Meridian Care of Alice

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of 6 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision and Resident #1 left the secured unit and was unaccounted for approximately 10 minutes from 6:30 PM to 6:40 PM on 05/14/26 before a 3rd party notified the facility that Resident #1 was outside the facility. The noncompliance was identified as PNC. The PNC began on 05/14/26 and ended on 05/15/26. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for serious injuries, hospitalization, or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the right to be free from abuse for two (Residents #15 and Resident #94) of 6 residents reviewed for abuse. The facility failed to ensure Resident #94 was free from sexual abuse on 03/03/26 when Resident #15, who had a history of sexual inappropriate behavior, was seen by CNA A putting his penis on or/in Resident #94's mouth. An Immediate Jeopardy (IJ) was identified on 03/25/26. The IJ template was provided to the facility Administrator on 03/25/26 at 5:42 pm. While the IJ was removed on 03/27/26 at 11:11 am, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 2 of 6 residents (Resident #15 and Resident #94) reviewed for developing and implementing abuse and neglect policies and procedures. The facility failed to follow their policy to investigate suspected sexual abuse of Resident #94 by Resident #15 on 03/03/26 when Resident #15 was witnessed in Resident #94's room with his penis in and or on Resident #94's mouth. An Immediate Jeopardy (IJ) was identified on 03/25/26. The IJ template was provided to the facility Administrator on 03/25/26 at 5:42 pm. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported to local law enforcement and HHSC Complaint and Incident Intake immediately, but no later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse for 2 of 6 residents (Resident #15 and Resident #94) reviewed for abuse. The facility failed to report an incident of sexual abuse that occurred on 03/03/26 to local law enforcement and to HHSC when Resident #15 was found in Resident #94's room with his penis in and or around Resident #94's mouth. An Immediate Jeopardy (IJ) was identified on 03/25/26. The IJ template was provided to the facility Administrator on 03/25/26 at 5:42 pm. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 resident (Resident #15) of 6 residents whose care plans were reviewed. The facility failed to ensure Resident #15's care plan addressed his history of inappropriate sexual behaviors as well as including interventions to manage those behaviors. An Immediate Jeopardy (IJ) was identified on 03/26/26. The IJ template was provided to the facility Administrator on 03/26/26 at 3:26 pm. While the IJ was removed on 03/27/26 at 11:11 am, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one of two residents observed during medication pass. (Resident #4) The facility failed to ensure RN T did not leave a cup containing Resident #4's medications on top of the medication cart, when she went in Resident #4's room to put a gown on. This failure could place residents at risk for medication errors and receiving medications that are not prescribed for them. Findings Included: Observation of resident #4's room on 3/25/26 at 7:56 am, revealed a medication cup left in top of medication cart by RN T while she was donning (putting on protective personal equipment) gown inside room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one of two residents observed during medication pass. (Resident #4) RN T left a cup containing Resident #4's medications on top of medication cart while she went inside the room to don gown. This failure could affect the 2 residents who received medications from RN T by placing them at risk for medication errors and receiving less than therapeutic benefits from medications. Findings Included: Observation of resident #4's room on 3/25/26 at 7:56am revealed a medication cup left in top of medication cart by RN T while she was donning gown inside room. The cup contained Levothyroxine (ordered for treatment of hypothyroidism). [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to store all drugs and biologicals in locked compartments on 2 of 8 medication carts (RN C's medication cart and the wound care cart) reviewed for storage of drugs. The facility failed to ensure RN C's medication cart located by the nurse's station in the 300 hall was locked when not in use. The facility failed to ensure the wound care cart located by room [ROOM NUMBER] was locked when not in use. This failure could place residents at risk of having access to unauthorized medications and lead to an increased risk of drug diversion, or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #1 and Resident #2) reviewed for pharmacy services in that:The facility failed to ensure that a multidose vial of Ativan (a medication used to treat anxiety, agitation, and sometimes seizures), that had not been dated when opened, was not administered after the recommended 28 days from opening to Resident #1 on [DATE], [DATE], and [DATE], and Resident #2 on [DATE]. These failures could place residents at risk for non-therapeutic responses to medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 7 residents reviewed for dignity and respect, in that: LVN A spoke to Resident #1 in front of other residents, in the dining room, about Resident #1 sitting in the dining room in his underwear, making Resident #1 feel embarrassed. This failure could place residents at risk for embarrassment, isolation, and possible depression.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #1 and #2) reviewed for pharmacy services. 1. The facility failed to administer Resident #1's Losartan per the recommended and prescribed blood pressure parameters in July and August of 2025. 2. The facility failed to administer Resident #2's Isosorbide per the recommended and prescribed blood pressure parameters in July and August of 2025. These failures could place residents at risk for complications, as well as jeopardize their health and safety.

Inspectors wroteBased on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #100), reviewed for care plans. The facility failed to implement and ensure Resident #100 had 2 beveled mats on floor as care planned dated 10/25/24. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #67) reviewed for pharmacy services. The facility failed to ensure Resident #67's physician order for Latanoprost Opthalmic Solution (eye drops) were administered at bedtime as ordered. This failure could place residents at risk for non-therapeutic responses to medications.

Inspectors wroteBased on observation, interview, and record review, 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 for sanitation in that: 1. The facility failed to keep accurate temperature and chemical logs 2. The facility failed to label and date items in the nutrition rooms 3. The facility failed to discard and replace dented pans 4. The facility failed to maintain cleanliness in the ice machine 5. The facility failed to maintain cleanliness of the floor These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on Observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: 1. The meat freezer was not sealing properly 2. The ice machine had jagged edges These failures could place residents at risk of foodborne illnesses and injury.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to provide a safe, functional, and comfortable environment to include fire extinguishers throughout the buildings were regularly inspected and maintained for 1 of 4 portable fire extinguishers inspected throughout the facility. One of four portable fire extinguishers that were observed for monthly quick checks were not inspected monthly. This failure could result in undetected impairments of the portable fire extinguishers delaying suppression of fires exposing residents and staff to smoke inhalation and other fire related injuries resulting in more than minimal harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen reviewed for pests. The facility failed to treat gnats in the kitchen This failure could affect all residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.