Alvarado Care Center

In the surveyor’s words

From the most serious findings on record at Alvarado Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Aug 22, 2025

  Based on interview and record review, the facility failed to prevent the development of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to: 1. Implement interventions to prevent PI (Pressure Injury - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Resident 1 who was admitted without PI, by not repositioning according to the Care Plan (CP- a document that details an individual's health conditions, treatments, needs, and goals, serving as a blueprint for their healthcare and support services) for quadriplegia dated 6/27/25. No documentation repositioning was done. Resident bedbound.2. […]

• Actual harm, isolatedF600Jul 10, 2024

  Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 1), when on 6/26/2024 Resident 2 hit Resident 1 on the nose causing pain and redness to the nose. Resident 1 was subjected to abuse and psychosocial (mental health) harm by Resident 2, while under the care of the facility. Findings: A review of Resident 2's admission record indicated the facility admitted the resident on 1/19/2024 with diagnoses including Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychosis (a mental disorder,… […]

• Actual harm, isolatedF600May 3, 2023

  Based on observation, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse for of one of four sampled residents (Resident 3) in accordance with the facility's policy and procedures (P&P), dated June 2022, by failing to: 1. Ensure Resident 4 did not push Resident 3 on April 29, 2023. 2. Thoroughly investigate the incident when Resident 3 reported to Licensed Vocational Nurse 3 (LVN 3) that Resident 4 pushed her on 4/29/2023 for the potential for resident-to-resident abuse. 3. […]

• No harm, potential for more than minimal, patternF605Jan 23, 2026

  Based on interview and record review, the facility failed to:-Ensure Risperdal (a medication used to treat mental illness) was used to treat a medical diagnosis clearly documented in the medical record for one of five residents (Resident 1) sampled for unnecessary medications-Define specific problematic behaviors related to the use of Risperdal and Depakote (a medication used to treat mental illness) for one of five sampled residents (Resident 69) for unnecessary medications (Resident 69).-Monitor for adverse effects (unwanted or dangerous medication-related side effects) related to the use of Cymbalta (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 69.)The deficient practices of failing to define specific problematic… […]

• No harm, potential for more than minimal, patternF641Jan 23, 2026

  Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include diagnoses of bipolar disorder (a mental illness characterized by having rapid changes in mood from depression to mania) and depression (a mental illness characterized by depressed mood, insomnia, and lack of energy or interest in usually enjoyable activities) per information in the medical record for two of five residents sampled for unnecessary medications (Resident 1 and Resident 69).The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 1 and Resident 69 may not have received care planning and… […]