Alamo Cove Rehab and Nursing Center

In the surveyor’s words

From the most serious findings on record at Alamo Cove Rehab and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 24, 2026

  This citation pertains to intake #2728846Based on interview and record review, the facility failed to provide adequate care to prevent skin breakdown and the worsening of pressure ulcers in 1 of 3 (Resident #101) residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer. Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #101's Care Plan revealed, Resident has potential for impairment to skin integrity r/t (related to) TBI (traumatic brain injury) post MVA (motor vehicle accident. Date Initiated: 06/16/2025. […]

• Actual harm, isolatedF760Feb 24, 2026

  This citation pertains to intake 2748436 and 2728846. Based on interview and record review the facility failed to ensure 2 residents (Resident #112 and Resident #101) were free from significant medication errors when (a) medications were administered outside physician prescribed parameters (b) medications were not administered as ordered without provider notification resulting in Resident #112 being hospitalized for hypoglycemia (low blood sugar) and Resident #101 missing multiple doses of seizure medication, having a seizure and subsequent change in condition resulting in hospitalization. […]

• Actual harm, isolatedF686Sep 22, 2025

  This citation pertains to intake #2595324.Based on observation, interview, and record review the facility failed to provide adequate care to prevent skin breakdown and worsening of pressure ulcers in 1 resident (Resident #108) of 3 residents reviewed for pressure ulcers, resulting in actual skin breakdown and worsening of pressure ulcers due to inadequate treatments, proper repositioning and incontinence care.Findings include:Review of an admission Record revealed Resident #108 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fall and pressure ulcer of sacrum (tailbone). […]

• Actual harm, isolatedF686Aug 28, 2024

  This citation pertains to intakes M100146395 and M100146349. Based on interview and record review, the facility failed to follow their policy and appropriately provide pressure ulcer care as ordered for 1 (Resident #2) of 4 residents reviewed for pressure ulcers, resulting in hospitalization . Findings include: A Wound Vacuum-Assisted Closure (or wound VAC) is a method used to decrease air pressure around a wound to assist the healing. It is also referred to as negative pressure wound therapy. During a VAC procedure, a healthcare professional applies a foam bandage over an open wound, and a vacuum pump creates negative pressure around the wound. This means the pressure over the wound is lower than the pressure in the atmosphere. […]

• Actual harm, isolatedF689Aug 28, 2024

  This citation pertains to intakes: MI00146486 and 146502 Based on interview and record review the facility failed to provide supervision and assistance in 1 of 4 residents (R1) reviewed for falls/safety, resulting in falls and injuries. Findings included: Review of R1's face sheet dated 8/26/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: personal history of traumatic brain injury, mild neurocognitive disorder, severe protein-calorie malnutrition, post-traumatic stress disorder and repeated falls. R1 was not his own responsible party. Review of R1's fall care plan dated 4/26/24 revealed, resident at risk for falls r/t (related to) weakness, repeated falls encephalopathy and debility. […]