Alvarado Care Center: Roommate Noise Complaints Ignored - CA
Federal inspectors found that Alvarado Care Center failed to create individualized care plans for the affected residents, despite multiple complaints from patients and staff awareness of the ongoing problems.
Resident 6, who has congestive heart failure and insomnia, told inspectors on June 26 that her previous roommate would stay awake in the middle of the night, watching TV or listening to music loudly after 9 p.m. The noise caused her to stay awake and remain unable to sleep.
The roommate would also open the sliding patio door in their shared room, and Resident 6 said she could smell smoke drifting into the space.
Resident 5, who has diabetes and depression, described similar disruptions. She told inspectors that the roommate played music and watched TV loudly until late at night, staying awake until 11 p.m., 1 a.m., and sometimes 3 a.m. The roommate would also have other people enter their room through the patio sliding door.
"She talked to the SSD multiple times about the incident as her office was just right in front of her room," inspectors noted, referring to the Social Services Director.
Both affected residents required total assistance from staff for basic activities like toileting, bathing, and personal hygiene. Their medical assessments showed they had intact cognition for daily decision-making.
The disruptive roommate, identified as Resident 1, was admitted with chronic obstructive pulmonary disease, dementia, and major depressive disorder with psychotic symptoms. Her condition includes delusions and hallucinations that create a disconnection from reality.
Licensed Vocational Nurse 1 confirmed to inspectors that Resident 1 used the sliding door to access the smoking patio even at night. "Resident 5 and 6 complained about Resident 1 because she would play music and watches TV late at night," the nurse stated.
Certified Nursing Assistant 2 told inspectors that both residents would complain about Resident 1 staying up all night playing music. The assistant also confirmed that residents complained about the smell of smoke in their room.
Registered Nurse 2 said she had spoken directly with Resident 1 about her music and TV playing at night because it prevented other residents from sleeping. The nurse confirmed that Residents 5 and 6 complained about their roommate on multiple occasions, and she had mentioned the situation to the Social Services Director.
When inspectors interviewed the Social Services Director on June 26, she acknowledged awareness of Resident 1 being loud at night and the complaints from her roommates. However, when asked whether any care plans had been developed to address the complaints, the director was unable to answer.
The Director of Nursing told inspectors there should have been care plans developed both for the residents complaining about the noise and for Resident 1's disruptive behavior.
Facility policy requires comprehensive person-centered care plans based on individual assessed needs. The policy states that care plans should address residents' medical, nursing, mental and psychosocial needs through collaboration between residents, families, physicians, and the interdisciplinary team.
The facility's resident environment policy specifically emphasizes providing "comfortable noise levels" as part of person-centered care that addresses residents' comfort, independence, and personal preferences.
Inspectors also found safety violations related to Resident 1's smoking habits. Despite being listed as a smoker on facility records from April 12, her admission assessment incorrectly indicated she did not smoke.
Registered Nurse 1, who completed the admission assessment, told inspectors that Resident 1's family had informed him she should not smoke due to her COPD diagnosis and physician orders. However, he acknowledged completing an inaccurate smoking assessment.
"He did not do a thorough and accurate assessment which puts Resident 1 at risk of smoking accident such as burning and respiratory issues due to her diagnosis," inspectors wrote.
The facility's smoking policy requires assessment of all residents who wish to smoke, with licensed nurses completing safety evaluations at admission and quarterly thereafter. The policy mandates that the interdisciplinary team create smoking care plans for identified smokers.
No care plan existed addressing Resident 1's smoking safety, despite her dementia diagnosis and psychotic symptoms that could impair judgment around fire safety.
The inspection occurred following a complaint and resulted in citations for failing to develop necessary care plans and ensure accident-free environments. Both violations were classified as minimal harm with potential for actual harm affecting few residents.
Federal inspectors noted that the deficient practices had potential for sleep disruption among vulnerable residents with serious medical conditions, as well as fire-related accidents throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alvarado Care Center from 2024-06-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALVARADO CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on June 26, 2024.
The noise caused her to stay awake and remain unable to sleep.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.