Inspection Reports for
Alvarado Care Center

The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medication, inadequate feeding assistance, incomplete care plans for falls and behavioral issues, inaccurate resident assessments, missing PASRR screening, medication errors including missed doses and expired medications, unsafe food handling and preparation, and failure to prevent urinary tract infections related to catheter care.

The facility failed to ensure that the medication Biktarvy, used to treat HIV, was available and administered as ordered for six consecutive days to one resident, resulting in treatment interruption, emotional distress, and risk of health decline. Documentation of omitted doses was incomplete, and facility staff did not follow protocol to notify the physician or provide alternative treatment.

The investigation was complaint-driven, focusing on Resident 1's care planning, fall risk management, nutritional care, and documentation accuracy. The deficiencies were substantiated based on interviews, record reviews, and policy comparisons.

The facility failed to develop and implement a complete care plan addressing Resident 1's fall risk, failed to update the care plan after Resident 1's falls on 8/18/25 and 8/30/25, failed to provide adequate nutritional interventions when Resident 1 refused meals, and failed to maintain accurate and complete fall risk assessments and documentation.

The investigation was complaint-driven, focusing on Resident 1's pressure injury and subsequent adverse outcomes. The complaint was substantiated as the facility failed to provide adequate care and communication, leading to Resident 1's deterioration and death.

The facility failed to implement pressure injury prevention interventions, accurately assess risk, provide pressure-relieving mattresses, and report abnormal lab results. Resident 1 developed a deep tissue injury that led to infection, hospitalization, and death. Documentation and staff competency deficiencies were noted.

The facility failed to ensure its policy for Unusual Occurrence Reporting included major accidents and did not report a major accidental fall with injury to the State Agency. The facility's policy was outdated and did not consider major accidents as reportable events despite state regulations requiring such reporting.

The complaint investigation found substantiated deficiencies related to failure to notify Resident 1's Power of Attorney about medical appointments, improper use of medical equipment, and medication administration documentation failures.

The facility failed to notify Resident 1's Power of Attorney about an MRI appointment, improperly used a low air loss mattress by placing a chux pad on it, and failed to document medication administration accurately, risking medication errors and delayed care.

The facility was found deficient in multiple areas including failure to timely and accurately assess residents, incomplete care plans, improper medication monitoring and storage, inadequate infection control practices, and unsafe food storage. These deficiencies posed risks of inadequate care, potential worsening of resident conditions, and risk of infection or foodborne illness.

The facility failed to provide ordered ROM exercises to two residents on multiple dates and did not have care plans addressing their restorative needs. The restorative nursing assistants did not sign documentation for ROM exercises on specified dates, and the care plans lacked interventions for these residents.

The complaint investigation involved Resident 1's allegation on 8/20/24 that a person entered her room and placed a hand over her mouth. The allegation was substantiated by interviews and record reviews, but the facility failed to adequately address the allegation through care planning, social services, and accurate documentation.

The facility failed to develop a person-centered care plan addressing Resident 1's allegation of an incident on 8/20/24. The facility also failed to provide necessary social services and maintain accurate medical records related to the allegation. Resident 1 had severe cognitive impairment and was dependent on assistance for daily activities.

The complaint investigation was substantiated. Resident 1 reported being physically hit by Resident 2 on 6/26/2024. Interviews with staff and review of records confirmed the incident and the facility's failure to protect Resident 1 from abuse.

The facility failed to protect Resident 1 from physical abuse by Resident 2, who hit Resident 1 causing pain and redness. Additionally, the facility failed to develop a care plan for psychotropic medications for Resident 2 and failed to obtain informed consent for an increased dosage of Fluvoxamine Maleate for Resident 1.

The complaint investigation focused on Resident 1's financial decision-making and failure to notify the durable power of attorney, noise disturbances caused by Resident 1 affecting roommates, lack of care plans addressing these issues, and unsafe smoking practices by Resident 1.

The facility failed to inform the durable power of attorney of Resident 1's financial activities, failed to maintain a comfortable environment by allowing noise disturbances from Resident 1 affecting roommates, failed to develop care plans addressing noise and behavior issues for Residents 1, 5, and 6, and failed to properly assess Resident 1's smoking ability, risking fire hazards.

The complaint investigation found that the call light was not within reach for Resident 2 and Resident 3, confirmed by observations and staff interviews. The deficiency was substantiated with minimal harm potential.

The facility failed to ensure that the call light was within reach for two of five sampled residents, which posed a potential risk for accidents or injuries. Observations confirmed that the call lights for Resident 2 and Resident 3 were not accessible, and staff acknowledged the issue.

The facility was found deficient in multiple areas including informed consent for vaccinations, advance directives documentation, notification of Medicare/Medicaid coverage changes, individualized care planning, hearing aid provision, respiratory care, dialysis emergency preparedness, nurse staffing postings, psychotropic medication management, therapeutic diet adherence, and food safety and sanitation practices.

The complaint investigation focused on an incident on April 29, 2023, where Resident 3 alleged Resident 4 pushed her to the floor causing injury. Resident 3 reported the incident to staff, but the facility staff failed to properly investigate or protect Resident 3. Staff interviews revealed failure to follow abuse policies. Resident 4 admitted to pushing Resident 3. The facility also failed to timely report the abuse allegation to authorities.

The facility failed to protect Resident 3 from physical abuse by Resident 4 and did not thoroughly investigate or implement safety measures following the incident. Additionally, the facility failed to timely report the alleged abuse to proper authorities, potentially delaying further investigation and placing residents at risk.