Alvarado Meadows Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Alvarado Meadows Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600May 22, 2024

  Based 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 [DATE] at 5:17 pm. […]

• Immediate jeopardy, isolatedF755Aug 26, 2023

  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. […]

• No harm, potential for more than minimal, widespreadF812Dec 15, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services. The facility failed to prevent the following: 1. Food and beverage items were not properly labeled with product and expiration date. 2. Food items were not properly sealed when not in use. 3. Food items were past expiration or use by date. 4. Food and beverage items were not discarded after 7 days of open date. 5. Frozen food was covered with freezer burn. 6. Food was not stored in appropriate containers. 7. […]

• No harm, potential for more than minimal, patternF550May 6, 2026

  Based 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. […]