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 The Heights Of Gonzales during CMS and state inspections, most recent first.
Unsecured kitchenette with hot steam table and unattended food items: The facility failed to keep a kitchenette area free of accident hazards when the door to kitchenette #1 was open and unlocked, the steam table was on and hot to the touch, and the refrigerator contained milk and trays of liquids marked for lunchtime service. No staff were present in or near the area, while staff and residents were nearby conducting a scheduled activity. The Activities Director confirmed the conditions during observation, and the Administrator later stated new locks had been directed for both kitchenette doors.
A resident with an indwelling urinary catheter, neurogenic bladder, and bowel incontinence received incontinent care that was not completed as directed. During observation, CNAs cleaned the resident’s genital and catheter area, but a soiled brief was left in place while the resident was rolled back onto her back, and the resident’s buttocks were not cleaned again before a clean brief was applied. The CNAs and DON confirmed the care was not done correctly, and the facility’s perineal care guideline required the rectal area to be washed after turning the resident to the side.
A resident with COPD, chronic respiratory failure with hypoxia, and dependence on supplemental O2 had tubing and a nasal cannula left on the floor and under the bed while not in use, with no receptacle available for storage. The resident said she was not provided a plastic bag or anything to place the tubing in, and a CNA and the DON stated the tubing should be stored in a plastic bag when not in use to avoid cross-contamination and potential respiratory infection.
Missing dosage on Zyrtec order: A resident with HTN, HF, and epilepsy had Zyrtec ordered once daily in the morning, but the MAR did not specify a dose. Medication history showed the medication was administered throughout the month without a listed dosage. During observation, an MA noticed the missing dose on the MAR and stated she had the order clarified by the DON before giving the medication. The DON said MAs are expected to follow physician orders and notify the charge nurse of any deviations.
A resident with COPD, HTN, and DM had a jar of Vicks observed on her bedside table even though there was no order for self-administration and no order for her use of Vicks. The resident said family brought the Vicks and that she had not had a self-medication assessment or used it. An LVN and the DON confirmed the Vicks was on the bedside table, and the facility policy stated medications should not be left with a resident unless approved for self-administration.
The facility failed to ensure its menus consistently provided a nourishing, well‑balanced diet with adequate fruits and vegetables as required by its own Nutrition Care Manual and dietary policy. An anonymous complaint alleged poor variety and noncompliance with nutritional guidelines. Surveyors observed a dinner meal where no fruit dessert cart or fruit distribution occurred, despite staff claims that such options were available. Review of the Fall/Winter 2025 menu showed multiple days where listed meals did not meet the manual’s expectations for daily fruit and vegetable intake, and reliance on juice and items like potatoes and cucumbers to count as vegetables was noted. The CDM reported following menus approved by a food company and the RD, and the ADM stated he relied on RD sign‑off for nutritional adequacy, but the written menus did not document the additional fruit and vegetable sources staff described.
A resident with severe cognitive impairment did not have their privacy maintained during incontinent care, as CNA and LVN failed to fully close the privacy curtains, leaving the resident exposed. Both staff members acknowledged the oversight, and the DON confirmed the requirement for privacy during care.
A long-term care facility failed to maintain an effective infection prevention and control program. A CNA did not follow proper hand hygiene while caring for a resident with a urinary catheter. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents requiring high-contact care, as staff did not wear gowns or have access to PPE. The facility's failure to adhere to infection control policies and CMS guidelines was confirmed by the DON.
The facility failed to update comprehensive care plans for two residents, one with improved cognitive status and another with discontinued anti-depressant medication. The care plans did not reflect these changes, potentially leading to confusion and improper care. The ADON and DON acknowledged the oversight, emphasizing the importance of accurate care plans.
A facility failed to provide proper incontinent care for a resident, risking infection and skin breakdown. A CNA did not clean the necessary areas during care, despite the resident's history of urinary tract infections and need for extensive assistance. The DON confirmed the oversight and noted the absence of a specific policy for female incontinent care.
A facility failed to secure medications properly, as an LVN left a vial of Fiasp Insulin unsecured on top of a medication cart while administering medications to a resident. The medication cart was out of the LVN's sight, which could lead to drug diversion and accidents. The DON confirmed that nurses are responsible for securing medications, and the facility's policy requires medication carts to be kept closed and secured.
The facility failed to properly store a 16-oz. bag of chips in the kitchen's dry storage room, as it was found opened and placed in an unsealed zip lock bag. This was against the facility's food storage policy and the U.S. FDA Food Code, which require opened items to be stored in tightly covered containers to prevent contamination and potential foodborne illness.
The facility failed to properly dispose of garbage and refuse by leaving the sliding doors of a dumpster open, creating a gap that could allow rodents to enter. This was confirmed by the DM, who acknowledged the importance of keeping the doors shut to prevent the spread of foodborne illness. The facility's policy and the U.S. Public Health Service Food Code require that outdoor receptacles have tight-fitting lids or doors, which were not adhered to in this instance.
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in the handling of oxygen tubing and nasal cannulas. Residents with COPD and acute respiratory failure were observed with their oxygen tubing and nasal cannulas on the floor, risking contamination and inadequate oxygen delivery. Staff acknowledged the issues but did not take corrective action.
Unsecured kitchenette with hot steam table and unattended food items
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible in 1 of 2 kitchenettes reviewed, near the Activities Area. During observation, the door to kitchenette #1 was open and unlocked, the steam table was on and hot to the touch, and the refrigerator contained a gallon container of milk and three trays with approximately 40 glasses of liquid marked to be served at lunchtime. No staff were present in the kitchenette or within the surrounding area at the time of the observation. Further observation showed staff and residents were within approximately 30 feet of the kitchenette conducting a scheduled activity. During interview, the Activities Director confirmed the kitchenette door was open, no staff were present, the steam table was hot, and the refrigerator contained milk and glasses of liquid. The Administrator later stated he had directed new locks to be installed on the doors to both facility kitchenettes and directed staff to ensure the doors remain locked at all times. Record review of the facility policy, Physical Environment, stated the community is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public.
Incontinent Care and Catheter Care Not Properly Performed
Penalty
Summary
A deficiency was cited for failure to provide appropriate incontinent care and catheter care for Resident #76, a female with intact cognition (BIMS 15), an indwelling urinary catheter, neurogenic bladder, bowel incontinence, low vision, spinal stenosis, type 2 diabetes with hyperglycemia, hypertension, tubulo-interstitial nephritis, and other urinary tract diagnoses. Her care plan directed incontinent care every shift and as needed, and catheter care every shift and as indicated. During observation of incontinent care, CNA A cleaned the resident’s suprapubic area, groin, and catheter tubing, and then turned the resident to her left side where a bowel movement was present. CNA A cleaned the rectal area and buttocks but did not remove the soiled brief before the resident was rolled back onto her back, leaving her buttocks touching the soiled brief. CNA B then removed the brief but did not clean the resident’s buttocks again before applying a clean brief. Both CNAs and the DON stated the brief should have been removed before the resident rolled onto it and the buttocks should have been cleaned again before the clean brief was applied. The facility’s perineal care guideline also stated that after washing the genital area, the resident should be turned to the side and the rectal area washed and rinsed from front to back using a clean area of the washcloth for each stroke.
Improper Storage of Supplemental Oxygen Tubing
Penalty
Summary
Resident #50, a [AGE]-year-old female admitted on 03/17/2026 with diagnoses including chronic respiratory failure with hypoxia, COPD with dependence on supplemental oxygen, heart failure, end stage renal disease, diabetes mellitus with neuropathy, hypertension, and a pelvic fracture, had a BIMS score of 15 indicating intact cognition. Her physician order dated 03/25/2026 directed oxygen at 2-4 L/min as needed for shortness of breath, and her care plan identified oxygen therapy as needed for ineffective gas exchange with interventions to assist with positioning and promote lung expansion. During observation, the resident was in bed with the head of bed elevated about 45 degrees, the oxygen concentrator was on the opposite side of the room, and the oxygen tubing was on the floor with the nasal cannula resting on the metal bed frame under the headboard. No receptacle was present in the room for storage of the tubing and cannula when not in use. The resident stated she usually wore oxygen only at night, did not have a plastic bag or anything provided to place the tubing in, and said she just laid it on the bed. A CNA stated the tubing and cannula should not be on the floor and under the bed and should be placed in a plastic bag because the floor can be dirty; the DON stated the expectation was to place oxygen tubing in a plastic bag when not in use to avoid cross-contamination and potential respiratory infection. The facility policy also stated that a storage receptacle should be provided for proper storage when not in use.
Missing dosage on Zyrtec order
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident by not ensuring that Zyrtec (Cetirizine) had a dosage ordered on the MAR. Resident #1 was a [AGE]-year-old female admitted on 1/22/26 with diagnoses including hypertension, heart failure, and epilepsy. Her initial MDS assessment dated 1/29/26 showed a BIMS score of 12, indicating moderate cognitive impairment. Review of her March 2026 physician orders showed Zyrtec ordered once daily in the morning, but no dosage was specified. Medication administration history showed Zyrtec was administered throughout March 2026 without a specified dosage. During observation, MA D was pulling medication from the cart and reading the MAR when she noticed the order did not specify a dosage. She stated the Zyrtec order did not list a dosage and that she had the order clarified by the DON before administering it. The DON stated certified medication assistants are expected to administer medications according to physician orders and notify the charge nurse of any deviations, and she was unaware why the Zyrtec order did not include a dose on the MAR. The facility policy required verification of the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.
Medication Left at Bedside Without Self-Administration Approval
Penalty
Summary
Drugs and biologicals were not secured properly for Resident #23 when a jar of Vicks was observed on the resident’s bedside table. Resident #23’s record showed she was an [AGE]-year-old female admitted with chronic obstructive pulmonary disease, hypertension, and diabetes mellitus. Her quarterly MDS showed a BIMS score of 15, indicating intact cognition. Review of her March 2026 physician orders did not show an order to self-administer medications, and there was no order for her use of Vicks. During observation of the room, the jar of Vicks was seen on the nightstand. The resident stated her family had purchased and brought the Vicks to her sometime before February 14, 2026, and that she had not been given a self-medication assessment and had not used the Vicks. CNA F did not recall seeing the jar during morning care. LVN E confirmed the Vicks was on the bedside table and stated the resident had not received a self-medication assessment and should not have access to medication for self-administration. The DON also reported that the jar of Vicks was found on the bedside table and stated no medication should be left on a resident’s bedside table without a self-medication assessment. The facility policy stated to avoid leaving medications with the resident to self-administer unless the resident is approved for self-administration.
Menus Failed to Ensure Adequate Fruits and Vegetables per Facility Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a nourishing, palatable, well‑balanced diet that met daily nutritional and special dietary needs, including adequate fruits and vegetables as outlined in its own nutrition resources. An anonymous complaint alleged that the facility did not serve a good variety of foods and that the food did not meet nutritional guidelines for each resident. During observation of a dinner meal, a requested sample tray did not include a fruit option from a dessert cart, and no dessert cart or staff passing out fruit to residents was observed during that dinner service. Record review of the facility’s Fall/Winter 2025 menu showed that on multiple days (Days 6, 12, 14, 16, 20, 22, 25, and 30), the planned meals did not consistently provide the number of fruit and vegetable servings described in the facility’s Nutrition Care Manual, which called for 2.5 cups or more of vegetables and 2 cups or more of fruits per day, with at least half of fruits from whole fruit rather than juice. For example, Day 6 listed only one vegetable (sweet peas) and one fruit (juice) for the entire day, and other days relied heavily on items such as potatoes, cucumbers, and juice to meet fruit and vegetable expectations. The written menus did not document additional sources of fruits and vegetables such as snacks or dessert carts. In interviews, the CDM stated she followed the menus approved by the contracted food company and the RD and questioned why some items like fruit were missing, but continued to follow the approved menus. The RD reported that potatoes and cucumbers were counted as vegetables on certain days and stated that they ensured five servings of fruits and vegetables per day, also indicating that fruit juice available all day, a dinner dessert cart with fruit, and snacks at the nurse’s station were counted toward residents’ fruit intake; however, these practices were not reflected on the written menus. The ADM stated his expectation that the purchased menus and RD approval ensured nutritional adequacy. The facility’s Dietary Services policy required menus to meet residents’ nutritional needs in accordance with recommended dietary allowances, but the cited National Research Council reference did not specify daily fruit and vegetable amounts for older adults, and the facility’s actual menus and documentation did not demonstrate compliance with the facility’s own Nutrition Care Manual standards for fruits and vegetables.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during the provision of incontinent care. Specifically, CNA A and LVN B did not completely close the privacy curtains while providing care, which resulted in the resident being exposed and visible from the room's door. This incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 00, and who required total care for activities of daily living due to incontinence of bladder and bowel. Interviews with CNA A and LVN B confirmed that the privacy curtains were not fully closed during the care, although they acknowledged that it should have been. The Director of Nursing (DON) also confirmed that privacy must be maintained during nursing care and that the staff had received training on resident rights within the year. The facility's policy emphasizes the importance of maintaining privacy during procedures, aligning with the expectation that residents are treated with dignity and respect.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. One significant issue involved a Certified Nursing Assistant (CNA) who did not follow proper hand hygiene protocols while providing care to a resident with severe cognitive impairment and multiple medical conditions, including a urinary catheter. The CNA did not change gloves or sanitize hands after handling soiled materials and before applying a clean brief, which was confirmed by both the CNA and the Director of Nursing (DON) during interviews. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents requiring high-contact care activities. This was observed in the care of three residents: one with a urinary catheter, another with a wound, and a third receiving medication via a G-tube. Staff members providing care did not wear gowns, and there were no EBP signs or personal protective equipment (PPE) supplies available outside the residents' rooms. Interviews with staff revealed a lack of training and awareness regarding EBP, and the Assistant Director of Nursing (ADON) admitted that EBP had not been implemented at the facility. The facility's failure to adhere to its own infection control policies and the Centers for Medicare & Medicaid Services (CMS) guidelines for EBP was evident. The DON confirmed that EBP was part of the facility's infection control policy but had not been executed, leaving residents with wounds or indwelling devices without the necessary precautions to prevent infection. This oversight was attributed to a lapse in implementing the updated guidelines, as acknowledged by the DON.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident, the care plan did not reflect the resident's improved cognitive status. The resident, who had been admitted with conditions including hypokalemia, cerebral infarction, and type II diabetes, had a quarterly MDS assessment indicating full cognition. However, the care plan still noted impaired cognitive function with a low BIMS score, which was outdated. The Assistant Director of Nursing (ADON) acknowledged that the care plan should have been updated to reflect the resident's current cognitive status. For another resident, the care plan was not updated to reflect the discontinuation of anti-depressant medication. This resident, diagnosed with dementia, bipolar disorder, and major depressive disorder, had a quarterly MDS assessment showing full cognition and no current use of anti-depressant medication. Despite this, the care plan still included a focus area on anti-depressant medication, which was no longer applicable. The ADON confirmed that the care plan was incorrect and should have been revised to include a focus area on the diagnosis of depression instead. The facility's policy requires that care plans be reflective of the resident's current medical, nursing, mental, and psychosocial needs, and be updated at least quarterly or with significant changes in condition. The failure to update these care plans could lead to confusion among staff and improper care for the residents. The Director of Nursing (DON) also acknowledged the importance of updating care plans to ensure proper care is provided.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections. During an observation, it was noted that a CNA did not thoroughly clean the rectal area, groin areas, and upper thighs of a resident who was incontinent of bladder. The resident, who had a history of urinary tract infections and required extensive assistance with activities of daily living, was at risk for infection and skin breakdown due to these improper care practices. The CNA admitted to not cleaning the necessary areas and attributed the oversight to nervousness, despite having received training in infection control and incontinent care within the past year. The Director of Nursing (DON) confirmed that the rectal and groin areas should have been cleaned and stated that the facility's training for infection control and incontinent care was conducted by the DON and Assistant Directors of Nursing (ADONs). However, it was revealed that the facility did not have a specific policy or procedure outlining the steps for providing incontinent care for female residents. This lack of a detailed procedure may have contributed to the improper care provided to the resident.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, a Licensed Vocational Nurse (LVN-F) prepared medications for a resident, including drawing up 16 units of Fiasp Insulin into a syringe. After locking the medication cart, the LVN left the vial of Fiasp Insulin unsecured on top of the cart and entered the resident's room to administer the medications. The medication cart was out of the LVN's sight, which posed a risk for drug diversion and accidents. In an interview, LVN-F acknowledged leaving the insulin vial unsecured, explaining that it was initially left out for the State Surveyor to view but was forgotten afterward. The Director of Nursing (DON) confirmed awareness of the incident and stated that each nurse is responsible for ensuring all medications are secured inside the medication cart unless directly supervised. The facility's policy on medication cart use and storage emphasizes that medication carts should be kept closed, secured, and within the line of sight when not in use, and medications should not be left on top of the cart unless within direct line of sight of authorized personnel.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, specifically in the storage of food items. During an observation, a 16-oz. bag of chips was found in the dry storage room that had been opened, rolled down, and placed inside a zip lock bag that was not sealed. This improper storage practice was acknowledged by the Dietary Manager (DM), who stated that the bag should have been sealed to prevent pests and potential foodborne illness. The facility's policy on food storage, revised in 2019, mandates that all food must be stored according to state, federal, and US Food Code and HACCP guidelines, which include storing opened items in tightly covered containers. The U.S. FDA Food Code also requires food to be protected from contamination by storing it in a clean, dry location, away from splash, dust, or other contamination. The failure to comply with these standards could place residents at risk for foodborne illness.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse for one of the two dumpsters reviewed. Specifically, the sliding doors on both sides of Dumpster #1 were observed to be open, leaving a gap of approximately six inches between the door and the wall of the dumpster. This observation was made during a survey, and the Dietary Manager (DM) confirmed that the doors should have been completely shut to prevent rodents from entering the dumpsters and potentially spreading foodborne illness. The facility's policy on garbage receptacles, revised in 2019, requires that outdoor receptacles have tight-fitting lids, doors, or covers and be stored in a manner that is inaccessible to insects and rodents, with doors and lids kept closed. Additionally, the U.S. Public Health Service Food Code mandates that receptacles for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment. The facility's failure to adhere to these guidelines was identified as a deficiency during the survey.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in the handling of oxygen tubing and nasal cannulas. Resident #6, a [AGE] year-old female with COPD and type II diabetes, was observed with her oxygen tubing on the floor in the dining room. Despite her requests to staff to keep the tubing off the floor, it was found stretched across the floor from the concentrator to her seating area. Staff acknowledged the issue but did not take corrective action, potentially risking contamination and inadequate oxygen delivery. Resident #7, a [AGE] year-old female with COPD, dependence on supplemental oxygen, and severe cognitive impairment, was also observed with her oxygen tubing on the floor while seated at the dining room table. The tubing was connected to an oxygen cylinder attached to her wheelchair. Staff confirmed their responsibility for the placement of the oxygen tubing and acknowledged that it should not be on the floor, yet the issue persisted. Resident #8, an [AGE] year-old female with acute respiratory failure, was found with her nasal cannula on the floor in the bathroom while she was seated in her room. The oxygen cylinder was in the bathroom, and the nasal cannula was lying on the floor in front of the toilet. Staff acknowledged the issue and the potential for contamination, but the problem was not addressed promptly. The facility's policy on oxygen-respiratory tubing management was not adhered to, leading to these deficiencies.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gonzales
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Gonzales | 0.6 mi | ★★★★★ | 3 | 0 |
| Diversicare Of Luling | 15 mi | ★★★★★ | 0 | 0 |
| Avir At Magnolia | 16.9 mi | ★★★★★ | 21 | 2 |
| Avir At Luling | 17.1 mi | ★★★★★ | 17 | 0 |
| Shiner Nursing And Rehabilitation Center Inc | 18 mi | ★★★★★ | 13 | 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 August 2026) and official state health department websites.