Alvarado Meadows Nursing & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #1) of six residents reviewed for changes in condition.1. The facility failed to notify Resident #1's RP of Resident #1's antibiotic order for a skin infection on 05/31/26.2. The facility failed to notify Resident #1's RP of treatment for head lice 06/08/26. These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents were treated with dignity and respect during meal service for 3 of 11 residents observed in the G Hall (Male Memory Care Unit) dining area. Resident 11, Resident 42, and Resident 51 were observed being served lunch on transport trays typically used for meal delivery rather than being provided with a standard dining setting appropriate for residents. This failure had the potential to compromise residents' dignity and created a non-traditional dining experience that did not promote a homelike environment. Observations conducted on 05/04/2026, at 12:41 PM, revealed residents eating lunch in the common dining area of the Male Secured Unit. Residents were observed being served meals on transport trays. [...]

Inspectors wroteBased on observation, interview, and records review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administ ering of all drugs and biologicals) to meet the needs of each resident. for one of one medication room (Medication room [ROOM NUMBER]), and for one of five medication carts (Medication Cart #1) inspected on 5/5/2026. The facility failed to dispose of: one box of expired Loperamide Hydrochloride, 2mg tablet, (an anti-diarrheal medication), with expiration date July 2025 in medication cart #1 (G hall Nurse cart). 28 syringes of expired AB 1MG-25/GM T/D Gel (topical anti-anxiety medication), with use by date of 12/1/2025 in medication room [ROOM NUMBER]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food items in the kitchen were properly labeled and dated. These failures had the potential to place residents consuming food prepared by the kitchen at risk for foodborne illness. During an observation conducted on 05/04/2026, at 9:32 AM Refrigerator #1: contained one large container of [NAME] Deluxe Mayonnaise and one bottle of Louisiana Hot Sauce that had been opened but was not labeled or datedDuring an observation conducted on 05/05/2026, at 12:07 PM, Freezer #1, contained two packages of prepared bread and two bags of single-serve ice cream that had no labels or use-by dates. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 of 5 residents reviewed for Significant Change Assessments. (Resident #39). The facility did not complete a significant change assessment for Resident #39 within 14 days of being admitted to hospice services. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 6 residents (Resident #1) reviewed for abuse/neglect. The facility failed to protect Resident #1 from physical abuse when LVN A forcefully dragged him to his bed on 05/26/2025 after an unwitnessed fall. An Immediate Jeopardy (IJ) existed from 05/26/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3's call light was within reach on 06/05/2025. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 2 of 2 residents (Resident #4 and Resident #5) reviewed. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting for Resident #4 and Resident #5. This failure could place residents at risk of not receiving necessary care or specialized services which could diminish the residents' quality of life and highest level of functioning.

Inspectors wroteBased on interviews , and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #2) reviewed for comprehensive care plans. Resident #2's comprehensive care plan did not reflect Resident #2 sustained a fracture to her upper right arm on 05/25/25. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on interview , and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that: The facility failed to conduct weekly skin assessments for Resident #1 for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. These failures placed residents at risk of physical harm, pain, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for four residents of 12 residents (Residents # 28, #29, #33, and #47) reviewed for care plans. The facility failed to ensure Residents # 28, #29, #33, and #47 care plans were complete and accurate. These failures could place the residents at risk of not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 12 residents (Residents #28, #31, #33, #47, and #56) reviewed for personal hygiene. The facility failed to ensure Residents #28, #31, #33, #47, and #56 received assistance with bathing, grooming, and personal hygiene. These failures could result in the resident having decreased sense of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 of 7 residents (Resident #7 and Resident #22) reviewed for Resident Rights. CNA G verbally abused Residents #7 and #22 when the residents requested to return inside the building following a smoke break, and she yelled at them telling they could not go inside and blocked the door. The failure placed residents at risk of feelings of decreased self-worth. The non-compliance was identified as PNC. The noncompliance began on 02/15/25 and ended on 02/21/25. The facility had corrected the non-compliance before the investigation began.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted to the facility, after being sent to the hospital for behaviors. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of five (5) residents reviewed for abuse, in that: The facility failed to prevent Resident # 1 from becoming sexually assaulted by Resident #2, who had a history of sexually inappropriate behaviors, when Resident #2 blocked Resident #1 in the shower room on 5/17/2024 and touched her breast, kissed her and masturbated in front of her. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/20/2024. The IJ template was provided to the facility on 5/20/2024 at 5:17 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 8 residents (Resident #18) reviewed for comprehensive assessments. The facility failed to complete an accurate quarterly comprehensive assessment dated [DATE] for Resident #18 by not including hospice services. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans. The facility failed to ensure Resident #7's comprehensive care plan included a new intervention for a fall mat after Resident #7 fell on [DATE]. This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident # 30) of six residents reviewed for infection control. CNA A failed to change gloves or wash her hands while performing perineal care when removing a soiled brief and applying a clean brief. This failure could place residents at-risk of cross contamination which could result in infections or illness.