Health inspection·August 26, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 8/25/2023 at 3:45pm with family member revealed, that she was in the activity room when she heard the staff CNA A yelling at Resident # 2. She stated Resident # 2 continued to get upset and she tried to get her to calm down. She stated Resident # 2 had advised CNA A that she left her jacket in the shower room. She stated she continued to argue and yell at the resident telling her that she did not leave her jacket in the shower room and tried to convince her that she never had a jacket. The family member stated that another staff LVN C heard them and stated she went and looked in the shower and got Resident # 2's jacket that she had left in the shower. The family member stated the staff instead of arguing and yelling at Resident # 2 should have just looked for the jacket and Resident # 2 would not have been upset and agitated. LVN C stated she had been trained on abuse/neglect and stated the ADM was the abuse/neglect coordinator if they see or suspected abuse/neglect to report immediately. In a face/time phone interview on 8/25/2023 at 4:00pm with Resident # 2, she stated she was doing fine. She was not able to recall the events of the incident. Resident # 2 appeared to be clean and dressed appropriate as she was wearing her favorite jacket when asked. Record review of facility investigation dated 7/26/2023 reflected CNA A was confirmed and terminated. Record review of the staff witness statement revealed, that CNA A was arguing with Resident # 2 about her jacket and stated she went into the shower and get Resident # 2 jacket. Record review of personnel file reflected; CNA A was terminated from the facility on 6/2/2023 confirmed for abuse. Record review of abuse/neglect in-service dated 7/28/2023 reflected staff had been in-serviced Record review of facility abuse/neglect policy dated April 2021 reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Record review of Resident #3 face sheet dated 8/24/2023, reflected Resident # 3 was a 71- year- old man, admitted to the facility on [DATE]. Resident # 3 was diagnosed with need for assistance with personal care, chronic respiratory failure with hypoxia (low blood oxygen levels that cause respiratory failure), intermittent explosive disorder (an impulse-control disorder characterized by sudden episodes of unwanted anger). Review of Resident # 3's care plan dated 5/4/2023, reflected Resident # 3 was at risk for fluid deficit. Goal: Resident # 3 will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor (elasticity). Interventions included the following: Ensue that the resident has access to cool water whenever possible, promote additional fluid intake. Review of Resident # 3's quarterly MDS dated [DATE] reflected a BIMS- 13 high level of cognitive functioning, section GG functional section reflected Resident # 3 required set -up and clean-up in the following areas hygiene, dressing, bathing, eating. In an interview on 8/24/2023 at 12:30pm with the ADM, revealed he felt that the staff took the other staff's statement out of content. He stated that Resident # 3 has behaviors and can be verbally aggressive with staff calling them derogatory names, he stated he had spoken with Resident # 3 a few times about calling staff derogatory names. He stated from his investigation he did verbally reprimand the staff and placed it in her personnel file. He stated he moved CNA B from the MC Unit, she was suspended pending the investigation, and the staff was in-serviced on abuse/neglect before returning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 2 of 10 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 08/26/2023 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 0600 to work. Level of Harm - Minimal harm or potential for actual harm In an interview on 8/24/2023 at 4:45pm with Resident # 3 revealed, staff would not do anything for him. He stated the staff cursed at him and told him to get his ice himself, the resident was not able to recall the staff's name but stated it was an aide. Resident # 3 stated the staff said F you, get your own damn ice. Resident # 3 stated he did complain to the ADM because the aide would not do anything for him. Residents Affected - Few Interview on 8/25/2023 at 12:07pm with CNA B, revealed she denied calling Resident # 3 any names. She stated Resident # 3 called her a dumb bitch because she was not able to get him any ice at the time that he wanted. CNA B stated he continued to call her names. She stated Resident # 3 continued to curse at her she stated, she did not go back and forth with the resident. CNA B stated she never told anyone that she called Resident # 3 a bitch. She stated the facility did suspend her pending the investigation, she stated she was moved from the MC unit, had to sign something, and was in-serviced on abuse/neglect before returning to work, she stated the ADM was the abuse/neglect coordinator. Record review of CNA D staff witness statement dated 7/25/2023 reflected, CNA B admitted to her that she did call Resident # 3 a Bitch and that he was going to quit calling her a bitch the statement also reflected that CNA B stated to Resident # 3 bitch, I'm not going to get you anything if you keep calling me names Record review of CNA B written statement dated 7/27/2023 reflected, she denied calling Resident # 3 a Bitch but stated he did call her a bitch and stated he continued to curse at her because she was unable to do what he wanted at that time. Review of Resident # 3 statement taken by ADM dated 7/27/2023 reflected, Resident stated the staff called him a Son of a Bitch get your own ice. Record review of facility investigation dated 7/26/2023 reflected CNA B was unconfirmed. Record review of the staff witness statement of CNA D reflected, that CNA B admitted to her that she cursed at Resident # 3 and called him a bitch. Record review of personnel file reflected, CNA B received personnel action, moved from the MC unit, and in-serviced on abuse/neglect. Record review of abuse/neglect in-service dated 7/28/2023 reflected staff had been in-serviced Record review of facility abuse/neglect policy dated April 2021 reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 3 of 10 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 08/26/2023 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 1 (Resident # 1) of 5 residents reviewed for pharmacy services. The facility failed to follow the physician orders when administering Resident # 1's medications causing the resident to aspirate, have labored breathing and being sent to the hospital and being admitted due to aspiration. An (IJ) Immediate Jeopardy was identified on 8/24/2023 at 7:26pm. While the (IJ) Immediate Jeopardy was removed on 8/26/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents at risk for inadequate therapeutic outcomes, and a decline in health. Findings included: Record review of Resident #1 face sheet dated 8/24/2023, reflected Resident # 1 was an 85- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with ATHEROSCLEROTIC HEART DISEASE (damage or disease in the hearts blood vessels), DYSPHAGIA (difficulty swallowing foods or liquids) FOLLOWING CEREBRAL INFARCTION (disrupted blood flow to the brain due to problems with the blood vessels that supply it.) Record review of Resident # 1's care plan dated 6/27/2023, reflected Resident # 1 had a swallowing problem. Record review of Resident # 1's swallowing assessment reflected he required (Reg diet pureed texture, pudding thick consistency for fluids) Record review of Resident # 1 significant change MDS dated [DATE] reflected a BIMS- high level of cognitive functioning. In the MDS section K swallowing/nutritional status reflected; pureed textured, thickened liquids therapeutic diet. Record review of Resident # 1 physician orders dated 2/14/2023 reflected- Pureed texture, pudding consistency, for fortified at breakfast and an order dated 8/22/2023 reflected- Crushed medications and mix with food/fluids due to swallowing disorder, every shift related to Dysphagia, Oropharyngeal Phase. In an interview on 8/24/2023 at 1:07pm with LVN A, revealed on 8/22/2023 the MA admitted he administered Resident #1 medications without crushing and without thickened liquids. LVN A stated when she asked the MA were Resident # 1's medications administered crushed he stated no were they supposed to be? When asked if the medications were given with water not a thickened liquid he stated yes. She stated these medications were not administered as prescribed in the orders. LVN A stated Resident # 1 was coughing and had labored breathing. She stated they sent Resident # 1 was sent for further evaluation and treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 4 of 10 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 08/26/2023 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In a phone interview on 8/22/2023 at 1:28pm with Resident # 1, revealed he had a choking incident on 8/22/2023, the resident was able to state he was feeling fine today. He stated on Tuesday he was not feeling very well. The resident stated he was not able to remember all of what happened but stated something was wrong. In a phone interview on 8/22/2023 with (RP) at 1:30pm, revealed she was contacted by the facility and advised that that Resident # 1 started choking and wasn't recovering well, continuing to cough and complain of chest pains so they sent him to the hospital to ensure that he did not aspirate. She stated when he got to the hospital, he was still having some choking problems and was not able to formulate his words. In an interview on 8/24/2023 at 5:53pm with MDS revealed, the MA administered the following medications to Resident # 1 without crushing or thickened liquid. The medications were as follows: Lodipine 10mg, Aspirin 81mg, Cholecalciferol 125mg 1 tablet, Clopidogrel Bisulfate tablet 75mg 1 tablet, Ferrous sulfate Iron 200mg 1 tablet, Finasteride tablet 5mg 1 tablet, Lactobacillus Capsule 1 caplet, Lasix tablet 20mg 1 tablet, Tamsulosin HCI Capsule 0.4 mg, Zinc tablet 50mg, buspirone HCI tablet 15mg 1 tablet, Metoprolol Tartrate tablet 25mg, Oxcarbazepine tablet 600mg, and Zanaflex tablet 4mg 1 tablet. Interview on 8/24/2023 at 1:54pm with hospital staff revealed, Resident # 1 was admitted to the hospital on [DATE] for aspirations and shortness of breath. In an interview on 8/24/2023 at 2:23pm with the DON revealed, on 8/22/2023 a CNA (unknown) walking down the hall advised her that Resident # 1 was choking. She stated when she entered the room LVN C was already in the room assisting Resident # 1. She stated that's when she learned that the MA had given Resident # 1 his medications not crushed or with thickened liquids. She stated Resident #1 complained of his chest hurting really bad and that he stated he was choking. The DON stated she never spoke with the MA herself but did advise the nursing staff to in-service the MA before he administered medication to any of the other residents. The DON stated the nurses were responsible for ensuring that all agency staff are trained on the care needs for the residents. She stated Resident # 1 was sent to the hospital for further evaluation and possible aspiration. The DON stated Resident # 1 could have aspirated due to not having his medications crushed and administered with thickened liquids according to the orders. In an interview on 8/24/2023 at 12:30pm with the ADM revealed, the incident happened on 8/22/2023 and he has not yet completed his five -day report. He stated he was advised that the MA gave Resident # 1 his medications without them being crushed. He stated when a person is not given their medication according to the orders the Resident could have an adverse reaction and could be terminal. He stated he contacted the staffing agency and advised that the agency staff should be placed on the DNR (do not return) list and advised that they could make a referral on the staff's certification. Record review of facility progress note dated 8/22/2023 reflected, Resident # 1 was sent to the hospital on 8/22/2023 for aspirating. Record review of hospital records dated 8/22/2023, reflected Resident # 1 was admitted to the hospital for aspiration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 5 of 10 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 08/26/2023 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of facility Administering Medications policy dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed. This was determined to be an (IJ) Immediate Jeopardy (IJ) on 78/24/2023 at 7:26pm. The ADM was notified. The ADM was provided with the IJ template on 8/24/2023 at 7:26pm. A Plan of Removal was first submitted by the ADM on 8/25/2023 at 9:14am. The Plan of removal accepted on 8/26/2023 at 12:18pm. Re: Plan of Removal of Immediate Jeopardy The following is a plan of removal, which has been immediately implemented for the facility to remedy the immediate jeopardy which was imposed 8/24/23 at 7:26pm for F-755 facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of resident 1. MA administered residents 1 medication whole and with water instead of the order which stated to crush all medications and serve with thicken liquids due to swallowing issues. All residents could potentially be affected by deficient practice. All items listed will be completed by 8/25/23 with continued follow up for scheduled staff. 1. Resident #1was assessed by LVN#1 post the event and sent to the hospital for evaluation. The initial radiological exam showed no obstructions or complications. Local Hospital is providing a higher level of care in place for this resident continues. 8-24-2023 thru 8-25-2023 2. All residents will be reviewed by DON for correct medication administration order that includes liquid administration order type. 8-25-2023 thru 8-25-2023 3. All residents were assessed by the DON/ADON regarding medication administration for crushed medication orders and/or the need for crushed medications due to diagnosis documented swallowing disorders. 8-24-2023 thru 8-25-2023 4. All residents' orders were reviewed by DON/ADON/MDS for crushed medication and orders for thickened liquids accuracy including order communication to EMAR (electronic medication administration record) regarding order. 8-24-2023 thru 8-25-2023 5. All residents requiring crushed mediations and thickened liquids care plans were reviewed by MDS/DON/ADON. 8-24-2023 thru 8-25-2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 6 of 10 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 08/26/2023 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 0755 6. Level of Harm - Immediate jeopardy to resident health or safety All Medication aides and nurses were in-serviced by the DON/ADON regarding medication administration policy and procedure with a special focus regarding order for crushed medications and those residents requiring thickened liquids. 8-24-2023 thru 8-25-2023 Residents Affected - Few 7. Regional Director of Care in -serviced DON/ADON/Admin on physician orders for crushed medication and thickened liquids. All staff were in-serviced by the Admin/DON/ADON regarding following physician orders for crushed medications and thickened liquids. 8-24-2023 thru 8-25-2023 8. A medication observation will be conducted by the DON/ADON 3 times a week randomly for 3 weeks. All negative findings will be immediately corrected and forwarded to QAPI for intervention change. 8-24-2023 thru 9-8-2023 9. Contracted pharmacy consult was contacted regarding the medication administration error and involvement in QAPI process/interventions, to schedule Inservice for September 4,2023 8-24-2023 thru 8-25-2023. All residents' potential to be affected by this deficient practice. If staff are unable to attend any of the in-services, they will be required to complete before starting their assigned shift. Staff will sign the Inservice sheet for each service that will be kept at the nurses station in a binder. All PRN and Agency Staff will be in-service before the start of shift by the DON/ADON/designee. The Medical Director was initially made aware of the immediate jeopardy 8/24/23 at 10:11pm and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all residents with swallowing disorders and medication administration passes as above with follow up if warranted for the next 30 days. The IDT will review and assess the orders in place to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 8/24/23 and will be monitored through completion. It will be monitored thereafter 30 days by the regional director of care and regional director of operations. Plan of Removal completion date is 8/25/23 by with continuation of oncoming staff and follow up. The Surveyor monitored the Plan of Removal on 8/26/2023 as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 7 of 10 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 08/26/2023 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 0755 3:00pm Entrance of facility Level of Harm - Immediate jeopardy to resident health or safety 3:10pm Entrance Conference with ADM and advised her the reason for the visit due to POR (Plan of Removal) monitoring. ADM was given a list of information needed. She stated the census is 58. Residents Affected - Few Review of nurse's progress dated 8/22/2023 reflected the resident had been assessed prior to going to hospital. The note reflected that the resident continued to have coughing and breathing problems, so the resident was sent to the hospital for further evaluation. The resident returned to the facility on 8/25/2023 late evening. Review of nurse's progress note dated 8/26/2023 reflected Resident # 1 was assessed upon return to the facility. Record review reflected that the ADM and DON were in-serviced by the regional director of Operations on abuse/neglect dated 8/25/2023 In an interview on 8/26/2023 at 3:30pm with the DON revealed she went through each resident's chart and reviewed their medications and orders to verify that they are current and correct for each resident. The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. Record review of medication log for residents with crushed medications developed and placed on each medication cart for staff to review on every resident with crushed medications, thickened liquids and how to administer to resident. Record review 8/26/2023 of resident roster will all residents who have a diagnosis of swallowing disorder, the facility had 47 residents with swallowing disorder. The DON stated she completed this task during the medication pass with the MA to ensure that all residents received the correct medication in the form required to take. Records reviewed reflected all 47 residents with swallowing disorders, care plan and orders had been updated in PCC system The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. In an interview with MDS on 8/26/2023 at 4:00pm, revealed she updated all care plans to reflect how to administration the medication and how to cleanse the resident's pallet. She stated she also developed a medication log that is kept placed on each medication cart that shows each resident with crushed medications and how they are to be administered, the log is updated daily to ensure all residents with crushed medications are listed and how to administer according to the order to help ensure that when giving medications the form is reviewed and checked off for each resident. Record review of in-services reflected 3 agency staff have completed the following in-services: Medication administration, crushing medications, Abuse/Neglect, Choking dated 8/26/2023. Record review reflected 4 agency staff completed the in-service on Where to find and read Physician orders dated 8/25/2023. Record review reflected 31 facility staff completed the following in-services Dysphagia dated 8/25/2023, 27 facility staff completed the in-service for Choking and Abuse/ Neglect dated 8/25/2023, 15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 8 of 10 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 08/26/2023 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility staff completed the in-service on Where to find and read physicians orders, crushing medications, and Medication administration dated 8/25/2023. Record review of in-service Physicians orders, crushed medications and thickened liquids dated 8/26/2023 completed by the regional director. Record review of two staff observations were completed by the DON administering medications. The staff were observed going through each step before administering to verify correct dosage, correct resident, and administered in the correct manner for, 1 MA and LVN on 8/25/2023 and 8/26/2023 Beginning at 3:56pm - Interview with 3 CNA's (agency staff) 6am to 6pm shift. Stated they have been in-serviced on where to find the care needs for the residents in PCC. Stated they have been in-serviced on abuse/neglect stated the protocol is to report immediately if they see or suspect abuse/neglect. Stated they have never seen or suspected abuse/neglect at this facility. Stated they have been trained on choking and protocols to take when a resident may choke, stated they do not pass medications. Beginning at 4:10pm -MA B (facility) doubles on the weekends 6am to 10pm. Stated she has been in-serviced on abuse/neglect, dysphagia, choking, crushed medications, medication administration and physician orders. She stated she looks in the MAR to verify what medication a resident requires the dosage, and how it is to be administered. She stated the protocol for abuse/neglect is to report immediately to the admin. who is the abuse/neglect coordinator, stated she has never seen or suspected abuse/neglect at this facility. Beginning at 4:34pm Interview with RN weekend supervisor double weekends (facility), LVN weekend nurse 6am- 10pn (facility) Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated staff are to report if there is any discrepancy or error made when medications are administered. She stated a log has been placed on each medication cart as an added way for MA, and nurses will know which residents require crushed medications and thickened liquids, but they should still check the MAR. 4:40pm Interview with LVN B (facility staff) weekend nurse 6am- 10pm Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated they check the medication log posted on the medication cart is one way to know and look in the MAR on the PCC system to see how medication is administered for the resident. 4:49pm Interview with Resident # 4 stated she as ok, stated she had no concerns at this time and stated she felt safe. 4:50pm Observation of Resident #1, appeared he was sleeping, did not appear to be in any pain or distress during this observation 5:00pm interview with Resident # 5 stated he was doing fine, stated he felt safe and had no concerns at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455601 If continuation sheet Page 9 of 10 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 08/26/2023 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 0755 4:53pm- Interview with ADMN. Level of Harm - Immediate jeopardy to resident health or safety Stated it was his expectation that staff follow all the training and protocols they have been given to provide the resident with the care needs they require that will allow them to have the best quality of life possible. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The ADM was informed that Immediate Jeopardy was removed on 8/26/2023 at 5:00pm. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455601 If continuation sheet Page 10 of 10