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Complaint Investigation

Alvarado Care Center

June 26, 2024 · Los Angeles, CA · 1154 S.alvarado St
Citations 6
CMS Rating 2/5
Beds 72
Provider ID 056157
Healthcare Facility
Alvarado Care Center
Los Angeles, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

ALVARADO CARE CENTER in LOS ANGELES, CA — inspection on June 26, 2024.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0551
Give the resident's representative the ability to exercise the resident's rights.

During an interview with Administrator (ADM), on 6/26/2024 at 4:35 p.m., ADM stated, Resident 1 has the capacity to make her own decisions and she (Resident 1) can make her own decisions. ADM stated, Resident 1 does have a history of being admitted to BHC 1 and with a history of dementia.

ADM further stated, she does not believe that they need to notify Resident 1 ' s Agent when it comes to her decision on her financial.

A review of the facility's policy and procedures (P&P) titled, Informed Consent, implemented on 10/1/2023, indicated, Informed consent is defined as the voluntary agreement of a resident (or a representative of an incapacitated resident) to accept a treatment or procedure .

Resident Without Decision Making Capacity With a Surrogate Decision-Maker: A.

The surrogate decision-maker can be any of the following: i.

The agent designated by the person in an Advance Directive or Durable Power of Attorney for Healthcare, if one exists; ii.

The person designated by the resident orally and documented in the medical record.

A review of the facility ' s P&P titled, Decision Making Capacity, implemented on 10/1/2023 indicated, In the case of a resident adjudged incompetent under the state law, the rights of the resident devolved to and are exercised by the resident representative appointed by the state to act on the resident ' s behalf. i.

The court appointed resident representative will exercise the resident ' s right to the extent judged necessary by the court.

Recognized surrogate decision-makers will be provided relevant information to make informed decisions regarding treatment for the resident.

056157 06/26/2024

Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

environment and person-centered care plan that emphasizes the resident ' s comfort, independence

056157 06/26/2024

Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

s being loud at night and Resident 5 and 6 complained about Resident 1 because they were roommate.

should be a CP developed regarding Resident 5 and 6 complained about the noise caused by Resident 1. DON further stated, there should also be a CP develop regarding Resident 1 ' s behavior.

A review of facility ' s policy and procedures (P&P), titled, Care Planning, date implemented on 10/1/2023 indicated, purpose is to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.

The care plan serves as a course of action where the resident (resident ' s family and/or guardian or other legally authorized representative), resident ' s Attending Physician, and the IDT work to help the resident move toward resident-specific goals that address the resident ' s medical, nursing, mental and psychosocial needs.

A review of facility ' s P&P, titled, Resident Rooms and Environment, date implemented on 10/1/2023, the P&P indicated that facility provides residents with a safe, clean, comfortable and homelike environment and facility staff will provide residents with 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.

056157 06/26/2024

Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

assessment which puts Resident 1 at risk of smoking accident such as burning and respiratory issues

A review of the facility ' s policy and procedures (P&P) titled, Smoking, date implemented 10/1/2023,

will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas .

Smokers shall be identified at the time of admission. A licensed nurse will complete Safe Smoking Assessment for resident who wish to smoke: all smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly, the licensed nurse will provide the Safe Smoking Assessment for review by IDT, the IDT shall create a smoking Care Plan for the resident.

During an interview with Resident 6 on 6/26/2024 at 10:49 a.m., Resident 6 stated, her previous roommate (Resident 1) would be awake in the middle of the night. Resident 6 stated, Resident 1 would watch TV or listen to music loudly after 9 p.m., which caused her to stay awake and unable to sleep at night. Resident 6 further stated, Resident 1 would open the sliding door in their room to the patio and she would smell smoke in her room. Resident 1 stated, she told the staff and she talked to the Social Services Director about Resident 1 and they are aware of the situation.

During an interview with Resident 5 on 6/26/2024 at 10:58 a.m., Resident 5 stated, Resident 1, her previous roommate plays music and watches TV loudly until late at night, she (Resident 1) also is awake until 11 p.m., 1 a.m. and sometimes at 3 a.m. and would have other people come in their room through their patio sliding door. Resident 5 further stated, she talked to the SSD multiple times about the incident as her office was just right in front of her room.

Observed SSD ' s office in front of Resident 5 and 6 ' s room.

During an interview with Licensed Vocational Nurse (LVN) 1, on 6/26/2024 at 12:56 p.m., LVN1 stated, Resident 1 uses the sliding door to the smoking patio even at night and goes to the patio herself. LVN1 stated, Resident 5 and 6 complained about Resident 1 because she would play music and watches TV late at night. LVN 1 stated, he knows that SSD talks to Resident 5 and 6 about their concerns.

During an interview with Certified Nursing Assistant (CNA) 2, on 6/26/2024 at 12:56 p.m., CNA2 stated, Resident 1 was indeed, goes to the smoking patio through their sliding door inside their room. CNA2 stated, Resident 5 and 6 would complain to him regarding Resident 1 as she would be up all night and would play music. CNA2 further stated, Resident 5 and 6 also complained of the smell of smoke in their room.

056157

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056157 B.

Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

During an interview with Resident 6 on 6/26/2024 at 10:49 a.m., Resident 6 stated, her previous roommate (Resident 1) would be awake in the middle of the night. Resident 6 stated, Resident 1 would watch TV or listen to music loudly after 9 p.m., which caused her to stay awake and unable to sleep at night. Resident 6 further stated, Resident 1 would open the sliding door in their room to the patio and she would smell smoke in her room. Resident 1 stated, she told the staff and she talked to the Social Services Director about Resident 1 and they are aware of the situation.

During an interview with Resident 5 on 6/26/2024 at 10:58 a.m., Resident 5 stated, Resident 1, her previous roommate plays music and watches TV loudly until late at night, she (Resident 1) also is awake until 11 p.m., 1 a.m. and sometimes at 3 a.m. and would have other people come in their room through their patio sliding door. Resident 5 further stated, she talked to the SSD multiple times about the incident as her office was just right in front of her room.

Observed SSD ' s office in front of Resident 5 and 6 ' s room.

During an interview with Licensed Vocational Nurse 1 (LVN1) on 6/26/2024 at 12:56 p.m., LVN1 stated, Resident 1 uses the sliding door to the smoking patio even at night and goes to the patio herself. LVN1 stated, Resident 5 and 6 complained about Resident 1 because she would play music and watches TV late at night. LVN 1 stated, he knows that SSD talks to Resident 5 and 6 about their concerns.

During an interview with Certified Nursing Assistant 2 (CNA2) on 6/26/2024 at 12:56 p.m., CNA2 stated, Resident 1 was indeed, goes to the smoking patio through their sliding door inside their room. CNA2 stated, Resident 5 and 6 would complain to him regarding Resident 1 as she would be up all night and would play music. CNA2 further stated, Resident 5 and 6 also complained of the smell of smoke in their room.

During an interview Registered Nurse 2 (RN 2) on 6/26/2024 at 3:27 p.m., RN 2 stated and confirmed, Resident 1 would play music and watches TV loudly late at night. RN 2 stated, she spoke with Resident 1 regarding her music and TV playing at night because it causes other residents to be unable to sleep. RN 2 stated, Resident 5 and 6 complained about Resident 1 in multiple occasions and she mentioned it to SSD.

During an interview with SSD on 6/26/2024 at 6:00 p.m., SSD stated, she was aware of Resident 1 ' s being loud at night and Resident 5 and 6 complained about Resident 1 because they were roommate.

When asked if there were any care plan developed regarding Resident 5 and 6 ' s complained about Resident 1, SSD was unable to answer.

A review of Resident 5 and Resident ' s care plan (CP), as of 6/26/2024 indicated, there was no CP developed regarding Resident 5 and 6 inabilities to sleep due to Resident 1 ' s noise and there was no CP developed regarding Resident 1 ' s noise.

056157

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056157 B.

Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALVARADO CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.