Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to store, prepare and distribute food in
accordance with professional standards for food service safety in 1 of 1 kitchen.
Residents Affected - Some
The facility failed to ensure the freezer in the main kitchen had a thermometer; the food in the refrigerator
was stored properly and not used past 3 days from storing it; the kitchen equipment was clean; the pans
were completely dry before stacking them; the food was covered after preparation; there were no flies in the
kitchen and that Dietary Staff wore their hair net containing the hair on the back of their head.
These deficiencies affected all residents who received food from the kitchen and could contribute to
foodborne illness.
The findings were:
Observation and interview on 06/06/23 at 10:45 AM, during initial tour of the kitchen, revealed the freezer in
the main kitchen did not have a thermometer. It contained fortified milk shakes provided to residents.
Further observation revealed the DM emptied the contents of the freezer. Interview with the DM revealed
there was not a thermometer in the freezer. She stated it was important to ensure all foods were monitored
and were within safe temperatures before serving to the residents.
Observation and interview on 06/06/23 at 10:48 AM revealed 1 celery stalk stored in the refrigerator. It was
not fully covered in a plastic bag. Interview with the DM revealed the celery stalk was sticking out of the
plastic bag and should be completely covered. Further observation revealed a container with crushed
pineapples that had a storage date of 5/26/23 and a container of ketchup with a storage date of 5/27/23.
The containers did not have an end date according to the label on the containers.
Interview on 06/06/23 at 10:50 AM with DA D revealed she did not know how long they could safely use the
pineapples and ketchup. She asked the DM who told her the food was good for 72 hours and should not be
used past the 72 hours due to spoilage. DA D further stated it could make the residents sick if served
spoiled food.
Observation and interview on 06/06/23 at 10:58 AM in the main kitchen revealed the conveyer toaster had
built up seeds/crumbs on the belt itself. Interview with [NAME] C revealed they were supposed to clean it
after every use but it did not look clean. The DM interjected and stated the Dietary staff was still learning
and further stated she ordered a new wire brush and it had just come in this week. The DM stated she was
in charge of the kitchen and training staff. She stated she had not
(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 7
Event ID:
675446
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
675446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Meadows Rehabilitation and Healthcare Cent
1615 Eleventh St
Floresville, TX 78114
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
provided staff instructions on how to clean the conveyer belt on the toaster. She stated that was her fault.
Level of Harm - Minimal harm
or potential for actual harm
Observation and interview on 06/06/23 at 11:12 PM revealed the top pan stacked on the bottom shelf of the
prep table in front of the stove was wet. Interview with [NAME] C revealed it was wet. She stated all pans
should be completely dry before stacking because bacteria could develop related to the moisture and get
the resident's sick.
Residents Affected - Some
Observation and interview on 06/06/23 at 11:25 AM revealed a bowl of sopapillas (fried portions of tortillas)
in a container left uncovered on top of the prep table. Interview with the DM revealed she fried them and
was supposed to cover them right after she finished frying them. Further observation revealed a fly circling
around the kitchen. The DM stated there was a fly.
Observation and interview on 06/06/23 at 11:30 AM of [NAME] C and DA D and DA E revealed the hair net
did not cover the back of their head. All staff noted had hair coming out of the back of their hair net.
Interview with the DM revealed [NAME] C and DA's, D and E had hair coming out of the back of their hair
net. She stated the hair net should contain the hair to keep it from falling into the food and contaminating it.
Review of a facility policy titled, Sanitation, undated, read in part: The food service area shall be maintained
in a clean and sanitary manner. Policy Interpretation and Implementation
1.
All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected
from rodents, roaches, flies and other insects.
10.
Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever
practical.
11.
For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the
following steps:
a.
Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts;
b.
Removable components will be scraped to remove food particle accumulation and washed according to
manual or dishwashing procedures.
Review of a facility policy titled, Dietary Employee Dress Code Policy, undated, read in part:
PROTOCOL
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675446
If continuation sheet
Page 2 of 7
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
675446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Meadows Rehabilitation and Healthcare Cent
1615 Eleventh St
Floresville, TX 78114
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
All employees will wear approved attire in order to perform their assigned duties.
Level of Harm - Minimal harm
or potential for actual harm
PROCEDURE
1.
Residents Affected - Some
All staff will have their hair off the shoulders, confined in a hairnet or cap-facial hair covered properly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675446
If continuation sheet
Page 3 of 7
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
675446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Meadows Rehabilitation and Healthcare Cent
1615 Eleventh St
Floresville, TX 78114
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to arrange for the provision of hospice care under a written
agreement to coordinate care provided by the LTC facility and hospice staff for 2 of 5 residents (Residents
#13 and #55) reviewed for hospice services.
1. The facility failed to obtain Resident #13's most recent hospice Plan of Care, Physician's certification of
the terminal illness and interdisciplinary documentation of the hospice staff providing services to the
resident.
2. The facility failed to obtain Resident #55's most recent hospice Plan of Care, Physician's certification of
the terminal illness and interdisciplinary documentation of the hospice staff providing services to the
resident.
These failures could place residents who receive hospice services at-risk of receiving inadequate
end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.
The findings were:
1. Record review of Resident #13's face sheet, dated 06/09/2023, revealed the resident had an initial
admission date of 02/07/2023 and readmission of 04/22/2023 with diagnoses that included: cerebral
infarction (ischemic stroke, a sudden loss of circulation to an area of the brain that results in an acute loss
of cerebral function), dysphagia (difficulty swallowing), and dysarthria (slurred speech).
Record review of Resident #13's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of
10 which indicated moderate cognitive impairment. Further review revealed the resident had a life
expectancy of less than 6 months and had received hospice care while a resident at the facility.
Record review of Resident #13's Care Plan, revised 03/16/2023, revealed a focus area, I have a terminal
prognosis r/t CVA, hemiparesis/hemiparalysis, advanced heart disease. Hospice agency [Hospice A] is a
participant in my care. Further review revealed interventions/tasks to include work cooperatively with
hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.
Record review of Resident #13's electronic medical record active orders as of 06/09/2023 revealed an order
on 02/08/2023 for: Admit to [Hospice A] [phone number], under the medical care of MD A.
Record review of Resident #13's electronic medical record, miscellaneous documents section, category
Hospice, revealed the following information was available:
- a hospice election form
- an OOH-DNR
- an initial plan of care dated 01/17/2023
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675446
If continuation sheet
Page 4 of 7
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
675446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Meadows Rehabilitation and Healthcare Cent
1615 Eleventh St
Floresville, TX 78114
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 0849
Level of Harm - Minimal harm
or potential for actual harm
- an uploaded packet that included general patient details, staff assignments, allergies, and medications,
and four skilled nursing visit notes dated 01/24/2023, 01/27/2023, 01/31/2023 and 02/06/2023.
Record review of Resident #13's hospice binder at the nursing station revealed the hospice name, contact
numbers, a medication list, and sign in sheets for visits by interdisciplinary team members.
Residents Affected - Few
Record review of Resident #13's electronic medical record and hospice binder revealed the following
information had not been obtained from the hospice agency:
- Most recent hospice Plan of Care
- Physician Certification of Terminal Illness
- Documentation by specific interdisciplinary hospice staff providing services to the resident
Record review of the facility's hospice services agreement with [Hospice A], provided by the Administrator,
effective 02/07/2023, revealed, this agreement pertains only to services relating to Resident #13, who is
qualified for admission to Hospice pursuant to Hospice's current admission policies. Whereas, the Facility
desires to make Hospice Services available to Resident #13, a resident with a medical prognosis of six
months or less, so that she/he may obtain Hospice Services covered under the Medicare/Medicaid Hospice
Benefit or by third-party payors while residing in the Facility. Section IV. Services to be provided by Facility,
4.4, Patient Chart. Hospice patient medical records shall be in compliance with Federal, State, and local
laws and regulations, and with Medicare and Medicaid guidelines. Facility and Hospice shall prepare and
maintain complete medical records for Hospice patients receiving Facility services and Hospice services in
accordance with the Agreement and shall include all treatments, progress notes, authorizations, physician
orders and other pertinent information. Copies of all documents of services provided by Hospice shall be
filed and maintained in the Facility chart.
2. Record review of Resident #55's face sheet, dated 06/08/2023, revealed the resident had an admission
date of 02/10/2021 with diagnoses that included: senile degeneration, essential hypertension (high blood
pressure), and cerebral infarction (ischemic stroke, a sudden loss of circulation to an area of the brain that
results in an acute loss of cerebral function).
Record review of Resident #55's Quarterly MDS, dated [DATE], revealed the resident had an uncompleted
BIMS score and staff had coded Resident #55's cognitive skills as severely impaired. Further review
revealed the resident had a life expectancy of less than 6 months and had received hospice care while a
resident at the facility.
Record review of Resident #55's Care Plan, created on 03/23/2021, revealed a focus area, Hospice: I am
receiving Hospice support care including pain management for end of life. [Hospice B] dx: senile dementia
of brain. Further review revealed interventions/tasks to include notify [Hospice B] with any changes or death
[phone number] and work cooperatively with hospice team to ensure the resident's spiritual, emotional,
intellectual, physical and social needs are met.
Record review of Resident #55's electronic medical record active orders as of 06/08/2023 revealed orders
for: Admit to [Hospice B] under the care of [MD B]. Notify [Hospice B] at [phone number] with any questions,
concerns, changes in condition, or death. No X-rays or labs without Hospice approval.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675446
If continuation sheet
Page 5 of 7
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
675446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Meadows Rehabilitation and Healthcare Cent
1615 Eleventh St
Floresville, TX 78114
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 0849
No labs or XR's without hospice prior approval.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #55's electronic medical record, miscellaneous documents section, category
Hospice, revealed a hospice election form and hospice services agreement with [Hospice B].
Residents Affected - Few
Record review of Resident #55's hospice binder at the nursing station revealed the following information
was available:
- the name of the hospice with contact numbers
- medication list
- sign in sheets for visits by interdisciplinary team members
- a plan of care dated for the period of 04/23/2022-06/21/2022.
Record review of Resident #55's electronic medical record and hospice binder revealed the following
information had not been obtained from the hospice agency:
- Most recent hospice Plan of Care
- Physician Certification of Terminal Illness
- Documentation by specific interdisciplinary hospice staff providing services to the resident
Record review of the facility's hospice services agreement with [Hospice B], effective 02/23/2021, revealed,
this agreement pertains only to services relating to Resident #55, who is qualified for admission to Hospice
pursuant to Hospice's current admission policies. Whereas, the Facility desires to make Hospice Services
available to Resident #55, a resident with a medical prognosis of six months or less, so that she/he may
obtain Hospice Services covered under the Medicare/Medicaid Hospice Benefit or by third-party payors
while residing in the Facility. Section IV. Services to be provided by Facility, 4.4, Patient Chart. Hospice
patient medical records shall be in compliance with Federal, State, and local laws and regulations, and with
Medicare and Medicaid guidelines. Facility and Hospice shall prepare and maintain complete medical
records for Hospice patients receiving Facility services and Hospice services in accordance with the
Agreement and shall include all treatments, progress notes, authorizations, physician orders and other
pertinent information. Copies of all documents of services provided by Hospice shall be filed and
maintained in the Facility chart.
During an interview with the SW on 06/09/2023 at 12:44 p.m., the SW revealed she was the staff
responsible to coordinate hospice services. The SW revealed her role to include referrals to hospice
agencies, initiate communication with hospice agencies to invite them to care plan conferences and to
ensure documentation was received from the hospice agency. The SW revealed there were some hospice
agencies the facility was having problems getting documentation from however she was not aware Resident
#13 or Resident #55 were missing documents and would check to see if the records had been misfiled or
not scanned into the electronic record.
In a follow up interview with the SW on 06/09/2023 at 1:57 p.m., the SW revealed all documentation was
not available and confirmed a resident's plan of care was important to provide consistent continuity of care
between facility and hospice care staff.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675446
If continuation sheet
Page 6 of 7
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
675446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Meadows Rehabilitation and Healthcare Cent
1615 Eleventh St
Floresville, TX 78114
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview with the Administrator on 06/09/2023 at 2:13 p.m., the Administrator confirmed the SW
was the one responsible and had done a weekly audit of the hospice charts to ensure all documentation
was in place. The Administrator revealed the facility has had difficulties with some of the hospice agencies
providing documentation in a timely matter and she will address this again.
Record review of the facility's policy titled, Hospice Program, revised July 2017, revealed, 12. Our facility
has designated _________ (Name) _____________(Title) to coordinate care provided to the resident by
our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and
assessment skills who is operating within the state scope of practice act). He or she is responsible for the
following:
d. Obtaining the following information from the hospice:
1. The most recent hospice plan of care specific to each resident;
2. Hospice election form;
3. Physician certification and recertification of the terminal illness specific to each resident;
4. Names and contact information for hospice personnel involved in hospice care of each resident;
5. Instructions on how to access the hospice's 24-hour on-call system;
6. Hospice medication information specific to each resident; and
7. Hospice physician and attending physician (if any) orders specific to each resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675446
If continuation sheet
Page 7 of 7
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Back to topCitations
2 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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
FAQ · About this visit
Common questions about this visit
What happened during the June 9, 2023 survey of Prairie Meadows Rehabilitation and Healthcare Cent?
This was a inspection survey of Prairie Meadows Rehabilitation and Healthcare Cent on June 9, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Prairie Meadows Rehabilitation and Healthcare Cent on June 9, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordanc..."
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
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.