LOS ANGELES, CA - Federal inspectors found significant deficiencies at Alvarado Care Center during a June 2024 investigation, citing the facility for failing to develop proper care plans and not maintaining appropriate resident living environments when roommate conflicts disrupted sleep patterns.
Roommate Conflicts Disrupt Resident Sleep and Safety
The most serious violations centered around three residents whose living situation had deteriorated over time without adequate intervention from facility staff. Resident 1, who has dementia and major depressive disorder with psychotic symptoms, was creating disturbances that prevented her roommates from sleeping.
According to inspection findings, Resident 6 reported that her roommate would stay awake in the middle of the night, watching television or listening to music loudly after 9 p.m. The noise prevented Resident 6, who has diabetes, congestive heart failure, and documented sleep problems, from getting necessary rest.
The situation was further complicated by safety concerns. Resident 6 told inspectors that "Resident 1 would open the sliding door in their room to the patio and she would smell smoke in her room." Multiple staff members confirmed that Resident 1 was accessing the facility's smoking patio through the room's sliding door, including during nighttime hours.
Resident 5, who requires maximum assistance with daily activities due to diabetes and depression, faced similar disruptions. She reported to investigators that "Resident 1, her previous roommate plays music and watches TV loudly until late at night, she also is awake until 11 p.m., 1 a.m. and sometimes at 3 a.m."
Failure to Address Known Problems Through Care Planning
Despite multiple complaints from affected residents, facility staff failed to develop appropriate care plans to address the ongoing conflicts. The Social Services Director's office was located directly across from the affected residents' room, and multiple staff members confirmed they were aware of the complaints.
Licensed Vocational Nurse 1 acknowledged that "Resident 5 and 6 complained about Resident 1 because she would play music and watches TV late at night." Certified Nursing Assistant 2 similarly confirmed receiving complaints from both residents about the noise and smoke odors.
When inspectors reviewed the care plans for all three residents involved, they found no documentation addressing the sleep disruption issues or the behavioral concerns that were creating the problems. This represents a fundamental failure in the care planning process, which federal regulations require to be comprehensive and address all identified resident needs.
Medical Impact of Sleep Disruption in Vulnerable Populations
Sleep disturbances in nursing home residents can have serious health consequences, particularly for individuals with multiple chronic conditions. Resident 6's combination of congestive heart failure and diabetes makes adequate sleep essential for managing her conditions effectively. Poor sleep can worsen heart failure symptoms and make blood sugar control more difficult.
For Resident 5, who has diabetes and depression, sleep disruption can exacerbate both conditions. Inadequate sleep can interfere with glucose metabolism and worsen depressive symptoms, creating a cycle of declining health.
The situation was particularly concerning given that Resident 1, whose behavior was causing the disruptions, has dementia with psychotic symptoms and is taking antipsychotic medications. Proper behavioral interventions and environmental modifications should have been implemented to address her nighttime restlessness while protecting other residents' sleep.
Missing Environmental Safeguards and Care Coordination
Federal nursing home regulations require facilities to provide residents with safe, comfortable living environments that promote rest and well-being. The facility's own policy, implemented in October 2023, specifically emphasizes providing "a pleasant environment and person-centered care plan that emphasizes the resident's comfort, independence and personal needs and preferences; paying close attention to the comfortable noise levels."
Despite having this policy in place, staff failed to implement effective interventions when residents' comfort and sleep were being compromised. The lack of care plan development meant there were no formal protocols for addressing the behavioral issues or protecting the affected residents' rest.
Proper nursing home practice would typically involve developing individualized interventions for the resident causing disruptions, potentially including medication timing adjustments, structured evening activities, or room reassignment if other measures proved ineffective.
Additional Issues Identified
The inspection also revealed that the facility had not adequately assessed and planned for the complex care needs of residents with multiple chronic conditions. The failure to develop comprehensive care plans extended beyond the roommate conflict situation, indicating broader systemic issues with the facility's care planning processes.
The violations occurred despite the facility having multiple staff members aware of the ongoing problems, suggesting potential communication and coordination failures within the care team.
The inspection findings highlight the importance of proactive care planning in nursing homes, particularly when residents with behavioral health conditions share living spaces with others who have serious medical conditions requiring adequate rest for proper management.
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.
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