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Inspection visit

Inspection

Alvarado Meadows Nursing & RehabilitationCMS #45560110 citations on this visit
10 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality in 1 of 13(Resident #5 ) residents reviewed for resident rights. The facility failed to prevent MA A and ADON from socializing with each other while MA-A was assisting Resident #5 with lunch. These failures could place residents requiring assistance with activities of daily living at risk for impaired dignity. Findings Included: Record review of admission Record, dated 12/13/2022, revealed Resident#5 is a [AGE] year-old female with a diagnosis of epilepsy (brain disorder causes seizures), mild protein-calorie malnutrition, weakness, need for assistance with personal care, and cognitive communication deficit (difficulty with thinking and how someone uses language). In an observation on 12/13/22 at 11:40 AM, MA A was sitting at table with Resident # 5 assisting her with eating. Throughout the observation, MA A was seen turning her upper body away from Resident #5 while speaking to ADON. When Resident #5 finished each bite, she had to wait for MA A to assist. Resident #5 then asked if she was done eating and begun pushing away from the table. MA A would respond by telling her not yet, here's another bite and go back to talking to ADON. In an interview on 12/14/22 at 09:52 AM, DIET said Resident #5 was eating food well but required assistance. She said she stopped the order for her health shake and added fortified foods to prevent further weight loss. She said she had not witnessed Resident #5 during a meal. She said her plan for fortified food would not be successful if she were not eating majority of her meal. She said not paying attention to a resident while assisting them was rude and could be considered a dignity issue. In an interview on 12/15/22 at 8:53 AM, MA-A said she was for having a conversation with an employee while assisting Resident #5 with eating. She said another employee pointed the error out to her the same day after the meal was completed. She said she knew better, but since it was her boss speaking to her, she did not consider how it could affect the resident at the time. She said she knew the resident had lost weight and got distracted easily so that was a concern for her, but also it was rude to the resident and could be considered a dignity concern. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 17 Event ID: 455601 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550 Level of Harm - Minimal harm or potential for actual harm In an interview on 12/15/22 at 9:42 AM, the ADON said she was wrong for having a conversation with an employee while they were assisting Resident #5 with eating. She said another employee pointed the error out to her the same day after the meal was completed. She said she knew better and there was no excuse. She said she knew the resident had lost weight and got distracted easily so that was a concern for her, but also it was rude to the resident and could be considered a dignity concern. Residents Affected - Few In an interview on 12/15/22 at 9:48 AM, the DON said an employee that was assisting a resident while eating should have been focused on the resident. She said an employee that was speaking to someone other than the resident, would not be respecting the resident's dignity. In an interview on 12/15/22 at 10:02 AM, the ADMIN said an employee that was assisting a resident while eating, should have been focused on the resident. She said an employee that was speaking to someone other than the resident, would not have been respecting the resident's dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 13 (Resident #54) reviewed for advanced directives. The facility failed to ensure Resident #54's Full Code Status was listed in his records and physician's orders. This deficient practice could place residents at risk of not having their end-of-life wishes honored. Findings include: Review of undated face sheet for Resident #54 reflected his code status was not indicated. Resident #54 was admitted on [DATE] with diagnosis of: COPD, unspecified dementia, major depressive disorder, malignant neoplasm (cancer) of prostate, hypothyroidism (underactive thyroid), type 2 diabetes, legal blindness, atrioventricular block 2nd degree (a disorder characterized by disturbance, delay, or interruption of atrial impulse conduction to the ventricles through eh atriventricular node and bundle), muscle wasting and atrophy, pacemaker. Review of quarterly MDS assessment for Resident #54, dated [DATE], reflected a BIMS score of 00 indicating he could not complete the assessment and his cognitive skills were severely impaired. He was assessed with behaviors not directed towards others every one to three days. His functional assessment reflected he required extensive assistance for all ADLs. He was assessed as always incontinent of bowel and bladder. Review of the care plan for Resident #54 reflected interventions were in place for: shortness of breath r/t COPD, arthritis, high blood pressure, diabetes, dementia/Impaired cognitive function, impaired vision, elopement risk, ADL performance deficit. His code status was not listed in his Care Plan. Review of physician's orders for Resident #54 on [DATE] reflected no mention of his code status (After the surveyor questioned facility staff about the Resident's code status, the facility obtained and entered an order for Full Code status). In an interview on [DATE] at 10:15 am, the Administrator stated residents should have their code status displayed in computer records, their care plan, and he would expect all residents to be treated as if they were a Full Code until their DNR status could be verified in records. In an interview on [DATE] at 10:40 am, LVN K stated she would make all efforts to revive a resident until it was confirmed the resident had a DNR order in place. She stated the professional expectation was to continue life-saving efforts until a DNR order could be checked. In an interview on [DATE] at 12:05 PM, LVN J stated she understood Resident #54 was a full code. She stated she clarified Resident #54's status with his RP and provider, and entered the physician's order on [DATE] after the surveyor questioned her. She stated she did not know why his code status had not been entered earlier. She stated all residents were to be responded to as if they were a full (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 code person. Level of Harm - Minimal harm or potential for actual harm In an interview on [DATE] at 12:00 PM, the Acting DON stated unless stated otherwise, all residents were full code status. She stated when a resident had a DNR order in place, all life saving efforts were to be made until the DNR could be verified. Residents Affected - Few In an interview on [DATE] at 10:02 AM the Administrator said the care plan signature date was the date the care plan was completed. He said, bottom line, even if all information was provided on form in the 48 hour time frame, if it was not signed and locked during that time frame it was not completed timely. He stated it had been difficult getting some things like this completed on time because a registered nurse had to open, sign, and lock the care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal health care information for one of two (Medication Cart B) medication carts reviewed for resident rights. Residents Affected - Few The facility failed to ensure LVN K protected the private healthcare information of all residents on the secure female unit by leaving her computer screen open to resident charts. These failures could affect residents by placing them at risk for loss of privacy and dignity. Findings included: An observation on 12/14/2022 at 7:41 AM revealed the computer screen on Medication Cart B was left open, facing the hallway, and exposed resident confidential information. During an interview on 12/14/22 at 8:16 AM, LVN K stated by leaving the computer screen unlocked, she could have compromised the privacy of residents by exposing their names, diagnoses, and what medications they were taking. During an interview on 12/15/22 at 9:27 AM, ADON stated if the screen on the computer was left open with residents' information, it would violate their HIPAA privacy rights. She further stated it was possible for someone to come along and change information on the screen. During an interview on 12/15/2022 at 10:37 AM, Acting DON stated the problem with leaving an open screen on the medication cart was that it's a HIPAA privacy issue. She further stated there was a lock icon that would hide the screen. During an interview on 12/15/2022 at 10:49 AM, ADMIN stated if the computer screen was left open it's a HIPAA violation and someone could see the resident's confidential information. Review of a facility policy titled Computer Terminals/Workstations revised April 2014 reflected Computer terminals and workstations will be positioned/shielded to ensure that protected health information and facility information is protected from public view or unauthorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for base line care plans for 1 of 13 (Resident #175) residents reviewed for care plans. The facility failed to complete Resident #175's baseline care plan within 48 hours of admission that included the minimum required healthcare information of initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. This failure placed residents at risk of not receiving effective and person-centered care. Findings include: Review of the face sheet for Resident #175 reflected he was admitted to facility on 12/02/22 with diagnosis of: Hyperlipidemia, Schizophrenia, Recurrent Depressive disorder, HTN, Heart failure and unspecified pain. Review of active physician's orders for Resident #175, dated 12/14/22, reflected he was to have pain management evaluation and treatment, Dental Care as needed, Psych Services evaluate and treat, Resident had shortness of breath when laying flat or on exertion, medication orders and full code status. Review of assessments for Resident #175, on 12/14/22, reflected Care Plan Assessments were 12 days overdue. No comprehensive Care Plan was entered before the survey was completed on 12/15/22. Review of the baseline care plan for Resident #175 reflected none was present on 12/13/22 and 12/14/22. On entering the facility on 12/15/22 surveyors found a document in the records which reflected a 48-hour Baseline Care Plan had been started on 12/2/22 and signed on 12/14/22 the document was signed by the LVN/MDS nurse. Record review of 48-hour baseline care plan for Resident # 222 revealed and admission date of 12/02/2022 and a completion date with electronic signature on 12/07/2022 by the LVN/MDS. In an interview on 12/15/22 at 8:50 am, CNA E, for the secured unit, stated she did not know where to find the care plan for Resident #175. She stated the daily list of tasks Resident #175 needed assistance with, was found in the [NAME] computer system. She stated Resident #175 was independent and could do most things for himself, he needed help for bathing and some dressing. She stated she could not find his Care Plan in the facility's computer system. In an interview on 12/15/22 at 9:03 am, MDS F stated Resident #175's comprehensive care plan was due that day (12/15/22) since he was admitted on [DATE]. She stated the comprehensive care plan and his MDS assessment had to be closed that day. MDS F stated Resident #175's baseline care plan was started on 12/2/22 and was signed on 12/14/22. She stated the Baseline care plan did not show up in records until it was signed but was in place. MDS F stated she did not know why the Baseline care plan was not signed earlier. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 12/15/22 at 9:10 am, the MDS nurse stated the Baseline care plan for Resident #175 was started on 12/2/22. She stated it was complete, it was just not signed before it showed as locked in the computer. The MDS nurse stated the computer did not show or highlight the Baseline care plan to be locked because things were often added or changed in the first 48 hours. When asked if there was any way to show the Baseline care plan was completed in the first 48 hours, she stated she did not know. The LVN/MDS nurse stated it was her job to enter and complete the Baseline care plan. In an interview on 12/15/22 at 9:40 am, the Acting DON stated she did not know if there was a way of verifying the 48-hour baseline care plans were completed or implemented. She reviewed records for Resident #175 which reflected his Baseline care plan was started on 12/2/22 and locked on 12/14/22. She had no further comment at the time. In an interview on 12/15/22 at 10:02AM, the Administrator said the Care Plan signature date was the date the care plan was completed. He said, bottom line, even if all information was provided on the form in the 48-hour time frame, if it was not signed and locked during that time frame, it was not completed in time. He said it had been difficult getting some things like that completed on time because a registered nurse had to open, sign, and lock the care plans but he was not aware the LVN/MDS Coordinator had been signing off and locking care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 4 of 10 residents (Residents #122, #7, #45 and #33) reviewed for quality of life. Residents Affected - Some The facility failed to ensure Residents #122, #7, #45 and #33 were provided with nail care. These failures could place residents at risk of skin breakdown, pain, infection, and loss of self-esteem. Findings included: Review of an undated face sheet for Resident #122 reflected he was an [AGE] year-old male admitted tot the facility on 07/07/2022 with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), unsteadiness on feet, mild protein-calorie malnutrition, Major Depressive Disorder, Generalized Anxiety Disorder, Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures) and Gastro-Esophageal Reflux Disease without Esophagitis (stomach acid repeatedly flows back into the tube (esophagus) connecting your mouth and stomach without causing inflammation). Review of a care plan for Resident #122, dated 09/01/2022 and revised on 09/19/2022, reflected he had an ADL self-care performance deficit, to check nail length and trim and clean on bath day and as necessary. Review of a quarterly MDS assessment, dated 09/05/2002, for Resident #122 reflected he was unable to complete a BIMS interview due to being rarely or never understood. Functional status reflected he required extensive assistance and two plus person physical assist for personal hygiene. Observation on 12/13/2022 at 9:54 AM revealed Resident #122 was sitting in a wheelchair in the activity room with a long, jagged thumbnail noted on his right hand. Review of the undated face sheet for Resident #7 reflected he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Covid-19, Dysphagia following Cerebral Infarction, (difficulty swallowing following brain stroke), Candida Stomatitis (yeast infection around opening for feeding tube), need for assistance with personal care, contracture right wrist (shortening and hardening of muscles and tendons leading to deformity and rigidity of joints), and unspecified pain. Review of a care plan for Resident #7, dated 12/22/2017, reflected he had an ADL self-care performance deficit related to Hemiplegia (partial paralysis on one side of the body). Personal hygiene: the resident requires one staff participation with personal hygiene. Review of an annual MDS dated [DATE] for Resident #7 reflected a BIMS score of 11 indicating moderate cognitive impairment. Functional status reflected he required extensive assistance and one-person physical assistance for personal hygiene. An observation on 12/13/2022 at 10:09 AM of Resident #7 revealed the fingernails on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677 contractured right hand were long and jagged. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/14/2022 at 2:10 PM, LVN K, who observed long nails on Resident #7's right hand, stated he refused nail care; however, he has pain in his right arm and that could be the reason why. She noted he had orders for prn (as needed) pain medication and further stated, the risks of long nails include scratching the skin which could lead to an infection. Residents Affected - Some During an interview on 12/14/2022 at 2:15 PM, Resident #7 stated, One nail is cutting in there a little bit on my right hand and the reason he did not want the nails cut was due to pain. Review of the undated face sheet for Resident #33 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (non-insulin dependent), Neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems), Muscle wasting and atrophy (decrease in size leading to decreased strength of muscles), Acute Respiratory Failure, Cardiomegaly (enlarged heart), and need for assistance with personal care. Review of the care plan for Resident #33, dated 05/07/2018, reflected he had an ADL self-care performance deficit related to impaired balance. The resident requires (X 1) staff participation with personal hygiene. Review of the annual MDS assessment, dated 11/08/2022, for Resident #33 reflected he had a BIMS score of 6 indicating severe cognitive impairment. Functional status reflected he required extensive assistance and one-person physical assist for personal hygiene. Observation on 12/13/2022 at 10:18 AM of Resident #33 revealed he had 1 long, jagged fingernails with brown debris underneath. Review of the face sheet for Resident #45 reflected he was admitted [DATE] with diagnoses of: Alzheimer's disease, Mild protein malnutrition, Major Depressive Disorder, Impulse Disorder, Chronic pain Syndrome, Dysphagia, Urine Retention, Unspecified Cognitive Dysfunction, Long Term use of Anticoagulants. Review of the quarterly MDS assessment for Resident #45 dated 11/14/2022 reflected a BIMS score of 4 indicating severe cognitive impairment. His functional assessment reflected he required supervision for most ADLs except toileting and hygiene which required extensive assistance. He was assessed as frequently incontinent of bladder and bowels. Review of the care plan for Resident #45 dated reflected interventions were in place for: Antidepressant medications, Impaired Cognitive Processes, Alzheimer's Disease, Anti-anxiety medication, Physically Abusive behaviors r/t Dementia and poor Impulse control, Elopement Risk, Wandering. Interventions for maintaining his function level reflected Resident #45's nails should be trimmed and cleaned each shower day and any problems reported to the nurse. In an interview on 12/14/2022 at 9:20 AM CNA B stated Resident #45 had a behavior of refusing showers and refusing to have his fingernails cut. She stated this was a frequent occurrence. Record review of Progress Notes for Resident #45 dating from 12/13/2022 back to 10/01/2022 reflected no mention of any shower refusals or nail trimming refusals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 12/14/2022 at 9:25 AM Resident #45 stated he had no reason not to have his fingernails cut. Resident #45 stated he had not refused to have his fingernails cut. An observation on 12/14/2022 at 9:25 AM revealed all of Resident #45's fingernails were 1 long and yellow. In an interview on 12/14/2022 at 9:30 AM LVN J stated Resident #45 frequently refused showers and having his fingernails cut. She stated he wanted to cut his fingernails himself but had trouble doing it safely. In an interview on 12/14/2022 at 9:50 AM CNA D stated she worked with Resident #45 frequently. She stated he had a history of refusing showers, but did not know why his fingernails were not cut. She stated she would normally assist residents to trim their nails on shower days unless they were Diabetic and then the nurse would have to do nail care. In an interview on 12/14/2022 at 9:55 AM Acting DON stated she had discussed Resident #45's care with staff and reminded them to keep trying. She stated when he refused a shower or nail trimming, staff were to go back later and try again. She stated when he refused showers or care that did not mean it could be left undone. In an interview on 12/15/2022 at 10:01 AM Administrator stated his expectation was the nurses should review conditions regularly and assist with bathing and grooming as needed. He stated a resident with long fingernails should be assisted to trim them. In an interview on 12/14/2022 at 1:59 PM, LVN J stated CNAs and nurses could trim fingernails and CNAS should do it on the resident's shower days and as needed. Nurses trim the diabetics fingernails. She checks nails whenever she is doing skin assessments, and residents with long nails could scratch themselves and cause an infection. In an interview on 12/15/2022 at 9:27 AM, ADON stated the system was supposed to be that residents get their nails trimmed on shower days and the nurses are supposed to be making rounds on shower days. The ADON stated only the nurses can cut diabetics nails and it is the nurse's ultimate responsibility to make sure nail care is completed. She further stated an in-service was needed for proper nail care and the CNAs need to notify the nurses if nails are getting too long or if residents refuse. In an interview on 12/15/2022 at 10:37 AM, Acting DON stated, CNAs should have been checking residents' nails with every shower and keep trying to get them trimmed. The Acting DON stated Wwhen nurses make rounds, if they see someone with long dirty nails, they should make a note of it and get someone to try to trim them. In an interview on 12/15/2022 at 10:49 AM, ADMIN stated, the nursing department was responsible for making sure resident ADLS are maintained, and he could play a part in that. He stated Nnails, showers, and hair are a focal point for the facility, and it is a dignity issue. He further stated they may have fallen off on (completing nail care) and it should be addressed with every shower. Review of a facility policy titled Activities of Daily Living, supporting revised March 2018, reflected Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and how orders were transcribed into resident records for 3 of 13 (Resident #54, #175 and #45) Residents reviewed for medical records. The facility failed to ensure residents Physician clarified the orders to state total dosage to be administered with each medication administration for Resident's #54, #175 and #45. This deficient practice could place residents who receive care from the Medical Director/Physician at-risk of inadequate monitoring of medication dosages and confusion about total dosages to be administered. Findings included: Review of the undated Face sheet for Resident #54 reflected he was admitted on [DATE] with diagnosis of: COPD, unspecified dementia, major depressive disorder, malignant neoplasm (cancer) of prostate, hypothyroidism, type 2 diabetes, legal blindness, atrioventricular block 2nd degree, muscle wasting and atrophy, pacemaker. Review of quarterly MDS assessment for Resident #54 dated 10/21/22 reflected a BIMS score of 00 indicating he could not complete the assessment and his cognitive skills were severely impaired. he was assessed with behaviors not directed towards others every one to three days. His functional assessment reflected he required extensive assistance for all ADLs. He was assessed as always incontinent of bowel and bladder. Review of the undated Care Plan for Resident #54 reflected interventions were in place for: shortness of breath r/t COPD, arthritis, high blood pressure, diabetes, dementia/impaired cognitive function, impaired vision, elopement risk, ADL performance deficit. Review of physician's orders for Resident #54 reflected: Depakote Sprinkles 125 mg give 2 capsules by mouth two times a day related to dementia in other disease, Unspecified severity with behavioral disturbance.(The order did not specify dosage total to be given). Metoprolol 25 mg give 0.5 mg tablet by mouth one time a day r/t essential hypertension***does not specify dosage. Review of undated sheet for Resident #175 reflected he was admitted to facility on 12/02/22 with diagnosis of: hyperlipidemia, schizophrenia, recurrent depressive disorder, HTN, heart failure and unspecified pain. Review of active physician's orders for Resident #175, dated 12/02/22, reflected he was prescribed: Seroquel tablet 100 mg, give three tablets by mouth three times a day related to schizophrenia (The order did not specify total dose for each administration). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of undated Face Sheet for Resident #45 reflected he was admitted [DATE] with diagnosis of: Alzheimer's disease, mild protein malnutrition, major depressive disorder, impulse disorder, chronic pain syndrome, dysphagia, urine retention, unspecified cognitive dysfunction, long term use of anticoagulants. Review of the quarterly MDS assessment for Resident #45 dated 11/14/22 reflected a BIMS score of 4 indicating severe cognitive impairment. His functional assessment reflected he required supervision for most ADLs except toileting and hygiene which required extensive assistance. He was assessed as frequently incontinent of bladder and bowels. Review of the Care Plan for Resident #45 dated reflected interventions were in place for: antidepressant medications, DNR status, pain management, high blood pressure, impaired cognitive processes, Alzheimer's disease, anti anxiety medication, physically abusive behaviors r/t Dementia and poor Impulse control, elopement risk, wandering. Review of the Physician's orders for Resident #45 dated current on 12/14/22 reflected: Depakote Sprinkles 125 mg 4 capsules by mouth two times a day, r/t Intermittent Explosive Disorder (F63.81) Clonazepam 0.5 mg give 0.5 tablet by mouth two times a day r/t Impulse Disorder. The above orders could create confusion about total dosage to be given. In an interview on 12/14/22 at 2:35 pm, LVN J stated she understood the orders as written for Resident #45. Depakote Sprinkles 125 mg 4 capsules by mouth two times a day, r/t Intermittent Explosive Disorder (F63.81) Clonazepam 0.5 mg give 0.5 tablet by mouth two times a day r/t Impulse Disorder When asked what the dosages to be given were, she stated the total for Depakote was to be 600 mg (incorrect) and the total for Clonazepam was 0.25 mg (correct). In an interview on 12/15/22 at 9:40 am, the Acting DON stated she agreed the medication orders for Residents #175, #54 and #45 needed to be clarified. She stated the orders did not reflect what the total dose of medications ordered was and could be confusing for the staff administering medication. In an interview on 12/15/22 at 10:01 am, the Administrator stated his expectation was the nurses should have reviewed and clarified any medication orders that are unclear. The Administrator stated a medication order which did not specify the milligrams or total dosage was likely to cause confusion for some. In an interview on 12/15/22 at 10:40 am, LVN K stated she would call the physician to clarify the dosage on some medication orders. She stated the orders which called for 0.5 tablet or multiple tablets were unclear and did not give the total dosage. She stated she would call the physician immediately to correct the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 2 nurse medication carts (Hall F nurse cart) reviewed and failed to ensure expired medications were removed from one of two medication storage rooms (Hall D) reviewed for expired medications. 1. The facility failed to ensure the nurse medication cart for Hall F was locked and supervised. 2. The facility failed to ensure a contaminated medication on the secure female hall was disposed of properly. 3.The facility failed to ensure five bottles of Vit D 3 50,000 IU with expiration date 05/2022 and two bottles of Iron Supplement Liquid with expiration date 11/2022 were removed from the medication storage room on Hall D. These deficient practices could place residents at increased risk of ingesting unprescribed and/or expired medications resulting in adverse health consequences. Findings include: An observation and interview on 12/14/2022 at 7:41 AM revealed LVN K threw a contaminated pill that had fallen on the cart in the trash bag at the side of her cart. When asked if that was the proper way to dispose of medications she stated no, pulled the trash bag out and left the cart unlocked to go to a room down the hall. During an interview on 12/14/2022 at 8:14 AM, LVN K stated if the medication cart was left unlocked, anyone could come and get anything out of it. She further stated the cart was left unlocked on a secure unit and the residents take everything including the computer mouse. Regarding the medication thrown in the trash bag she stated, the risk is the residents could go through the trash and take and ingest the pill . During an interview on 12/14/2022 at 2:24 PM, the Acting DON stated, the potential risk of expired medications was they would not be effective. She further stated all the nursing staff is responsible and no one person is solely responsible, so expired medications could get missed. During an interview on 12/15/2022 at 9:27 AM, ADON stated expired medications would not have full potency and there could be a serious adverse reaction if past the expiration date. The cart being unlocked could cause a hazard as anyone could come along and ingest meds. She stated they could take meds to their room and hoard them and they could get ill and overdose. She stated if meds are dropped on the floor or contaminated, they have the nurse place them in the sharps container or bring them to us to waste. Anyone could have gotten it out of the garbage bag and ingested the pill and could have had an allergic reaction. During an interview on 12/15/2022 at 10:37 AM, Acting DON stated if the medication cart was unlocked it was a safety issue as the residents could get access to medications that could be hazardous to their health. She further stated, the nurse should never throw medications in the trash bag, as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some women on the secure unit do not have intact cognition. Taking non-prescribed meds could be hazardous to their health, they could have an allergic reaction and become ill. She stated the medication should have been placed in the sharps container if it was not a controlled substance. During an interview on 12/15/2022 at 10:49 AM, ADMIN stated the ADON, and Charge Nurses were responsible for ensuring expired medications are removed from the storage room and the potential risk with expired medications is they could make the resident sick, and they wouldn't work as well. He further stated with the medication cart being unlocked, residents, staff, or visitors could take medications out of the cart. The resident could overdose or have an allergic reaction. Someone could reach in the garbage bag, remove the discarded pill, and ingest it. It could make them sick, and they could be allergic to that medication. Record review of a facility policy dated April 2019 and titled Storage of Medications The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services. The facility failed to prevent the following: 1. Food and beverage items were not properly labeled with product and expiration date. 2. Food items were not properly sealed when not in use. 3. Food items were past expiration or use by date. 4. Food and beverage items were not discarded after 7 days of open date. 5. Frozen food was covered with freezer burn. 6. Food was not stored in appropriate containers. 7. Food was not held at appropriate temperature. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: An observation on 12/13/22 at 9:30AM revealed pistachio pudding dated 12/4/22, rice dated 12/10/22, cream of chicken dated , in the refrigerator, covered loosely with torn foil. An observation on 12/13/22 at 9:30AM revealed a Styrofoam cup labeled tea. in refrigerator with no dates. An observation on 12/13/22 at 9:30AM revealed salsa dated 12/3/22 with torn foil cover, soft butter dated 12/1/22, Teriyaki sauce dated 1/18/22, sweet and sour sauce opened 10/11/22, creamy salad dressing no open dated 1/4/22 used, cheddar cheese cubes dated 11/29/22, cheddar cheese cubes dated 11/28/22 in refrigerator with opened date greater than 7 days without manufacturer expiration date , An observation on 12/13/22 at 9:30AM revealed Worcestershire sauce, premium romaine salad best of used by date 12/10/22, in refrigerator with manufacturer expiration date of 12/1/21. An observation on 12/13/22 at 9:30AM revealed 1 bag of whipped cream, 1 gallon of whole milk with very little inside container in refrigerator with no opened date. An observation on 12/13/22 at 9:30AM revealed 4 bags of sealed whipped cream in refrigerator without the manufacturer expiration date. An observation on 12/13/22 at 9:30AM revealed 2 bags of breakfast sausage patties, 2 bags of waffle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many fries, 4 bags of French fries, 3 bags of breaded vegetables, 2 bags of corn nuggets, 3 bags of winter vegetable blend, pot soup dated 12/6/22 sealed in freezer without the manufacturer expiration date. An observation on 12/13/22 at 9:30AM revealed [NAME] fish dated 9/27/22, bag dated 6/16/22, breaded pork filet dated 9/16/22, hamburger patty dated 10/5/22 in unsealed bag, 1 bag labeled mix veg opened 11/8/22, freezer bag labeled meat dated 10/11/22 in freezer with opened date greater than 7 days and without manufacturer expiration date. An observation on 12/13/22 at 9:30AM revealed 4 bags of fajita vegetable blend, 6 sealed containers of unlabeled sausage links, 1 bag of unlabeled cut sausage, salmon patties dated 12/5/22 inside freezer bag, salmon patties dated 8/8/22 inside freezer bag, freezer bag labeled salisb stk dated 11/15/22, 2 freezer bags with burritos all with freezer burn. An observation on 12/13/22 at 9:30AM revealed 2 opened loaves of wheat bread and 2 opened packages of dinner rolls. in dry storage bread rack without manufacturer expiration date, open date, or expiration date. An observation on 12/13/22 at 9:30AM revealed in dry storage room the following opened food: An observation on 12/13/22 at 9:30AM revealed 1 bag of smart food white cheddar popcorn dated 11/22/22, jambalaya rice dated 4/21/22, light corn syrup 1/2 empty with no open date or manufacturer exp date, French's crispy fried onions dated 12/24/22, 2 containers of jet puffed marshmallow with expiration date 06/18/22, refried beans, balsamic vinegar, top ramen soy sauce soup, in dry storage room the following unopened food without manufacturer expiration date. An observation on 12/13/22 at 9:30AM revealed Raisin Bran with use by date 12/4/22, Cheerios use by date 11/7/22, Fruit Loops use by date 12/4, rice crispies opened date 11/15/22, rainbow sprinkles with use by date 11/30/22, flour with used by date 12/6/22, sugar with used by date 10/18/22, corn meal with used by date 10/18/22 in dry storage area inside kitchen in plastic containers. An observation on 12/13/22 at 9:30AM revealed food sitting uncovered on top of 2 freezers was 20 plated pieces of cake, 1 sheet pan with full cake, and 1 sheet pan with 1/2 of a cake. An observation on 12/13/22 at 9:30AM revealed a black substance attached to the inside of ice machine where water filled the trays. In an interview on 12/13/22 at 9:30AM with the DMGR, she said she was not aware all food had to have an expiration date on label. She was unsure how long food was good for once it was opened. She said they normally go through things quickly, so she had not thought to label with expiration dates. She said items without a manufacturer label were all taken from cardboard box where an expiration date was located but could not produce these boxes or dates. She said she did not have lids to fit the plastic containers and had always used foil. She said she was responsible for ensuring all expired food had been removed and must have missed the items observed. She said the food with freezer burn, she normally knocked it off then cooked as normal. She knew food was not to be left uncovered to open air but was busy and had not gotten around to covering it. She said she did not know the ice machine opened up from the top and was not aware of the black stuff growing inside. She said the ice machine had been cleaned the previous week by her and another kitchen member. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In a follow up observation on 12/14/22 at 10:37AM, the ice machine, inside of kitchen, had a black substance attached to the inside of ice machine where water trays are filled.and black substance seen inside of ice freezer below. In an interview on 12/14/22 at 10:37AM, the DMGR said the black substance inside of ice freezer below was likely from where she had cleaned machine overnight and did not know what else to do about getting it cleaned. She said she did not have any documentation on when the maintenance company could have last cleaned it or if they even do clean it. She said she always cleaned it once a quarter. She said she would empty the ice from machine and deep clean it before serving ice to residents. In an interview on 12/15/22 at 8:48AM with DMGR, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill. In an interview on 12/15/22 at 8:48AM with ADON, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill. In an interview on 12/15/22 at 8:48AM with DON, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill. In an interview on 12/15/22 at 8:48AM with ADMIN, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill. Record review of policy Proper Labeling and Storage of Food (undated) revealed a 7-day rule, and a date mark system should be clear to employees and the regulatory authority that covers the following items: foods prepared in foodservice, foods from a processing plant must be marked at the time their original container is opened, and foods combined or mixed together. Leftovers should be stored in National Science Foundation approved foodservice containers with proper fitting lids or cover the food tightly, labeled with date prepared/opened and use by date, and identify product. General storage all refrigerated foods should be discarded within 7 days from the date prepared/opened. Record review of policy Food Holding and Service, revised 06/01/19, revealed policy to serve all hot food at temperatures of 135 degrees Fahrenheit or greater. If hot food drops below 135 degrees Fahrenheit, reheat to 165 degrees Fahrenheit for a minimum of 15 seconds. Record review of policy Manual Cleaning and Sanitizing of Utensils and Portable Equipment, dated 10/01/18, revealed monthly cleaning schedule for ice machine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 17 of 17

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Citations

10 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0711GeneralS&S Epotential for harm

    F711 - Physician Visits

    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

  • 0363GeneralS&S Dpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  • 0583GeneralS&S Dpotential for harm

    F583 - Privacy and Confidentiality

    Keep residents' personal and medical records private and confidential.

  • 0655GeneralS&S Epotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0677GeneralS&S Epotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the December 15, 2022 survey of Alvarado Meadows Nursing & Rehabilitation?

This was a inspection survey of Alvarado Meadows Nursing & Rehabilitation on December 15, 2022. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Alvarado Meadows Nursing & Rehabilitation on December 15, 2022?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each req..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.