up in bed with the call light on the floor at the head of the bed near the wall. This resident was unaware of the call light's location. Staff interviews revealed that both nursing and administrative staff acknowledged the importance of keeping call lights within residents' reach for safety and emergency purposes. However, the licensed vocational nurse was not aware that the call lights for these two residents were out of reach. The facility's policy stated that call lights should be placed within easy reach of residents, but this was not followed in these instances.
Resident Privacy Compromised Due to Broken Window Blind
Penalty
Summary
A deficiency was identified when a resident's right to personal privacy was not maintained due to a broken window blind in the resident's room. The blind was unable to cover the window, allowing people outside the facility to see into the room. Observations confirmed that the resident was visible from outside while in her room, and the resident expressed concern about her privacy, particularly when changing clothes. The resident reported being unsure when the blind broke and believed she had informed the facility about the issue. Interviews with staff, including a CNA and an LVN, confirmed awareness of the broken blind and acknowledged that it could compromise the resident's privacy, especially during personal care activities. The CNA stated that the resident did not directly report the issue, while the LVN and DON both recognized that staff are responsible for protecting residents' privacy. The facility's policy on residents' rights includes the right to privacy and confidentiality, which was not upheld in this instance.
Broken Window Blind Compromises Resident Privacy
Penalty
Summary
A deficiency was identified when a resident's window blind was found to be broken, preventing it from fully covering the window. Observations revealed that the resident, who had intact cognition and required setup or cleanup assistance for activities of daily living, was concerned about her privacy, especially when changing clothes in her room, as people outside could see through the uncovered window. The resident stated she thought she had reported the issue but was unsure when the blind became broken. Staff interviews confirmed the blind was not functioning, and both CNAs and an LVN acknowledged that the lack of a working blind could compromise the resident's privacy during care and personal activities. Further review of the resident's care plan indicated she required assistance with incontinence care, and staff typically used blinds to protect privacy during such care. However, the broken blind was not reported by the resident to the staff, and some staff were unaware of the issue until it was brought to their attention. The Director of Nursing also confirmed that the broken blind could affect the resident's privacy, and emphasized that all staff are responsible for protecting residents' privacy during care. Facility policy supports the right to privacy and confidentiality, including private and unrestricted communication and privacy during treatment and personal care.
Failure to Ensure Call Lights Were Accessible as Care Planned
Penalty
Summary
The facility failed to implement person-centered care plans for two residents by not ensuring their call lights were within reach, as required by their individualized care plans. For one resident with hemiplegia, vascular dementia, and a history of falls, the care plan specified that the call light should be in reach to address fall risk. On observation, the call light was found wedged between the bed rail and mattress, not accessible to the resident. The resident confirmed the call light was on his side of the bed but did not indicate it was within easy reach. For another resident with a history of stroke, epilepsy, diabetes, and an above-the-knee amputation, the care plan also required the call light to be in reach due to fall risk. Observation revealed the call light was on the floor near the wall, and the resident was unaware of its location. Interviews with nursing staff, including an RN and an LVN, confirmed the importance of keeping call lights within reach for resident safety and acknowledged that the care plan should be followed. The Director of Nursing also stated that the care plan should be adhered to for patient-centered care and that call lights should always be accessible to prevent falls or ensure help in emergencies. The facility's policy emphasized that care plans are to be used as guides to identify risks and direct care needs, but in these cases, the interventions were not implemented as documented.
Failure to Clean Deep Fryer After Use
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation standards in the kitchen, specifically regarding the cleaning of the deep fryer. On multiple occasions throughout the day, the deep fryer and its baskets were found to contain crumbs, grease, and food residue from previous use. The pan underneath the fryer was also observed to be dirty, with visible crumbs and grease. Despite being used the previous evening, the fryer and its components remained uncleaned after two subsequent meals had been served. Interviews with the Dietary Manager (DM) confirmed that the fryer should have been cleaned after each use and that all kitchen staff were responsible for ensuring the cleanliness of kitchen appliances. Further interviews with the Registered Dietitian (RD) and the DM emphasized the importance of cleaning kitchen equipment daily to prevent contamination and foodborne illness. The facility's own policy on General Kitchen Sanitation, dated 2018, requires all multi-use utensils and food-contact surfaces to be cleaned and sanitized after use. The failure to clean the deep fryer as required by both facility policy and professional standards was directly observed and acknowledged by staff, but no corrective action was taken prior to or during the survey observations.
Failure to Document Oxygen Tubing Changes in Medical Record
Penalty
Summary
Facility nurses failed to document their initials on the medication administration record after changing a resident's oxygen tubing and nasal cannula as ordered. Specifically, for one resident with multiple diagnoses including osteomyelitis of the vertebra, discitis, heart failure, hypertension, muscle weakness, urinary tract infection, and cirrhosis of the liver, the treatment administration record for the month showed blank entries on the scheduled dates for changing the oxygen tubing and nasal cannula. Observation confirmed that the tubing and cannula had been changed and labeled accordingly, but the required documentation was missing. Interviews with the ADON and DON confirmed that the night nurses performed the changes but did not document them, and that there was no specific facility policy regarding documentation of this task. However, both acknowledged that documentation should have occurred to maintain accurate medical records and ensure communication among nursing staff. This lack of documentation resulted in incomplete medical records for the resident.
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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 Pleasanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasanton South Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 13 | 0 |
| Pleasanton North Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 3 | 0 |
| Jourdanton Nursing And Rehabilitation | 3 mi | ★★★★★ | 29 | 0 |
| Hunters Pond Rehabilitation And Healthcare | 24.9 mi | ★★★★★ | 2 | 0 |
| Lytle Nursing Home | 25 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 October 2026) and official state health department websites.