Alvarado, TX

Alvarado Meadows Nursing & Rehabilitation

1-star overall rating with 2-star inspections with abuse icon flag with $90,873 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

101 N Parkway, Alvarado, TX

(817) 790-3304

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

115

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Creative Solutions In Healthcare

Operator or chain grouping

Approved since

1985-11-05

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

149 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.33

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.71

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.15

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.04

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.74

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.34

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.39

CMS adjusted RN staffing hours

Adjusted total hours

3.70

CMS adjusted total nurse staffing hours

Case-mix index

1.17

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.2%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 7.69%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.27	1.02 0.2 pts worse
Drug regimen review with follow-up	59.09%	95.27% 36.2 pts worse	Numerator 13 · Denominator 22
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 22
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	4.55%	2.29% 2.3 pts worse	Numerator 1 · Denominator 22 · Adjusted rate 3.7%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 91
Staff flu vaccination coverage	28.67%	42% 13.3 pts worse	Numerator 41 · Denominator 143
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.5 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.1	2.1 1 pts worse	1.8 1.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.8%	3.3% 1.5 pts worse	3.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.8% · Q3 4.9% · Q4 3.0% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.3%	2.7% 0.4 pts better	11.4% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 5.9% · 4Q avg 2.3%
Percentage of long-stay residents who lose too much weight	3.8%	3.3% 0.5 pts worse	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 8.3% · Q4 2.0% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.1%	18.9% 0.8 pts better	19.6% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 23.9% · Q3 14.0% · Q4 10.0% · 4Q avg 18.1%
Percentage of long-stay residents who received an antipsychotic medication	23.0%	10.8% 12.2 pts worse	16.7% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 23.3% · Q3 21.1% · Q4 27.0% · 4Q avg 23.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	31.4%	15.4% 16 pts worse	16.3% 15.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 29.4% · 4Q avg 31.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	33.3%	16.1% 17.2 pts worse	14.9% 18.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 33.3% · Q3 20.5% · Q4 40.0% · 4Q avg 33.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	0.8% 0.1 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.5%	15.0% 8.5 pts worse	19.8% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 20.9% · Q3 37.0% · Q4 22.0% · 4Q avg 23.5%
Percentage of long-stay residents with pressure ulcers	3.6%	4.2% 0.6 pts better	5.1% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.8% · Q3 3.3% · Q4 6.7% · 4Q avg 3.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	89.7% 9.5 pts better	81.7% 17.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.1% · 4Q avg 99.2%
Percentage of short-stay residents who had an outpatient emergency department visit	12.8%	12.0% 0.8 pts worse	12.0% 0.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 15.2% · Expected 13.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	35.1%	25.9% 9.2 pts worse	23.9% 11.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 35.1% · Observed 30.3% · Expected 20.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-06 · Fire 2025-03-06

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2024-02-07 · Fire 2024-02-07

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-12-15 · Fire 2022-12-15

10 health deficiencies

Top issue: Resident Rights (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-03-06

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2025-03-06

E · Potential for more than minimal harm 2025-03-06

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-03-06

F · Potential for more than minimal harm 2024-02-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-04-08

E · Potential for more than minimal harm 2024-02-07

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-04-08

F · Potential for more than minimal harm 2022-12-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-04-02

D · Potential for more than minimal harm 2022-12-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-04-02

Inspection history

Recent health citations

J · Immediate jeopardy 2025-06-10

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-06-10

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-06-10

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-06-10

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-06-10

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-06-11

E · Potential for more than minimal harm 2025-03-06

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-03-07

E · Potential for more than minimal harm 2025-03-06

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-03-07

D · Potential for more than minimal harm 2025-03-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-02-09

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2025-02-10

J · Immediate jeopardy 2024-05-22

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-05-23

D · Potential for more than minimal harm 2024-02-07

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2024-03-12

D · Potential for more than minimal harm 2024-02-07

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-03-04

D · Potential for more than minimal harm 2024-02-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-12

J · Immediate jeopardy 2023-08-26

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-08-27

D · Potential for more than minimal harm 2023-08-26

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-08-27

F · Potential for more than minimal harm 2022-12-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-01-15

E · Potential for more than minimal harm 2022-12-15

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-01-15

E · Potential for more than minimal harm 2022-12-15

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-01-15

E · Potential for more than minimal harm 2022-12-15

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2023-01-15

E · Potential for more than minimal harm 2022-12-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2023-01-15

D · Potential for more than minimal harm 2022-12-15

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-01-15

D · Potential for more than minimal harm 2022-12-15

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2023-01-15

D · Potential for more than minimal harm 2022-12-15

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-01-15

Penalties and ownership

What sits behind the stars

$15,940 2025-06-10

Fine

Fine · fine $15,940

Fine

$4,329 2025-02-09

Fine

Fine · fine $4,329

Fine

$7,141 2024-05-22

Fine

Fine · fine $7,141

Fine

$44,925 2024-03-15

Fine

Fine · fine $44,925

Fine

$0 2024-03-15

Payment Denial

Payment Denial · denial start 2024-04-12 · 5 days

5 day denial

$18,538 2023-08-26

Fine

Fine · fine $18,538

Fine

Ownership

Alvarado I Enterprises, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2024-08-01

Alvarado I Enterprises, LLC

Operational/Managerial Control · Organization

0% 1 facilities 2024-08-01

Blake, Gary

5% Or Greater Indirect Ownership Interest · Individual

0% 136 facilities 2024-08-01

Blake, Gary