Alvarado Care Center

F-F584.

Findings:

1. A review of Resident 5's Admission Record indicated that Resident 5 was originally admitted to the facility

on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest).

A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 6/6/2024, MDS indicated Resident 5 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required maximal assistance from staff for activities of daily living (ADL-rolling left to right, sit to lying, toilet transfer). The MDS also indicated, Resident 5 was total dependent from staff with toileting hygiene, shower/bathe self and personal hygiene.

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

2. A review of Resident 6's Admission Record indicated that Resident 6 was admitted to the facility on [DATE REDACTED] with diagnosis including DM-a chronic condition that affects the way the body processes blood sugar [glucose]), congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle) and insomnia (inability to sleep).

A review of Resident 6's MDS dated [DATE REDACTED], indicated Resident 6 has intact cognition for daily decision-making and was total dependent from staff for ADLs - toileting hygiene, shower/bathe self, lower body dressing and personal hygiene. The MDS also indicated, Resident 6 has symptoms of feeling down, depressed or hopeless and trouble falling or staying asleep.

A review of Resident 6 ' s CP as of 6/26/2024 indicated, there was no CP developed regarding Resident 6 ' s inability to sleep due to Resident 1 ' s noise and complained about Resident 1 (roommate).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 3. A review of Resident 1's Admission Record indicated that Resident 1 was admitted to the facility on [DATE REDACTED] with diagnosis including chronic obstructive pulmonary disease (COPD - a group of lung diseases Level of Harm - Minimal harm or that block airflow and make it difficult to breathe), unspecified dementia (loss of cognitive potential for actual harm functioning-thinking, remembering, and reasoning), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) severe Residents Affected - Few with psychotic symptoms (a collection of symptoms, including delusions [false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them] and hallucinations [seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them] which happen when a person experiences a disconnection from reality).

A review of Resident 1's MDS dated [DATE REDACTED], indicated Resident 1 has modified independence cognition for daily decision-making and was independent from staff for ADLs - toileting hygiene, shower/bathe self, personal hygiene, mobility such as sit to lying, sit to stand, toilet transfer, and walking 150 feet. The MDS also indicated, Resident 1 was taking antipsychotic medications (a medication which are available on prescription to treat a certain type of mental health problems).

A review of Resident 1 CP, as of 6/26/2024 indicated, there was no CP developed regarding Resident 1 ' s behavior and noise especially at night.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview Registered Nurse (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 Level of Harm - Minimal harm or regarding her music and TV playing at night because it causes other residents to be unable to sleep. RN 2 potential for actual harm stated, Resident 5 and 6 complained about Resident 1 in multiple occasions and she mentioned it to SSD.

Residents Affected - Few 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.

During an interview with Director of Nursing (DON), on 6/26/2024 at 4:25 p.m., DON stated, there 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was a smoker was assessed for their ability to smoke safely prior to being allowed to smoke independently while in the facility.

This deficient practice had the potential for fire related accidents in the facility among residents, staff and visitors.

Findings:

A review of Resident 1's Admission Record indicated that Resident 1 was admitted to the facility on [DATE REDACTED] with diagnosis including nicotine dependence, cigarettes (involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) severe with psychotic symptoms (a collection of symptoms, including delusions [false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them] and hallucinations [seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them] which happen when a person experiences a disconnection from reality).

A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 6/1/2024, indicated Resident 1 has modified independence cognition (mental action or process of acquiring knowledge and understanding for daily decision-making and was independent from staff for ADLs - toileting hygiene, shower/bathe self, personal hygiene, mobility such as sit to lying, sit to stand, toilet transfer, and walking 150 feet. The MDS also indicated, Resident 1 was taking antipsychotic medications (a medication which are available on prescription to treat a certain type of mental health problems).

A review of Resident 1 ' s Care Plan (CP) as on 6/26/2024 indicated, there was no specific CP developed regarding maintaining a safe environment with the focus of Resident 1 ' s smoking.

A review of Resident 1 ' s Safe Smoking Assessment/Admission assessment dated [DATE REDACTED] indicated, the smoking assessment completed by Registered Nurse (RN) 1 indicated, Resident 1 does not smoke.

A review of the List of Smokers (list of residents) in the facility, dated 4/12/2024 indicated, Resident 1 was a smoker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview with RN 1 on 6/26/2024 at 2:20 p.m., RN 1 stated, Resident 1 was a smoker and was independent with smoking. RN 1 stated, upon admission, Resident 1 ' s family member informed him that Level of Harm - Minimal harm or Resident 1 should not smoke in the facility because of her diagnosis of COPD and it was ordered by her potential for actual harm (Resident 1 ' s) physician. RN 1 reviewed Resident 1 ' s admission assessment with surveyor and confirmed,

he completed the smoking assessment during admission in which he answered that Resident 1 does not Residents Affected - Few smoke. RN 1 further stated, 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.

A review of the facility ' s policy and procedures (P&P) titled, Smoking, date implemented 10/1/2023, the P&P indicated, Smoking is not allowed anywhere inside the Facility . Resident who want to smoke 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 056157

F-F656.

Findings:

1. A review of Resident 5's Admission Record indicated that Resident 5 was originally admitted to the facility

on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest).

A review of Resident 5's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 6/6/2024, MDS indicated Resident 5 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required maximal assistance from staff for activities of daily living (ADL-rolling left to right, sit to lying, toilet transfer). The MDS also indicated, Resident 5 was total dependent from staff with toileting hygiene, shower/bathe self and personal hygiene.

2. A review of Resident 6's Admission Record indicated that Resident 6 was admitted to the facility on [DATE REDACTED] with diagnosis including DM-a chronic condition that affects the way the body processes blood sugar [glucose]), congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle) and insomnia (inability to sleep).

A review of Resident 6's MDS dated [DATE REDACTED], indicated Resident 6 has intact cognition for daily decision-making and was total dependent from staff for ADLs - toileting hygiene, shower/bathe self, lower body dressing and personal hygiene. The MDS also indicated, Resident 6 has symptoms of feeling down, depressed or hopeless and trouble falling or staying asleep.

3. A review of Resident 1's Admission Record indicated that Resident 1 was admitted to the facility on [DATE REDACTED] with diagnosis including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) severe with psychotic symptoms (a collection of symptoms, including delusions [false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them] and hallucinations [seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them] which happen when a person experiences a disconnection from reality).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 A review of Resident 1's MDS dated [DATE REDACTED], indicated Resident 1 has modified independence cognition for daily decision-making and was independent from staff for ADLs - toileting hygiene, shower/bathe self, Level of Harm - Minimal harm or personal hygiene, mobility such as sit to lying, sit to stand, toilet transfer, and walking 150 feet. The MDS potential for actual harm also indicated, Resident 1 was taking antipsychotic medications (a medication which are available on prescription to treat a certain type of mental health problems). Residents Affected - Few

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 A review of the facility ' s policy and procedures (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 Level of Harm - Minimal harm or and homelike environment and facility staff will provide residents with a pleasant environment and potential for actual harm person-centered care plan that emphasizes the resident ' s comfort, independence and personal needs and preferences; paying close attention to the comfortable noise levels. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 056157 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for three of seven sampled residents (Resident 1, Resident 5, and Resident 6) regarding Resident 5 and 6 ' s inability to sleep and complained due to Resident 1 ' s noise at nighttime.

This deficient practice had the potential to result negative impact on residents ' health and safety, as well as

the quality of care and services received.

Cross Reference