Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alvarado Meadows Nursing & Rehabilitation during CMS and state inspections, most recent first.
Residents in the Male Memory Care Unit were observed eating lunch in the common dining room while meals were served on transport trays instead of a standard dining setting. Staff assisted with tray setup and utensils, and a CNA stated this had been standard practice in the unit. An LVN stated meals should have been removed from the transport trays before service and that dining in G Hall was normally expected to be similar to the main dining area to promote a homelike environment.
Expired medications were found in a med cart and in a locked refrigerator in a medication room, including loperamide, topical gel, morphine sulfate solution, hydromorphone syrup, influenza vaccines, and acetaminophen suppositories. An LVN acknowledged the expired items in the cart and medication room, and staff stated they were responsible for checking expiration dates, but narcotic checks did not include expiration dates. The RNC, DON, and MD were unaware of the expired stock, and facility policy required outdated medications to be removed from stock immediately.
Improperly labeled and dated food items were found in kitchen storage, including opened condiments in a refrigerator and prepared bread and single-serve ice cream in a freezer with no labels or use-by dates. The DM said all kitchen staff were responsible for labeling and dating food, but staff interviews showed inconsistent understanding of the dating timeframe and no formal training specific to labeling and dating practices.
Missed Significant Change MDS After Hospice Admission: A resident with COPD, asthma, anxiety, and vascular dementia was admitted to hospice and had care plan updates reflecting terminal prognosis and hospice services, but no significant change assessment was completed within the required timeframe. The MDS LVN and RCN both confirmed that hospice admission was a significant change in condition and that the assessment should have been completed within 14 days.
A resident with severe cognitive impairment and multiple medical conditions was found on the floor after an unwitnessed fall. An LVN, assisted by two CNAs, forcefully dragged the resident by the wrist to his bed, causing the resident to express pain and distress. The improper transfer was witnessed by staff and captured on video, and the incident was identified as abuse by facility leadership.
A resident with severe cognitive impairment and multiple health conditions was found with her call light out of reach, despite being dependent on staff for daily care and having a care plan intervention to ensure access to the call bell. Staff interviews confirmed the expectation that call lights should always be within reach, but the facility lacked a written policy on this practice.
The facility did not properly coordinate assessments with the PASRR program or incorporate PASRR recommendations into care planning for two residents with complex mental health and developmental conditions. Additionally, the facility failed to submit complete and accurate NFSS requests in the LTC online portal within the required timeframe after IDT meetings, as confirmed by staff interviews and policy review.
A resident with severe cognitive impairment and multiple dependencies experienced a right arm fracture after a fall, but the care plan was not updated to reflect this change in condition. Staff interviews confirmed that the omission meant the care plan did not address the resident's new needs, contrary to facility policy.
A resident with severe cognitive impairment and multiple comorbidities did not receive required weekly skin assessments over two consecutive weeks, despite facility policy and care plan directives. Nursing staff, the DON, and the administrator confirmed the expectation for weekly assessments and were unaware of the missed documentation in the EMR.
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to inaccuracies and omissions in their care plans. A resident's care plan inaccurately reflected cognitive impairment, another's omitted a known allergy, and others lacked details on self-care deficits and medical conditions. Interviews revealed confusion among staff about responsibility for care plans, highlighting a failure to ensure they were complete and accurate.
The facility failed to provide adequate assistance with activities of daily living for several residents, including bathing and personal hygiene. A resident with chronic kidney disease was bathed only twice in a month, while another with mild cognitive impairment had not been bathed in over a week. A resident with paralysis was found unkempt, and a hospice patient was left in soiled briefs daily. Staff interviews revealed inconsistencies in documentation and insufficient staffing to meet residents' needs.
Two residents were verbally abused by a CNA during a smoking break when they were prevented from returning inside the building after finishing smoking. The CNA yelled at them and blocked the door, violating their rights to move freely within the facility. The incident was reported to the nursing staff and administration.
A resident with severe cognitive impairment and other health issues was improperly discharged from an LTC facility to a hospital for behaviors without being readmitted. The resident's representative was not notified or involved in the discharge process, and staff interviews revealed a lack of awareness and involvement in the discharge. The facility failed to provide the required 30-day notice, violating LTC regulations.
A resident with severe cognitive impairment was sexually abused by another resident with a known history of inappropriate behavior. The incident occurred in a shower room, where the perpetrator blocked the victim and engaged in sexual acts. Despite previous incidents and staff awareness of the perpetrator's behavior, inadequate supervision and documentation led to the abuse, resulting in an immediate jeopardy situation.
Residents Served Meals on Transport Trays During Dining Service
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during lunch service in the G Hall Male Memory Care Unit. On 05/04/2026 at 12:41 PM, residents were observed eating lunch in the common dining area while being served meals on transport trays typically used for meal delivery rather than on a standard dining setting. A male staff member assisted with meal setup and provided utensils such as forks, knives, and spoons when needed, but the meals remained on the transport trays during dining service. On 05/05/2026, residents in the Male Secured Unit were again observed being served lunch on transport trays in the common dining room. During an interview on 05/06/2026, CNA A stated it had been standard practice for residents in the Memory Care Unit to receive meals on transport trays and that staff placed the tray in front of the resident, removed the lid, and assisted with meal setup. LVN A stated meals should have been removed from the transport trays prior to service and that residents in G Hall were normally expected to be served similarly to those in the main dining area to promote a homelike environment.
Expired Medications Found in Cart and Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring that medications and biologicals were accurately acquired, received, dispensed, and administered without expired products being available for use. During inspection of medication cart #1, surveyors found an expired box of loperamide hydrochloride 2 mg tablets with an expiration date of 7/2025. In the locked refrigerator in medication room [ROOM NUMBER], surveyors found expired AB 1MG-25/GM T/D Gel, expired morphine sulfate solution 100/5 mL, expired hydromorphone 4 mg/mL syrup, expired influenza vaccines, and expired acetaminophen suppositories. During interview, LVN A acknowledged the expired loperamide in the cart and stated it was the nurse's responsibility to check the cart for expired medications. She stated carts were checked once a month and as needed, and that expired medications should be removed from the cart and placed in the destruction box in the medication room so residents would not receive expired medications. LVN B acknowledged the expired gel, morphine sulfate solution, hydromorphone syrup, influenza vaccines, and acetaminophen suppositories in the medication room refrigerator. She stated she checked narcotic medication every shift but did not check expiration dates, and said she would need to start checking expiration dates when she checked medication counts. RNC stated nursing staff were responsible for medications on the med carts, but she was unsure who was responsible for medication room [ROOM NUMBER]. She stated all medications should be checked for expiration dates before being given to residents and that pharmacy came in once a month and was supposed to check those items. DON C stated she was not aware of the expired medications in medication room [ROOM NUMBER] and thought nurses on the floor had been checking the medication room and carts. The MD stated he was not aware of the expired medications and said expired medications could be less effective if given to residents. Facility policy PCU027 stated outdated medications are to be immediately removed from stock and disposed of according to medication destruction procedures.
Improperly Labeled and Dated Food Items in Kitchen Storage
Penalty
Summary
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. During an observation in Refrigerator #1, one large container of [NAME] Deluxe Mayonnaise and one bottle of Louisiana Hot Sauce had been opened but were not labeled or dated. During a later observation in Freezer #1, two packages of prepared bread and two bags of single-serve ice cream had no labels or use-by dates. During interviews, the DM stated that when new items were received in the kitchen, staff checked for damage and labeled and dated items appropriately, and that all kitchen staff were responsible for labeling and dating food items. The DM stated the facility used Cambro StoreSafe Food Rotation Labels and that fresh items were dated for three calendar days and prepared items for six calendar days, and if a date label could not be read, the item should have been discarded. Kitchen staff stated they labeled and dated items when opened, but they were unsure whether items should have been dated for seven days from opening or three days from opening. One staff member stated staff had not received formal training specifically related to labeling and dating practices, and another stated improperly labeled or undated food items could result in residents consuming spoiled food or becoming ill.
Missed Significant Change Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change assessment for Resident #39 after she was admitted to hospice services. Resident #39 was a female resident with diagnoses including chronic obstructive pulmonary disease, mild intermittent asthma, anxiety, and vascular dementia, and her annual MDS reflected impaired short-term and long-term memory and hospice care. Her physician's order summary and hospice election form both reflected hospice admission on 01/09/2026, and her care plan was updated the same day to reflect that she had a terminal prognosis and/or was receiving hospice services. Record review showed a quarterly MDS completed on 12/24/25 and an annual MDS completed on 3/26/26, but no significant change assessment was completed after the hospice admission. In interviews, the MDS LVN stated Resident #39 should have had a change in condition MDS completed within 14 days of hospice admission and said she must have missed that assessment. The RCN stated the MDS coordinator was responsible for scheduling all MDS assessments and confirmed that hospice admission was considered a significant change in condition that should have triggered a significant change assessment within 14 days.
Resident Dragged by LVN After Fall Constitutes Abuse
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, chronic kidney disease, muscle wasting, and lack of coordination experienced an unwitnessed fall in his room. The resident was found on the floor, unclothed, with evidence of bowel movement on himself, the bed, chair, and floor. The resident required partial to moderate assistance with activities of daily living and was care planned for impaired cognitive function, with specific interventions for communication and agitation. Following the fall, video surveillance and written statements from staff revealed that an LVN forcefully grabbed the resident by the wrist and dragged him across the room toward his bed, while two CNAs assisted by holding his other arm. During this improper transfer, the resident was heard expressing pain and distress, saying "oh my arm" and "please don't." The LVN did not respond to the CNAs' concerns about the resident's injuries, and the transfer was not performed according to proper procedures for assisting a resident after a fall. Interviews with the DON and ADM confirmed that the incident was considered abuse and not in line with staff training or facility policy. The facility's abuse and neglect policy explicitly prohibits such actions and requires staff to recognize and report any suspected abuse or neglect. The incident was reported to the police, and witness statements were collected from the involved staff.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and bipolar disorder, was found with her call light pinned to the back upper left side of her bed, out of her reach. The resident was dependent on staff for activities of daily living, including toileting and personal hygiene, and her care plan specifically included the intervention to ensure she could use the call bell to call for assistance. At the time of observation, the resident was awake in bed but unable to communicate due to her cognitive impairment. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it is the responsibility of all staff to ensure call lights are always within reach of residents. Staff acknowledged that if a call light is not within reach, the resident would not be able to call for assistance. The ADM also confirmed that the facility did not have a written call light policy. The failure to ensure the call light was within reach constituted a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Coordinate PASRR Assessments and Timely Submission of NFSS
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program to the maximum extent practicable, resulting in the omission of PASRR Level II determination recommendations and evaluation reports from residents' assessments, care planning, and transitions of care. Specifically, for two residents with significant mental health and developmental diagnoses, the facility did not incorporate specialized services and recommendations identified during the PASRR process into their care plans. The records showed that both residents had complex conditions, including autistic disorder, bipolar disorder, anxiety disorder, dementia, moderate intellectual disabilities, and developmental disorders, yet the required coordination and documentation were not completed as mandated. Additionally, the facility did not submit complete and accurate requests for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meetings for both residents. Interviews with facility staff confirmed that the NFSS should be completed within the specified timeframe, and failure to do so would prevent verification that residents were receiving PASRR services. Review of facility policy also indicated that the IDT meetings and documentation in the portal were not performed according to regulatory requirements, contributing to the deficiency.
Failure to Update Care Plan After Resident Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had sustained a fracture to her upper right arm. Despite the resident's significant medical history, including severe cognitive impairment, dementia, muscle wasting, and lack of coordination, the care plan was not updated to reflect the new diagnosis of an acute nondisplaced fracture of the right humeral neck following a fall. The resident was dependent on staff for multiple activities of daily living, and the omission was confirmed through record reviews and staff interviews. Interviews with facility staff, including the LVN, DON, and ADM, revealed that the fracture and change in condition should have been incorporated into the resident's care plan to ensure appropriate care. The facility's own policy required that care plans be updated to address all identified needs, including measurable objectives and interventions. However, the care plan did not reflect the resident's fracture, and staff acknowledged that this failure could result in staff not knowing how to manage the resident's new condition.
Missed Weekly Skin Assessments for Cognitively Impaired Resident
Penalty
Summary
The facility failed to conduct weekly skin assessments for one resident during two consecutive weeks, as required by both facility policy and the resident's care plan. The resident in question was an elderly male with multiple diagnoses, including Alzheimer's disease, chronic kidney disease stage 3, muscle wasting, and impaired coordination. He was severely cognitively impaired and required moderate assistance with activities of daily living. Despite being care planned for risk of pressure ulcer development and receiving hospice services, there were no documented weekly skin assessments for the specified periods. Interviews with nursing staff, the DON, and the administrator confirmed that all residents were expected to receive weekly skin assessments, and that it was the responsibility of the nursing staff to complete them. Both the DON and the administrator were unaware that the assessments had not been completed for the resident during the identified weeks. The facility's policy also required weekly skin assessments to be documented in the EMR, which was not done for the resident during the deficiency period.
Incomplete and Inaccurate Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which could place them at risk of not receiving appropriate care. Resident #28's care plan inaccurately reflected cognitive impairment and resistance to care, which was not supported by her BIMS score indicating she was cognitively intact. Resident #29's care plan failed to list her allergy to penicillin and did not accurately reflect her ADL self-care deficit. Resident #33's care plan did not address her self-care deficit related to her stroke and paralysis. Resident #47's care plan was incomplete, lacking details on her hemiplegia, risk for falls, potential fluid deficit, and allergies. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and updating of care plans. LVN A was unaware of who was responsible for care plans, while LVN B indicated that the admitting nurse initiated baseline care plans, with the DON and MDS nurse completing them. The DON acknowledged that the interdisciplinary team was responsible for updating care plans, but there was a lack of assurance that care plans were complete and accurate. The facility's policy required person-centered comprehensive care plans to meet residents' preferences and goals, addressing their medical, physical, and psychosocial needs, but this was not consistently implemented.
Inadequate Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, grooming, and personal hygiene, for five residents. Resident #28, a cognitively intact female with chronic kidney disease and morbid obesity, reported being bathed only every two weeks due to staffing shortages, despite her care plan indicating she required assistance three times a week. Her bathing task record confirmed she was bathed only twice in a month, leading her to feel uncomfortable and isolated in her room. Resident #31, a male with mild cognitive impairment and multiple health issues, had not been bathed in over a week, as observed by surveyors. His hair was greasy, and he expressed frustration over the lack of staff to assist him, despite his care plan requiring maximum assistance with bathing. His bathing task record showed only two baths in a month, with most days marked as 'Activity did not occur.' Other residents, including Resident #33, who was totally dependent due to paralysis, and Resident #47, who had not been bathed since admission, also suffered from inadequate hygiene care. Family members of Resident #56, who was on hospice care, reported finding her in soiled briefs daily, with no facility staff checking on her throughout the day. Interviews with staff revealed inconsistencies in documentation practices and a lack of sufficient staffing to meet residents' needs, contributing to the deficiencies observed.
Verbal Abuse During Smoking Break
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically verbal abuse, during a smoking break. Two residents, both with intact cognition, were involved in the incident. One resident, who required substantial assistance with certain activities due to an above-knee amputation and other health issues, and another resident, who was independent in most activities but used a walker, were verbally abused by a CNA. The CNA yelled at the residents, telling them they could not return inside the building after finishing their smoke break and physically blocked the door, preventing them from entering. The incident occurred during a scheduled smoke break when the CNA was responsible for supervising the residents. The CNA insisted that the residents wait outside until everyone was ready to return inside together, despite the cold weather and the residents' desire to return inside. This action was against the residents' rights to move freely within the facility. The CNA's behavior was reported by the residents to the nursing staff, who then informed the facility's administration. The facility's policy on resident rights emphasizes the importance of allowing residents to exercise their rights, including the right to move freely and make choices about their activities. The CNA's actions were in direct violation of these rights, as the residents were not allowed to return inside the building when they wished, leading to feelings of decreased self-worth among the residents involved.
Improper Resident Discharge Without Adequate Notice
Penalty
Summary
The facility failed to comply with discharge regulations by not allowing a resident to remain in the facility unless the discharge was necessary for the resident's welfare and their needs could not be met. A resident with severe cognitive impairment, unspecified dementia, blindness in the right eye, hearing loss, and hypertension was sent to the hospital for behaviors and was not readmitted to the facility. The resident was given a 30-day discharge letter on the same day they were sent to the hospital, and the letter was delivered to the hospital's emergency room. The resident's representative was not notified of the discharge, did not receive any discharge paperwork, and was not involved in finding alternative placement for the resident. Interviews with facility staff revealed a lack of awareness and involvement in the discharge process. The social worker and business office manager were not informed about the immediate discharge, and the director of nursing had just started at the facility after the discharge occurred. The administrator, who had been in the role for two weeks, stated that the immediate discharge was initiated for the safety and well-being of all residents, without providing a 30-day notice. The facility's actions were not in compliance with long-term care regulations, which require written notification of discharge at least 30 days before the intended discharge date.
Failure to Prevent Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident with a known history of sexually inappropriate behavior. The incident occurred when the resident with a history of inappropriate behavior blocked the victim in a shower room, touched her inappropriately, and engaged in sexual acts in front of her. This incident was not isolated, as there were previous reports of the perpetrator's inappropriate behavior towards female residents, including watching pornography in public areas and making inappropriate comments. The victim, a female resident with severe cognitive impairment due to vascular dementia, was unable to provide a statement about the incident due to her condition. The perpetrator, a male resident with mild cognitive impairment, had a documented history of sexually inappropriate behavior, which was inadequately addressed by the facility. Staff interviews revealed that there were previous incidents involving the perpetrator, including being found in bed with another female resident, which were not properly documented or reported to the appropriate authorities. The facility's failure to adequately supervise and monitor the perpetrator, despite his known history of inappropriate behavior, led to the incident. Staff members were aware of the perpetrator's tendencies and had previously intervened to separate him from female residents, but these measures were insufficient to prevent the incident. The lack of proper documentation and communication among staff members contributed to the facility's inability to prevent the abuse, resulting in an immediate jeopardy situation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Alvarado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town Hall Estates Keene, Inc. | 6.7 mi | ★★★★★ | 0 | 0 |
| Grandview Nursing And Rehabilitation Center | 9.6 mi | ★★★★★ | 1 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 10.7 mi | ★★★★★ | 13 | 1 |
| Avir At Burleson | 11 mi | ★★★★★ | 3 | 0 |
| Colonial Manor Nursing Center | 11.4 mi | ★★★★★ | 3 | 0 |
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