BURBANK, CA - Federal inspectors cited Alameda Care Center for multiple violations including failure to protect resident privacy and inadequate controlled substance oversight during a July 2024 inspection.
Resident Privacy Compromised Despite Known Behavioral Issues
The most concerning violation involved a 70-year-old resident with dementia and Alzheimer's disease who was repeatedly found undressed in her room with the door open to hallway traffic. On July 23, 2024, inspectors observed the resident sitting in her wheelchair with her shirt off and breasts exposed while other residents passed by her room. The privacy curtain was only partially drawn, allowing anyone in the hallway to view the resident in her undressed state.
The resident's medical records documented significant cognitive impairment and lack of capacity to make decisions. She required maximum assistance with all activities of daily living including dressing, toileting, and bathing. Despite these documented needs and known behaviors, facility staff failed to implement adequate care planning to address the resident's tendency to remove her clothing.
A Restorative Nursing Assistant confirmed the resident had a history of disrobing but explained that such behaviors were simply reported to the charge nurse without specific interventions in place. The lack of systematic response left this vulnerable resident exposed to potential embarrassment and dignity violations on multiple occasions.
Systematic Care Planning Failures
Investigation revealed that Alameda Care Center had no formal care plans or interventions addressing the resident's disrobing behavior despite facility staff being aware of the issue since her admission in September 2023. The Director of Medical Records confirmed no care plans existed to address this behavioral concern.
Staff interviews revealed inconsistent reporting and awareness of proper protocols. One Certified Nursing Assistant stated she had witnessed the resident disrobe "once or twice" in recent weeks and reported it to charge nurses, but could not recall specific dates or which supervisors received the reports. Crucially, she was unaware of any specific approaches to help manage the resident's disrobing behavior.
The Director of Staff Development, who was serving as charge nurse on the day inspectors observed the privacy violation, could not remember if the disrobing behavior had been reported to her that day. While acknowledging awareness of the resident's disrobing tendencies, she confirmed that no formal interventions or care planning addressed this behavior.
Most concerning was the registered nurse's confirmation that without documentation in the Medication Administration Record or formal care plans, the disrobing behavior was not being systematically addressed. As the nurse explained, "if the behavior is not in the MAR, it is not care planned." This meant the resident was missing out on measurable goals and specific approaches that staff could implement during care.
Medical Implications of Inadequate Behavioral Management
For residents with dementia and Alzheimer's disease, disrobing behaviors often stem from confusion, discomfort, or sensory processing issues. Proper care planning should include environmental modifications, clothing adaptations, regular comfort assessments, and staff training on redirection techniques.
The failure to address this behavior systematically creates multiple health risks. Beyond the obvious privacy and dignity concerns, residents found undressed may be at increased risk for temperature regulation problems, skin injuries, and psychological distress. Additionally, the lack of structured interventions suggests inadequate assessment of underlying causes such as pain, medication side effects, or environmental factors that might be triggering the behavior.
Industry standards require nursing homes to develop individualized care plans that address each resident's unique needs and behaviors. These plans should include specific interventions, measurable goals, and regular evaluation of effectiveness. The absence of such planning for a known behavioral concern represents a fundamental failure in person-centered care.
Controlled Substance Oversight Deficiencies
Beyond the privacy violations, inspectors identified serious deficiencies in the facility's management of controlled substances awaiting disposal. During the review of accountability logs on July 24, 2024, all seven sampled Antibiotic or Controlled Drug Record logs lacked required verifying signatures from either the Director of Nursing or registered nurses.
Federal regulations require strict oversight of controlled substances to prevent diversion - the illegal transfer of medications from lawful to unlawful use. Proper documentation and dual signatures create accountability systems that protect both residents and the broader community from potential drug trafficking or abuse.
The Director of Nursing acknowledged the failures, stating she was "unable to locate the verifying signatures of LVNs and the RN/DON on the seven accountability logs." She confirmed that while controlled substances were counted upon receipt, there was no consistent process for signing verification logs.
Facility Policy Violations
Alameda Care Center's own policies required comprehensive care planning for all residents. Their policy on "The Resident Care Plan" mandated implementation for each resident upon admission, with development throughout the assessment process including measurable goals and specific approaches.
Similarly, their "Resident Rights" policy guaranteed residents the right to be informed of and participate in care planning and treatment. By failing to address the disrobing behavior through formal care planning, the facility violated both regulatory requirements and their own established policies.
For controlled substances, facility policies required strict compliance with federal Drug Enforcement Administration regulations. Their March 2023 policy specifically stated that "waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet." The missing signatures on all sampled logs represented systematic non-compliance with these requirements.
Risk Assessment and Implications
The inspection classified both violations as having potential for "minimal harm or actual harm," indicating that while no severe injuries occurred, the deficient practices created significant risk for residents. The privacy violations affected "few" residents, while the medication oversight failures affected "some" residents, suggesting broader systemic issues.
The combination of inadequate behavioral management and poor medication controls reveals concerning gaps in the facility's quality assurance systems. Effective nursing home operations require robust policies, consistent staff training, and systematic monitoring of care delivery. The violations suggest deficiencies in multiple areas of facility oversight.
Regulatory Requirements and Next Steps
Federal nursing home regulations require facilities to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes protecting dignity and privacy while ensuring safe medication management practices.
The inspection findings require Alameda Care Center to develop and implement corrective action plans addressing both the specific violations and underlying systemic issues. For the privacy concerns, this should include comprehensive behavioral assessment, individualized care planning, staff training on dementia care approaches, and environmental modifications as needed.
For medication oversight, the facility must establish consistent procedures for controlled substance accountability, ensure proper staff training on documentation requirements, and implement monitoring systems to prevent future compliance failures.
These violations highlight the importance of person-centered care planning and robust quality assurance systems in nursing home operations. Residents and their families should expect facilities to proactively address behavioral needs while maintaining strict safety protocols for all aspects of care delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alameda Care Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
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