The Heights of Bulverde

In the surveyor’s words

From the most serious findings on record at The Heights of Bulverde, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 21, 2025

  Based on interview, and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 1 of 23 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide that Resident # 1's environment remained as free of accident hazards as is possible when Resident #1 swallowed wet wipes, choked and expired. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:11 p.m. […]

• Actual harm, patternF689May 5, 2024

  41937 Based on observations, interview, and record review the facility failed to ensure residents' environment remained as free of accidents and hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 6 of 20 residents (#1, #3, #27, #39, #46 and #185 ) reviewed for assistance with safe mechanical lifts and falls. 1. On 05/05/2024 at 03:54 PM CNA R transferred Resident #39 from her bed to her wheelchair with the assistance of 1 person and caused Resident #39 discomfort and pain. 2. On 04/16/2024 The facility assessed 4 residents (#1, #3, #27, and #46) with the need for a mechanical lift and planned for residents to receive assistance with mechanical lifts with the aid of 1 person. 3. […]

• No harm, potential for more than minimal, widespreadF812May 5, 2024

  FACILITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed, in that: 1. The walk-in freezer container approximately twenty-five boxes of frozen foods which were stored on the floor and haphazardly stacked on top of each other. 2. The reach-in refrigerator near the kitchen door contained a bottle of soda which belonged to a staff member. 3. The floor under the three-part sink in the dish room was soiled with a dark brown substance that appeared to be dirt or mud. 4. The walls throughout the kitchen were soiled with substances of various color. 5. The commercial toaster was soiled with an abundance of crumbs. 6. […]

• No harm, potential for more than minimal, widespreadF814May 5, 2024

  Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster site reviewed, in that: The area near the facility's two dumpsters was soiled with spilled kitchen oil and other refuse. This deficient practice could lead to an unsanitary environment and encourage the presence of pests. The findings were: Observation on 05/03/2024 at 4:40 p.m., of the area near the facility's two dumpsters revealed two, forty-gallon drums were located behind the facility dumpsters. The lids of both drums were loose and used fryer oil had spilled from the drums onto the ground underneath, beside, and in front of the facility dumpsters. […]

• No harm, potential for more than minimal, patternF755Aug 14, 2026

  Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services including procedures that assured accurate dispensing, administering, and timely documentation of medications given, to meet the needs of each resident for three (3) of twelve (12) residents (Resident #44, #69 and #86) reviewed for pharmacy services. 1. The facility failed to make sure Resident #44's self-administered eye drops GenTeal Tears Lubricant Eye Drops (Dextran 70 0.1%) and Ultra Lubricant Eye Drops (Polyethylene Glycol 400 0.4%) matched physician's orders. 2. […]