Other·May 9, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated survey for a complaint investigation. Complaint number: CA00629973 and CA00630622 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 40354 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of CA00629973 and CA00630622. Highest Severity and Scope: J Immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called under F689 on 3/23/19 at 8:26 p.m. The facility administrator, Director of nursing, registered nursing supervisor, and social services/activity director were notified of the immediate jeopardy situation. The lacked of supervision of Resident 1 who was assessed at risk for elopement, increased episodes of wandering out of the facility, and failure to immediately respond to the door alarm resulted to elopement of Resident 1. The above deficient practices had the potential for 12 other residents at risk for elopement to elope. An acceptable immediate written plan of action was accepted on 3/25/19 at 5:57 p.m., the plan LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of action-included the following: - Hourly visual monitoring of residents with code alarm (wander guard -) by their respective certified nursing assistant (CNA) and will be documented in the code alarm clipboard, immediate reporting of incomplete head count to charge nurses by CNA. - Director of Nurses (DON) in-serviced all staff regarding need for immediate respond with code alarm on 3/22/19. - Director of Nurses in-serviced charged nurses on 3/23/19 regarding to be ultimately responsible for an immediate respond by any nursing staff as soon as warning sounds triggers. Charge nurses must ensure that the cause of the code alarm was not triggered by a resident before resetting the alarm sounds. Charge nurses will also ensure that a visual check of the immediate area for any resident that might have eloped will be done. - Video surveillance monitor was installed in the medical record near the nurses' station and the charge nurses, registered nurses supervisor DON and Administrator were in service on how to access the surveillance. - Charge nurses must review video every time the code alarm is triggered. The immediate jeopardy was abated on 3/26/19, at 3 p.m., after the Evaluator verified that the facility's written plan of action was implemented.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/25/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed at risk for elopement (leaving without notice or permission), had an increased episode of wandering out of the facility, and had triggered the door alarm (a device that resident wear and when attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) received adequate supervision to prevent elopement by failing to: 1. Respond immediately to door alarm when it was triggered on 3/21/19 at 7:49 p.m. and immediately check the immediate area for any resident that might have eloped. 2. Ensure the cause of the door alarm was immediately identified before resetting the alarm sound. 3. Ensure the video surveillance was immediately checked when door alarm was triggered to immediately identify possible elopement. These deficient practices resulted in Resident 1 eloping from the facility on 3/21/19 and was still missing and had the potential for 12 other residents identified by the facility as high risk for elopement to elope. Immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called under F689 on 3/23/19 at 8:26 p.m. The facility administrator, Director of Nursing (DON), registered nursing supervisor (NS), and social services/activity director (SSD) were notified of the immediate jeopardy situation. The lack of supervision of Resident 1 who was assessed at risk for elopement, increased episodes of wandering out of the facility, and failure to immediately respond to the door alarm resulted to elopement of Resident 1. The above deficient practice had the potential for 12 other residents at risk for elopement to elope. An acceptable immediate written plan of action was accepted on 3/25/19 at 5:57 p.m.which included the following: - Hourly visual monitoring of residents with code alarm (a wander guard [wristband] - that when a resident wearing a wander guard attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) by their respective certified nursing assistant (CNA) and will be documented in the code alarm clipboard. Immediate reporting of an incomplete head count to charge nurses by CNA. - Director of Nurses (DON) in-serviced all staff regarding need for immediate response to code alarms on 3/22/19. - Director of Nurses in-serviced charged nurses on 3/23/19 to be ultimately responsible for an immediate response by any nursing staff as soon as warning sound triggers. Charge nurses must ensure that the cause of the code alarm was not triggered by a resident before resetting the alarm sound. Charge nurses will also ensure that a visual check of the immediate area for any resident that might have eloped will be done. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - Video surveillance monitor was installed in the medical records near the nurses' station and the charge nurses, registered nursing supervisor, DON and Administrator were inserviced as to how to access the surveillance monitor. - Charge nurses must review video every time the code alarm is triggered. The immediate jeopardy was removed on 3/26/19 at 3 p.m., after the Evaluator verified through onsite observation, interview, and record review that the facility's written plan of action was implemented. Findings: On 3/23/19 at 12:47 p.m., an unannounced visit was made to the facility to investigate a facilityreported incident (FRI) regarding Resident 1 who walked out of the facility on 3/21/19, and was still missing. A review of Resident 1's Admission Record dated 3/22/19 indicated Resident 1 was originally admitted to the facility on 3/27/08 and was readmitted on 2/10/13. Resident 1 diagnoses included hypertension (high blood pressure), atrial fibrillation (irregular, rapid heart rate), psychosis (mental disorder in which thoughts and emotions are so impaired), and paranoid schizophrenia (mental disorder in which a person loses touch with reality). The admission record indicated Resident 1's responsible party is a Public Guardian (PG, is a guardian appointed by a court and is deemed to be an officer of the court. A public guardian may be appointed as guardian for many incompetent or incapacitated persons). A review of Resident 1's History and Physical Examination dated 8/23/18 indicated that Resident 1 had a cardiovascular accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (damage to the brain from interruption of its blood supply) with right hemiplegia (paralysis of one side of the body). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/23/19 indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 needed limited assistance and one-person physical assist for transfer, walk in room, walk in corridor, locomotion off unit and dressing. The MDS indicated that resident needed supervision for locomotion on unit. A review of Resident 1's Assessment Risk of Elopement/Wandering Review dated 2/11/19 indicated "Yes" on the following questions: 1. Is the resident cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disorientation)? 2. Does the resident have a pertinent diagnosis of schizophrenia? 3. Does the resident have a history of: Leaving the facility without informing staff? ("Yes multiple") 4. Has the resident verbally expressed the desire to go home or packed belongings to go home or stayed near exit door? A review of Resident 1's elopement care plan initiated 2/11/19 indicated resident had a tendency to wander out of the facility manifested by staying close to exit doors and history of leaving the facility. The care plan goal indicated for Resident 1 was to have less episodes of wandering out of the facility. The interventions included to obtain an order for wander guard alarm and do visual checks when resident frequents being near exit doors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Physician Order dated 2/10/2013 indicated resident may have a code alarm (a wander guard [wristband] - that when a resident wearing a wander guard attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) on lower extremities and to check placement of code alarm every two hours. A review of Resident 1's Physician Order dated 2/10/13 indicated to monitor behavior manifested by wandering out of the facility and chart frequency of occurrence (tally by hash mark) every shift. A review of Resident 1's Medication Administration Record (MAR) for January 2019 indicated zero behavior of wandering out of the facility. The MAR for February 2019 indicated Resident 1 started showing behavior of wandering out of the facility on 2/18/19 to 2/28/19: 7 a.m. to 3 p.m. shift = 10 episodes, 3 p.m. to 11 p.m. shift = 4 episodes, and 11 p.m. to 7 a.m. shift = 0 episode. A review of Resident 1's MAR for March 2019 indicated the resident had documented episodes of wandering out of the facility on 7 a.m. to 3 p.m. shift on 3/17/19 = 3 episodes, 3/18/19 = 1 episode, 3/19/19 = 2 episodes, 3/20/19 = 1 episode, and 3/21/19 = 1 episode. A review of Resident 1's Nurse's Notes dated 3/21/19 at 8 p.m., indicated that physician was notified that Resident 1 left the facility. The notes indicated that law enforcement, PG, DON, and administrator were notified. A review of Resident 1's Incident Report dated 3/21/19 indicated that on 3/21/19 at 8 p.m., Resident 1 was noted not to be present in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility. The report indicated that a search was conducted by two staff members. The report indicated that on 3/21/19 at 8:45 p.m., law enforcement and public guardian were notified. During an interview with the Nursing Supervisor (NS) on 3/23/19 at 3:50 p.m., NS stated he was the outgoing nursing supervisor on the day Resident 1 was missing. NS stated that Resident 1 had a wheelchair and can ambulate (walk) using the wheelchair. NS stated that resident has wander guard (code alarm) on his lower extremity. On 3/23/19 at 2:13 p.m, a review of the facility's video surveillance footages dated 3/21/19 of Resident 1 incident leaving the facility was done in the presence of the Administrator and a follow up review on 3/25/19 at 4:24 p.m., in the presence of the Administrator and Administrative Assistant revealed the following timeline highlights: 1. On 3/21/19 at 7:48:06 p.m., NS was seen walking towards right side of the building. At this time, Resident 1 was seen sitting on her wheelchair using her feet to propel. Resident 1 stopped by outside room 113 where Licensed Vocational Nurse (LVN) 1 was seen facing Resident 1 with the medication cart in between them. 2. At 7:48:36 p.m., Resident 1 was seen still sitting on her wheelchair and she turned right proceeding to door number 3, same direction where NS went. LVN 1 still seen outside room 113 with medication cart. 3. At 7:48:51 p.m., from outside surveillance camera, Resident 1 was seen inside the facility sitting on wheelchair propelling towards door number 3. She was seen opening the door and exiting from the building. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4. At 7:49:29 p.m., from outside surveillance camera, Resident 1 was seen outside the facility building and stayed momentarily near the metal post. 5. At 7:49:48 p.m., from outside surveillance camera, Resident 1 was seen standing up and went behind her wheelchair. 6. At 7:50:53 p.m., from outside surveillance camera, Resident 1 was seen walking by pushing her wheelchair in front of her leaving the facility parking lot. Then she turned left and disappeared from the video surveillance. 7. At 7:52:24 p.m., from inside surveillance camera, Certified Nursing Assistant 1 (CNA 1) and LVN 1 were seen coming out from room 113. CNA 1 hurriedly went to check door number 3. 8. At 7:52:36 p.m., from inside surveillance camera, LVN 1 was seen walking towards the nursing station and appeared resetting the alarm. LVN 1 was seen walking back to the medication cart parked in front of room 113. 9. At 7:53:02 p.m., from inside surveillance camera, LVN 1 was seen going back the second time to the nursing station and appeared resetting the alarm. 10. At 7:53:12 p.m., from inside surveillance camera, LVN 1 was seen going back the third time to the nursing station and appeared resetting the alarm. 11. At 7:53:37 p.m., from inside surveillance camera, CNA 1 was seen hurriedly going to the right side of the building where door number 3 was. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12. At 7:54:26 p.m., from inside surveillance camera, LVN 1 was seen going to the right of the building where door number 3 was. 13. At 7:55:15 p.m., from inside surveillance camera, CNA 1 was seen coming back from the right side of the building and was seen going to rooms 115, 112, and 113. On 3/23/19 at 3:25 p.m., during an inspection and demonstration of door number 3 where Resident 1 exited, on when and how far the door alarm will trigger. NS (the outgoing nursing supervisor at the time Resident 1 left the facility on 3/21/19) was holding a wander guard and the monitor alarm attached to the door sounded audibly eight feet away from the door and when the door was opened the same alarm sounded louder. There were two alarm sounds triggered: one from the door and another in the nursing station. The alarms continuously to sound loudly and to stop the alarms one has to put in the codes in the code pad attached to the door to stop the alarm in the door. Once the alarm in the door had stopped, one had to reset the alarm in the nursing station to stop the alarm sound in the nursing station. NS stated that the door alarm will be triggered when there is a resident wearing a wander guard close to exit door or opening the door. NS stated that all the facility three exit doors were automatically set to alarm when opened at 7:30 p.m. even without a wander guard. NS stated that for the alarm not to trigger, the staff had to enter the code number on the door code pad. During an interview with CNA 2 on 3/23/19 at 4:22 p.m., CNA 2 stated he heard the alarm sound off on 3/21/19. CNA 2 stated he was cleaning one of the residents when he heard the alarm and he did not respond immediately to see the reason why the door alarm was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056157 (X3) DATE SURVEY COMPLETED 03/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALVARADO CARE CENTER 1154 S Alvarado St Los Angeles, CA 90006 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE triggered. During a telephone interview with LVN 1 on 3/23/19 at 4:40 p.m., LVN 1 stated that on 3/21/19, at the time of the incident, she was passing medications when NS stated "Goodbye" and NS left. LVN 1 stated she heard the alarm was triggered, she assumed it was NS who triggered the alarm when he left the facility. LVN 1 stated she instructed CNA 1 to check and do a head count, but unable to tell the exact time she instructed CNA 1. A review of the facility's undated Policy and Procedure for Code Alert Monitoring System indicated that "All facility personnel are to respond to alarming doors set off by resident activity trying to get out. Responsibility should primarily be on CNAs, however other department personnel are also required to monitor doors." A review of the facility's undated Policy and Procedure for Elopement indicated the following procedure: "Identify resident for tendency to elope; obtain a physician's order for a code alarm; secure a photograph of resident if possible; inform resident the purpose of the code alarm and seek her consent; and monitor resident for wandering out." Policy indicated that "in the event a resident is able to elope: search everywhere in the facility, then search outside vicinity of the facility; urgency on notification of local authorities; notify physician, family or public guardian; notify DHS of the elopement; document incident; and follow up calls will local authorities." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FLGI11 Facility ID: CA970000129 If continuation sheet 11 of 11