Asbury Care Center: Suicide Attempt Unreported - TX
The administrator at Asbury Care Center of Alamo never reported the suicide attempt to state authorities, despite facility policy requiring notification within 24 hours.
Resident #1 had been crying in her bedroom on May 14 when a certified nursing assistant found her. She told staff she didn't want to live and didn't want to be at the facility anymore. Her responsible party and doctor were contacted, and she was transferred to the hospital.
The psychiatric evaluation during that hospitalization was stark. The resident was physically capable of harming herself, the psychiatrist noted. She wasn't being supervised at her current facility and would potentially be able to hurt herself there. The recommendation was clear: transfer to a memory care facility with closer observation.
She returned to Asbury's general population instead.
Three months later, Licensed Vocational Nurse B found the resident bleeding from her right wrist at 5:00 PM on August 14. The razor lay on the bed beside her.
The resident told the nurse she wanted to die and wanted to go to the hospital.
The wound was superficial, about two centimeters long. The nurse applied pressure, cleaned it, treated it with antibiotic cream, and covered it with a dry dressing. The resident's vital signs were normal. She was placed on one-to-one watch until transport arrived and taken to the emergency room.
When she returned to the facility on August 16, medical records showed she had sustained an acute fracture to her right ulnar bone and a healing fracture of her distal radius during the incident.
She was placed back in her previous room. Not on the memory care unit.
The Director of Nursing called the administrator on August 14 to report that Resident #1 had been sent to the hospital. He recalled describing the resident cutting herself but couldn't remember if he used the term "suicide attempt" during what he called an ongoing situation.
The administrator had assumed her position just ten days earlier, on August 4. She was out of town when the incident occurred.
During an interview with inspectors on August 22, the administrator said the DON had described the situation as the resident having "suicidal ideation" but didn't mention that the resident had actually injured herself. She didn't believe the resident's razor incident constituted a suicide attempt requiring state notification.
The DON remembered the resident's May hospitalization for suicidal ideation but was unaware of the psychiatrist's recommendation for secure placement. He didn't believe the resident needed a secure unit and thought she could be managed with increased supervision.
Nobody had reported the August 14 incident to state authorities.
The facility's own policy on abuse, neglect and exploitation, updated in 2025, requires written procedures for reporting all alleged violations to the administrator, state agency, adult protective services and other required agencies. The timeframe is specific: immediately but not later than two hours if events involve abuse or result in serious bodily injury, or within 24 hours if they don't involve abuse and don't result in serious bodily injury.
The administrator filed a self-reported incident on August 16, two days after the razor incident. Her brief narrative summary read: "Resident sent out to hospital on [DATE] due to suicidal ideation. Returned to facility today 08/16/2025 with hospital records that resident with acute fracture to right ulnar and a healing fracture of distal radius."
The summary made no mention of the razor, the wrist wound, or the resident's statement that she wanted to die.
Federal inspectors conducted their investigation on August 23, finding the facility had failed to immediately report the suspected neglect of a resident. The violation affected few residents but carried the potential for actual harm.
The sequence of events revealed a facility that ignored professional psychiatric recommendations and failed to follow its own reporting policies. A resident who had been identified as a suicide risk in May, with specific warnings about inadequate supervision, injured herself three months later with a razor in her room.
She returned from the hospital with fractures that weren't there when she left, placed back in the same general population setting that a psychiatrist had deemed insufficient for her safety.
The administrator's interpretation that a resident cutting her wrist with a razor while stating she wanted to die didn't constitute a reportable suicide attempt highlighted the gap between what happened and what was acknowledged.
The resident remained at the facility, still not in the secure memory care setting that medical professionals had recommended four months earlier.
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 18, 2026 · Our methodology
Broadway Nursing & Rehabilitation in SAN ANTONIO, TX was cited for violations during a health inspection on August 23, 2025.
Resident #1 had been crying in her bedroom on May 14 when a certified nursing assistant found her.
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.