Asbury Care Center: Immediate Jeopardy Violations - TX
The inspection, completed August 23, resulted in an immediate jeopardy citation — the most serious violation level — indicating conditions that could cause serious injury, harm, impairment or death to residents.
Resident #2, admitted July 3 for planned hospice respite care, had a BIMS cognitive assessment score of zero, indicating severe cognitive decline. Her diagnoses included senile degeneration of the brain, schizophrenia and dementia — conditions that affect a person's ability to distinguish reality from delusions and cause progressive memory loss.
The facility's own care plan acknowledged the resident "demonstrates wandering and/or exit-seeking behavior placing self at risk for elopement or injury." Despite this documented risk, she successfully left the building on July 4.
Progress notes from that day show Licensed Vocational Nurse D documented seeing the resident just five minutes before going into the nurses station restroom. The note abruptly ends mid-sentence: "after this nurse" — suggesting the discovery of the elopement interrupted the documentation.
Federal inspectors identified systemic failures in the facility's approach to resident safety. The investigation revealed problems with both elopement prevention and management of suicidal and self-harm behaviors affecting multiple residents, including Resident #1 and Resident #10.
Staff training appeared inadequate across all departments. According to rosters provided by administration, 57 employees required emergency training or interviews about elopement behaviors following the incident. This included 11 registered and licensed vocational nurses, 18 certified nursing assistants, eight dietary workers, five housekeeping and maintenance staff, seven physical and occupational therapists, and eight administrative personnel.
The facility scrambled to address the training gaps, with administration noting that staff not yet interviewed would be required to complete training before beginning work shifts between August 22 and August 25.
Inspectors found the facility did maintain some safety protocols. Resident welcome packets included sections on restricted items, identifying unsafe objects that could pose risks to vulnerable patients.
The medical director's involvement in the facility's quality assurance program appeared limited. When inspectors called on August 22 at 12:35 PM requesting information, they had to leave a voicemail. Records showed the medical director participated in quality meetings by phone rather than in person, while a psychiatric nurse practitioner attended meetings physically.
The timing of Resident #2's elopement proved particularly concerning. The incident occurred during a holiday weekend when staffing patterns often differ from normal operations. The resident had been admitted just one day earlier for what should have been a carefully managed short-term stay focused on providing family caregivers temporary relief.
Her discharge date of July 8 indicates the elopement didn't immediately end her stay, suggesting either she was quickly located or the incident didn't prompt immediate discharge. The inspection report doesn't specify how long she remained missing or the circumstances of her return.
The immediate jeopardy citation affects few residents, according to federal classifications, but highlights broader systemic issues with the facility's safety protocols. Elopement represents one of the most serious risks in dementia care, as cognitively impaired residents may become lost, injured, or exposed to weather conditions they cannot navigate safely.
The facility's quality assurance program documented the presence of psychiatric expertise, with a nurse practitioner specializing in mental health participating in facility meetings. This suggests awareness of the complex behavioral health needs among residents, making the safety failures more significant.
Federal inspectors noted the investigation revealed problems beyond the single elopement incident, citing concerns about the facility's handling of suicidal and self-harm behaviors among residents. These issues affect multiple patients and point to gaps in staff training, supervision, and emergency response protocols.
The August inspection occurred more than a month after the July 4 elopement, suggesting either ongoing problems or a delayed complaint that triggered the federal investigation. Complaint inspections typically result from reports by family members, staff, or other concerned parties who witness or learn about concerning incidents.
Resident #2's case illustrates the vulnerability of patients with severe cognitive impairment who require specialized care and constant supervision. Her zero BIMS score indicates she likely couldn't communicate her needs clearly or understand safety instructions, making effective supervision critical for preventing dangerous incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Asbury Care Center of Alamo from 2025-08-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Broadway Nursing & Rehabilitation in SAN ANTONIO, TX was cited for immediate jeopardy violations during a health inspection on August 23, 2025.
Resident #2, admitted July 3 for planned hospice respite care, had a BIMS cognitive assessment score of zero, indicating severe cognitive decline.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.