Inspection·November 15, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm 10/24/24, the MDS indicated Resident 2 had moderately impaired cognitive skills. The MDS indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene, needed substantial assistance (helper does more than half the effort) with shower/bathe, lower body dressing, moderate assistance (helper does less than half the effort) with upper body dressing and supervision with oral hygiene and personal hygiene. The MDS indicated Resident 2 was independent with eating. Residents Affected - Few During a review of Resident 2's Restorative Administration Record (RAR, documentation of provision of restorative nursing program) for 11/2024, the RAR indicated the following dates were not signed: 11/5/24, 11/7/24 and 11/12/24. 2. During a review of the admission Record for Resident 3, the admission record indicated the facility admitted Resident 3 on 6/6/24 with diagnoses including Huntington's disease (a condition when the brain cells in certain parts of the brain start to break down) and movement disorder. During a review of the MDS for Resident 3 dated 9/13/24, the MDS indicated Resident 3 had severely impaired cognitive skills. Resident 3 needed supervision with eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/off footwear and personal hygiene. During a review of the Physician Order for Resident 3 dated 6/11/24 at 1:55 p.m., indicated a physician order for the RNA to do AROM on Resident 3's left and right upper extremity daily five times a week one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday. During a review of the Rehabilitation Screening Form dated 6/11/24 and 9/11/24 indicated PT recommendations that included RNA program for Resident 3. During a review of Resident 3's RAR, indicated the following dates were not signed 11/5/24, 11/7/24 and 11/12/24. During a concurrent interview and record review on 11/15/24 at 11:15 a.m. with RNA 1, Resident 2 and Resident 3's RAR for 11/24 were reviewed. During a concurrent interview RNA 1 stated Resident 2 and Resident 3 had order for ROM exercises daily Monday to Friday for about 10 to 15 minutes. RNA 1 stated the following dates were not signed by the RNA - 11/5/24, 11/7/24 and 11/12/24. RNA 1 stated sometimes Resident 2 and Resident 3 refused the ROM exercises but stated she cannot find documentation that Resident 2 and Resident 3 refused. RNA 1 stated the ROM exercises was to improve the flexibility and muscles of Resident 2 and Resident 3. During a concurrent interview and record review on 11/15/24 at 11:50 a.m., the facility's policy and procedures (P&P) titled Restorative Nursing Program Guidelines was reviewed with the registered nurse supervisor 1 (RNS 1). The P&P indicated the interdisciplinary care plan will reflect the written plan of cate for meeting the restorative needs of each resident. RNS 1 reviewed the care plan for Resident 2 and Resident 3 and stated RNS 1 was unable to find care plan addressing the restorative needs of Resident 2 and Resident 3. RNS 1 stated the care plan is for the facility to determine what interventions are being given to Resident 2 and Resident 3. RNS 1 also agreed that the RAR were not signed as done on 11/5/24, 11/7/24 and 11/12/24. RNS 1 stated the RNA exercises is to prevent Resident 2 and Resident 3 from potentially developing contractures. During the exit conference on 11/15/24 at 12:10 p.m., the administrator (ADM) stated once the RNA exercises were done, the RNA must sign the RAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled Restorative Nursing Program Guidelines reviewed on 10/1/23, indicated the interdisciplinary care plan will reflect the written plan of care for meeting the restorative needs of each resident including problems/needs, measurable goals, and individualized approaches. The care plan for each resident will be reviewed quarterly or as needed by the interdisciplinary team. The same P&P indicated the RNA carries out the restorative program according to the care plan and documents daily. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 3 of 3