Inspection Report

Alameda Care: Infection Control & Hospice Gaps - CA

September 20, 2025

Burbank, CA

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BURBANK, CA - Federal inspectors found serious gaps in infection control protocols and hospice coordination at Alameda Care Center on West Alameda Avenue, including failures to properly identify and isolate potentially life-threatening bacterial infections and confusion among staff about who coordinates end-of-life care.

Critical Infection Control Breakdown Endangered Residents

The most serious violations centered on the facility's failure to implement proper infection control measures when a resident developed signs of invasive group A streptococcus (IGAS), a severe bacterial infection that can become life-threatening if not promptly treated. Inspectors documented multiple breakdowns in the facility's response to this infectious disease emergency.

When Resident 76 developed open wounds on the left wrist showing signs of IGAS infection, Licensed Vocational Nurse 3 (LVN 3) failed to properly monitor, identify, and report the suspicious wounds. The facility's Treatment Nurse 1 (TN 1) also missed identifying and reporting the infected wounds, creating a dangerous delay in medical intervention.

The facility failed to immediately test the resident's wounds for IGAS bacteria and did not place the resident in contact and droplet isolation - critical safety measures designed to prevent the spread of this serious infection to other residents, visitors, and staff members throughout the facility.

Invasive group A streptococcus represents one of the most dangerous bacterial infections that can occur in healthcare settings. The bacteria can spread through respiratory droplets when an infected person coughs or sneezes, or through direct contact with contaminated surfaces. Without proper isolation precautions, a single case can rapidly spread throughout a nursing home population, potentially causing severe illness or death among vulnerable elderly residents.

Delayed Antibiotic Treatment Violated Medical Standards

Adding to the infection control failures, TN 1 did not administer the first dose of Keflex antibiotic immediately or within the required four-hour window after receiving a verbal order from the Wound Care Consultant. This delay violated established medical protocols for treating active skin infections and could have allowed the bacteria to multiply and spread throughout the resident's body.

Medical standards require immediate antibiotic intervention when IGAS infection is suspected because the bacteria can rapidly progress from a localized skin infection to invasive disease affecting blood, muscle, and organ systems. The four-hour administration window exists because research shows that early antibiotic treatment significantly improves patient outcomes and reduces the risk of complications.

The facility's failure to follow proper medication timing protocols demonstrates a breakdown in both nursing supervision and clinical judgment that could have resulted in serious harm to the affected resident.

Enhanced Barrier Precautions Not Followed

Inspectors also identified violations of enhanced barrier precautions (EBP) protocols designed to protect high-risk residents from acquiring infections. Certified Nursing Assistant 4 (CNA 4) failed to wear required protective gowns while providing care to Resident 2, who had been placed on enhanced barrier precautions due to infection risk.

Enhanced barrier precautions require healthcare workers to wear gowns and gloves during high-contact care activities for residents who have known infections or are at elevated risk for acquiring new infections. These precautions are particularly important in nursing home settings where residents often have compromised immune systems and multiple chronic health conditions that make them more susceptible to serious infections.

The failure to follow EBP protocols creates unnecessary exposure risks for vulnerable residents and can contribute to the spread of dangerous bacteria throughout the facility.

Hospice Care Coordination Confusion

In addition to infection control failures, inspectors found significant problems with the facility's hospice care coordination that could impact the quality of end-of-life care for terminally ill residents. Multiple staff members, including licensed nurses and the Director of Staff Development, could not identify who serves as the facility's hospice coordinator.

When interviewed by inspectors, LVN 3 stated that licensed nurses "directly coordinated care with the hospice nurse and physician" but could not identify a specific facility coordinator. The Treatment Nurse 1 and Director of Staff Development also did not know who the facility's hospice coordinator was, indicating widespread confusion about care coordination responsibilities.

The facility's policy titled "Hospice Program" contained blank lines where the name and title of the hospice coordinator should have been documented, leaving staff without clear guidance about communication channels for hospice-related issues.

The Administrator acknowledged during the inspection that "there could be gaps in communication and provision of care if the facility's staff did not know who the facility's hospice coordinator was." The Director of Nursing later clarified that the Social Services Designee serves as the main hospice coordinator, with the Director of Nursing providing backup coverage.

Proper hospice coordination ensures that terminally ill residents receive appropriate comfort care, pain management, and emotional support during their final days. When staff members don't know who to contact for hospice-related concerns, residents and families may experience delays in receiving needed services or modifications to their care plans.

Additional Issues Identified

Beyond the major violations, inspectors noted other areas where the facility's policies and procedures did not meet federal standards. The facility's hospice program policy lacked specific details about staff roles and responsibilities in coordinating care between facility staff and hospice providers.

The inspection findings indicate systemic problems with staff training and policy implementation that extend beyond individual incidents. Multiple licensed nurses and department directors demonstrated lack of knowledge about basic facility procedures, suggesting inadequate orientation and ongoing education programs.

These violations occurred during a routine federal inspection conducted on July 26, 2024, at the 925 W. Alameda Avenue facility in Burbank. The Centers for Medicare & Medicaid Services inspection team found that both the infection control and hospice coordination failures had the potential for actual harm to residents, though they classified the violations as causing minimal harm.

Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs to protect residents from healthcare-associated infections. The regulations also mandate clear policies and procedures for coordinating care with outside healthcare providers, including hospice services, to ensure continuity of care for residents with complex medical needs.

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.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 20, 2026 · Our methodology

Quick Answer

ALAMEDA CARE CENTER in BURBANK, CA was cited for violations during a health inspection on July 26, 2024.

Inspectors documented multiple breakdowns in the facility's response to this infectious disease emergency.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at ALAMEDA CARE CENTER?

Inspectors documented multiple breakdowns in the facility's response to this infectious disease emergency.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in BURBANK, CA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ALAMEDA CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 555690.

Has this facility had violations before?

To check ALAMEDA CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.