Inspection·July 10, 2025

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure their policy for Unusual Occurrence Reporting included major accidents and follow it to report a major accidental fall with injury according to the State and Federal regulations for one of three sampled residents (Resident 1). This deficient practice resulted an outdated policy and procedures being implemented when the facility made the decision not to report a major accidental fall with injury to the State Agency (SA). During a review of Resident 1's admission Record dated 7/10/25, indicated the resident was admitted to the facility on [DATE] with diagnosis including unsteadiness on feet, lack of coordination, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), repeated falls, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 1's History and Physical (H&P) dated 7/9/25 indicated the resident was having memory problems and had fluctuating capacity to make medical decisions. During a review Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/7/25 indicated Resident 1 had moderately impaired cognitive (process of thinking, reasoning, judgement or remembering) function. Resident 1 was dependent (helper does all the effort) with toileting, shower, lower body dressing, putting on footwear and sit to stand and transfers. The assessment for walking was not attempted due to medical condition of safety concerns.During a review Resident 1's of the Nurses Notes dated 6/25/25 at 00:20 am indicated, resident again trying to physically fight the nurse. resident started to take steps toward his walker and he lost his balance and fell to the floor. During a review of Resident 1's Nurses Notes dated 6/25/25 at 2:50 am indicated, 911 was called due resident's unrelieved pain. resident transferred to hospital at approximately 3:00 am. During a review of Resident 1's CT (medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) pelvis (central core of your skeletal system) imaging report dated 6/25/25 at 8:43 am indicated Resident 1 had and fracture of the right femur (long bone of the thigh). During a review of Resident 1's Nurses Notes dated 6/30/25 at 10:48 pm the resident was readmitted to the facility. During a review of the facility's policy and procedures (P&) titled Unusual Occurrence Reporting implemented October 2023, indicated the facility will follow all applicable state and federal laws and regulation regarding the reporting of unusual occurrences. The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies. Other Occurrences. Death of a resident, employee or visitor due to unnatural causes. Allegations of abuse, or neglect. Allegations of misappropriation of resident property; and. Other occurrences that interfere with Facility operations and affect the welfare, safety, or health of residents, employees or visitors. During a review of the California Code Regulations - 72541 - Unusual Occurrences, indicated Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056157 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 07/10/2025 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)