Alameda Care Center

F-F550.

Findings:

During a review of Resident 70's Admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and uneasiness).

During a review of Resident 70's History and Physical (H&P), dated 11/8/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated Resident 70 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and needed maximum assistance with upper body dressing, lower body dressing, toileting, hygiene, and bathing.

During an observation on 7/23/2024 at 11:10 a.m., outside of Resident 70's room, Resident 70 could be viewed from the hallway disrobed from the waist up; the privacy curtain was partially drawn. Upon entering Resident 70's room, Resident 70 was up in her wheelchair with her shirt off, exposing her breasts while other residents were passing by the room. Resident 70 yelled out nonsensically (not making sense) when interview was attempted.

During a concurrent observation and interview on 7/23/2024, at 11:15 a.m., inside Resident 70's room, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 70 back into her shirt and confirmed that Resident 70 had the behavior of disrobing in the past. RNA 1 further explained the behaviors are to be reported to the charge nurse. When asked about privacy, RNA 1 confirmed the curtain was not completely closed and pulled the curtain over to provide privacy. RNA 1 further stated he will report the behavior to the charge nurse.

During an interview and record review on 7/23/2024, at 12:30 p.m., with the Director of Medical Records (DMR), reviewed the Clinical Chart of Resident 70. The DMR stated there were no care plan or notes for the behavior of disrobing for Resident 70.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0656 During an interview on 7/25/24 at 8:30 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she cared for Resident 70 approximately 4 times in the last month and Resident 70 disrobed once or twice. CNA Level of Harm - Minimal harm or 7 further stated she reported to the charge nurse each time the resident had the behavior of disrobing but potential for actual harm does not remember which date or charge nurse she reported it to.

Residents Affected - Some During a concurrent interview and record review on 7/25/24 at 9:15 am with the Director of Staff Development (DSD), reviewed the MAR and care plan of Resident 70. The DSD stated on 7/23/2024 she was covering as the charge nurse for the first shift (7:00 a.m.- 3:30 p.m.) in station two (the station that covers the area of Resident 70) and did not remember if the behavior of disrobing was reported to her that day. The DSD stated she remembers Resident 70 disrobing her shirt since she was admitted to the facility and any new identified behaviors are to be reported to the supervising registered nurse. The DSD further stated the behaviors are tallied in the MAR, but disrobing is not listed as a behavior to monitor in the MAR nor was there a care plan to address the behavior of disrobing.

During a concurrent interview and record review on 7/25/2024 at 9:55 a.m. with Registered Nurse (RN) 2, reviewed the MAR, care plan and notes of Resident 70. RN 2 stated the disrobing behavior was not reported to her and if the behavior is not in the MAR, it is not care planned. RN 2 confirmed disrobing is not mentioned

in any notes, care plans or the MAR in Resident 70's chart. RN 2 further stated the resident could miss out

on measurable goals and approaches that staff could use during care without the care plan.

During a review of the facility's policy and procedure (P&P) titled, Policy: The Resident Care Plan, last reviewed 1/10/2024, the P&P indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. It further indicated, although the care area assessment (CAAs) triggers most problem areas, all other problems not identified in the CAAs must also be included in the care plan.

During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024,

the P&P indicated residents have the right to be informed of, and participate in, his or her care planning and treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49947 potential for actual harm Based on interview and record review, the facility failed to provide care in accordance with professional Residents Affected - Some standards of quality by:

1. Failing to ensure the nurses were rotating (a method to ensure repeated injections are not administered in

the same area) the insulin (a medication that regulates sugar in the blood) injection sites for one of two sampled residents, (Resident 10) investigated during review of insulin care area.

2. Administering insulin when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) for one of two sampled residents (Resident 38) investigated during review of insulin care area.

These deficient practices had the potential to result in bruising, pain, and/or lipohypertrophy (lump or accumulation of fatty tissue under skin) to Resident 10 and placed Resident 38 at risk for hypoglycemia (a condition when the blood sugar is dangerously low).

Cross-reference to

F-F580.

Findings:

During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P did not indicate the name and title of the staff to coordinate care provided to the resident by the facility staff and hospice staff.

During an interview on 7/25/2024 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 did not know who the facility's hospice coordinator was. LVN 3 stated the licensed nurses directly coordinated care with

the hospice nurse and physician.

During an interview on 7/25/2024 at 9:11 a.m. with the Administrator (ADM), the ADM stated the Director of Nursing (DON) or the Registered Nurse (RN) supervisor coordinated care with the hospice.

During an interview on 7/25/2024 at 11:02 a.m. with the Treatment Nurse (TN 1), TN 1 did not know who the facility's hospice coordinator was.

During an interview on 7/25/2024 at 1:00 p.m. with Registered Nurse 2 (RN 2), RN 2 stated the DON communicated information from the hospice to the nursing staff.

During an interview on 7/25/2024 at 2:09 p.m. with the Director of Staff Development (DSD), the DSD did not know who the facility's hospice coordinator was.

During an interview on 7/25/2024 at 2:26 p.m. with the DON, the DON stated the Social Services Designee (SSD) and the DON are the facility's hospice coordinators. The DON stated the SSD is the facility's main hospice coordinator and the DON fills in when SSD is not available. The DON stated the SSD involved the interdisciplinary team (group of healthcare professionals working together to treat a person) and ensured the resident was appropriate for hospice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0849 During an interview on 7/26/2024 at 7:59 a.m. with the Minimum Data Set ([MDS] a comprehensive assessment and care planning tool) Nurse (MDSN), the MDSN did not know who the facility's coordinator Level of Harm - Minimal harm or was. potential for actual harm

During an interview on 7/26/2024 at 11:30 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the Residents Affected - Few hospice nurse came to the facility but did not know who the facility's hospice coordinator was.

During a concurrent interview and record review on 7/26/2024 at 12:12 p.m. with the ADM, the facility's P&P titled, Hospice Program, was reviewed. The ADM stated the facility's hospice coordinator was SSD with the DON and the ADM as back-up coordinators. The ADM stated the staff knew to communicate with SSD for any hospice related issues. The ADM reviewed the facility's P&P and stated the policy had blank lines that did not indicate the name and title of the staff to coordinate care provided to the resident by the facility staff and hospice staff. The ADM stated 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review the facility failed to implement and maintain an infection Residents Affected - Few control program for two of six sampled residents (Resident 76 and Resident 2) reviewed under the Infection Control task by failing to:

1. Ensure Licensed Vocational Nurse 3 (LVN 3) monitored, identified, and reported Resident 76's open wounds (a break in the skin) with signs and symptoms (s/s) of invasive group A streptococcus (IGAS - a severe and sometimes life-threatening infection that is spread from person to person through respiratory droplets or touching other surfaces contaminated with bacteria that may invade parts of the body where bacteria are not usually found) on the left wrist.

2. Ensure Treatment Nurse 1 (TN 1) identified and reported Resident 76's open wounds with s/s of IGAS on

the left wrist.

3. Ensure Resident 76's open wound was immediately tested for IGAS and the resident was placed in contact /droplet isolation (used to help prevent the spread of infectious agents that spread by direct or indirect contact with a resident or a resident's environment) for suspected IGAS or colonization of IGAS.

4. Ensure TN 1 administered the first dose of Keflex (an antibiotic [medication that fights infections caused by bacteria delivered directly into the bloodstream]) immediately or within four hours of receiving a verbal order from the Wound Care Consultant (WCC) for a resident with an active skin infection.

5. Ensure Certified Nursing Assistant 4 (CNA 4) wore a gown while providing care to Resident 2 who was placed on enhanced barrier precautions (EBP - a type of precaution that involves utilizing gown and gloves

during high contact activities for residents with known infection or at risk for acquiring infections).

These deficient practices had the potential to spread microorganisms including IGAS to facility residents, visitors, and staff.

Cross reference to

F-F656

Findings:

During a review of Resident 70's Admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and uneasiness).

During a review of Resident 70's History and Physical (H&P), dated 11/8/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated Resident 70 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and needed maximum assistance with upper body dressing, lower body dressing, toileting, hygiene, and bathing.

During an observation on 7/23/2024 at 11:10 a.m., outside of Resident 70's room, Resident 70 could be viewed from the hallway disrobed from the waist up; the privacy curtain was partially drawn. Upon entering Resident 70's room, Resident 70 was up in her wheelchair with her shirt off, breast exposed while other residents were passing by the room. Resident 70 yelled out nonsensically (not making sense) when interview was attempted.

During a concurrent observation and interview on 7/23/2024, at 11:15 a.m., inside Resident 70's room, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 70 back into her shirt and confirmed that Resident 70 had the behavior of disrobing in the past. RNA 1 further explained the behaviors are to be reported to the charge nurse. RNA 1 further stated he will report the behavior to the charge nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0742 During an interview and record review on 7/23/2024, at 12:30 p.m., with the Director of Medical Records (DMR), reviewed the Clinical Chart of Resident 70. The DMR stated there were no care plans or Level of Harm - Minimal harm or interventions addressing Resident 70's behavior of disrobing. potential for actual harm

During an interview on 7/25/24 at 8:30 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she Residents Affected - Few cared for Resident 70 approximately 4 times in the last month and Resident 70 disrobed once or twice. CNA 7 stated she reported to the charge nurse each time the resident had the behavior of disrobing but does not remember which date or charge nurse she reported it to. CAN 7 further explained she was unaware of specific approaches to assist Resident 70 when she disrobes.

During a concurrent interview and record review on 7/25/24 at 9:15am with the Director of Staff Development (DSD), reviewed the MAR and care plan of Resident 70. The DSD stated on 7/23/2024 she was covering as

the charge nurse for the first shift (7:00 a.m.- 3:30 p.m.) in station two (the station that covers the area of Resident 70) and did not remember if the behavior of disrobing was reported to her that day. The DSD stated

she remembers Resident 70 disrobing her shirt since she was admitted to the facility and any new identified behaviors are to be reported to the supervising registered nurse. The DSD further stated the behaviors are tallied in the MAR, but disrobing is not listed as a behavior to monitor in the MAR nor was there a care plan or interventions to address the behavior of disrobing.

During a concurrent interview and record review on 7/25/2024 at 9:55 a.m. with Registered Nurse (RN) 2, reviewed the MAR, care plan and notes of Resident 70. RN 2 stated the disrobing behavior was not reported to her and if the behavior is not in the MAR, it is not care planned. RN 2 confirmed disrobing is not mentioned

in any notes, care plans or the MAR in Resident 70's chart. RN 2 further stated the resident could miss out

on measurable goals and approaches that staff could use during care without the care plan.

During a review of the facility's policy and procedure (P&P) titled, Policy: The Resident Care Plan, last reviewed 1/10/2024, the P&P indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. The P&P further indicated, the care plan should include measurable goals and approaches to meet the goals.

During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024, indicated residents have the right to be informed of, and participate in, his or her care planning and treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 43455

Residents Affected - Some Based on interview and record review, the facility failed to ensure control and accountability of Controlled Substance (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known an Controlled Medication [Drug]) awaiting final disposition (process of returning and/or destroying unused medications) when the facility's Antibiotic or Controlled Drug Record accountability logs did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN) for seven of seven sampled logs.

This deficient practice increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and accidental exposure of residents to harmful medications, potentially negatively impacting their health and wellbeing.

Findings:

During a review of Antibiotic or Controlled Drug Record accountability logs on 7/24/2024 at 1:13 PM, with the DON, 7 Antibiotic or Controlled Drug Record accountability logs indicated the CSs awaiting final disposition did not contain any verifying signatures.

During a concurrent interview on 7/24/2024 at 1:13 p.m., with the DON, the DON stated she was unable to locate the verifying signatures of LVNs and the RN/DON on the seven accountability logs. The DON stated

the DON failed to sign the seven Antibiotic or Controlled Drug Record accountability logs upon receipt of the CS's. The DON stated the DON counts the CSs with the LVNs upon receipt of the accountability logs, however there was no consistent process of signing the logs. The DON stated the DON needed to immediately implement a process for including verifying signatures on the accountability logs to ensure each CS dose was accounted for until disposed. The DON stated it was also important to verify and sign the logs to prevent diversions and accidental exposure of harmful substances to residents.

During a review of the facility's policy and procedures (P&P) titled, Controlled Medications, dated April 2008,

the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.

A. The DON and the consultant pharmacist (CP) in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.

A review of the facility's P&P titled, Controlled Medication Disposal, dated April 2008, indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0755 A. The DON, in collaboration with the CP, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Level of Harm - Minimal harm or potential for actual harm B. When a dose of a controlled medication is removed from the container for administration but refused by

the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence Residents Affected - Some of two licensed nurses, and the disposal documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of CS wasted for any reason.

Review of the facility's P&P titled, Controlled Substances, dated March 2023, the P&P indicated that The facility complies with all laws, regulations, and other requirements related to administration, handling, storage, disposal, and documentation of controlled medications.

9b. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 43455

Residents Affected - Few Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for June 2024 Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was carried out as per facility policy and procedure for one of four sampled residents (Resident 70).

The deficient practice increased the risk of receiving medication that was not optimal for Resident 70's medical condition, that would not maintain the resident's highest level of physical, mental, and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy.

Cross reference to

F-F758.

Findings:

During a review of Resident 70's Admission Record (a document containing demographic and diagnostic information,) dated 7/26/2024, the Admission Record indicated the facility originally admitted Resident 70 on 9/8/2023 and readmitted the resident on 11/7/2023 with a diagnosis of anxiety.

During a review of Resident 70's Order Summary Report, dated 7/26/2024, the report indicated Resident 70 was prescribed Ativan (a medication used for anxiety) 0.5 milligram ([mg] - a unit of measure of mass) tablet to give 1 tablet by mouth twice a day for anxiety manifested by constant movement/rolling out of bed to exhaustion, starting 2/21/2024.

During a review of the MRR note for Resident 70 by the CP on 7/25/2024 at 2:43 PM, titled Note to Attending Physician/Prescriber and dated 6/13/2024, stated Resident has been taking Ativan 0.5 mg BID (abbreviated for twice a day), since 2/2024. Please consider a dose reduction if appropriate. If therapy is to continue, please document risk versus benefit assessment. The document did not contain a response from a physician and was not signed or dated by a physician.

During a review of Resident 70's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) on 7/25/2024 at 2:48 PM,

the MAR indicated Resident 70 was prescribed Ativan 0.5 mg to give 1 tablet by mouth twice a day for anxiety manifested by constant movement/rolling out of bed to exhaustion, since 2/21/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0756 During an interview on 07/26/24 at 9:35 AM, with the Director of Nursing (DON,) the DON stated per facility policy the MRR irregularity notes by the CP needed to be reviewed and documented within 30 days of the Level of Harm - Minimal harm or written report. The DON stated it was important to review the irregularities timely to ensure residents were potential for actual harm receiving treatment that was optimal for their condition and to maintain their highest level of well-being. The DON stated the facility and physician failed to timely review and address the CP MRR note written on Residents Affected - Few 6/13/2024 for the Ativan 0.5 mg BID identified irregularity and failed to document a rationale for continuing

the Ativan order for anxiety manifested by constant movement/rolling out of bed to exhaustion, for Resident 70.

Review of facility policy and procedure (P&P) titled Medication Regimen Review (Monthly Report), dated July 2024, the policy indicated The consultant pharmacist performs a comprehensive MRR at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.

C. Recommendations are acted upon and documented by the facility staff and or the prescriber.

1) If irregularities are found the DON and/or designated licensed nurse will follow up with the prescriber within 30 working days of receipt of the MRR report.

3) The prescriber, the DON or the designated licensed nurse will document the rational if the recommendation is declined.

Review of the facility's P&P titled Policy for Unnecessary Medication, dated July 2024, the P&P indicated: Facility will follow state and federal regulation to ensure that all residents will be free from unnecessary psychotropic medication and unnecessary drugs.

Licensed nurse will review resident's drug regimen based on the following criteria:

1. Excessive dose

2. Excessive duration

3. Adequate indication

Licensed nurse will communicate with the primary physician and adjusting the medication dosage, duration, frequency and/or discontinue the medication if indicated.

Licensed nurse will communicate with the primary physician regarding the pharmacist recommendation on a monthly basis to ensure all residents' medications are appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Few was less than five percent (%). Two medication errors out of twenty-five (25) total opportunities contributed to

an overall medication error rate of eight % affecting one of seven residents observed for medication administration (Resident 14.) The medication errors were as follows:

1. Resident 14 did not receive a dose of Tylenol (a medication used for pain) as ordered by Resident 14's physician, and

2. Resident 14 received Keflex (a medication used to treat an infection) in a form that was not ordered by Resident 14's physician.

These failures had the potential to result in Resident 14 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 14's health and well-being to be negatively impacted.

Findings:

During an observation on 7/23/2024 at 12:15 PM, in Medication Cart Station 1, Licensed Vocational Nurse (LVN) 1 was observed opening Keflex 500 milligram ([mg]-a unit of measure of mass) capsule and pouring

the contents into a small plastic cup (a process similar to when crushing [pressing the medication very hard so that the shape is destroyed and forms a soft powder] medications) containing applesauce for Resident 14.

During an observation on 7/23/2024 at 12:22 PM with LVN 1, Resident 14 was observed swallowing spoonsful of the applesauce containing the contents of the Keflex 500 mg capsule followed by a glass of juice.

During an interview on 7/23/2024 at 3:11 PM, with Registered Nurse (RN) 1, RN 1 stated that Resident 14's clinical chart did not contain physician orders instructing to open Keflex capsules and mix with applesauce. RN 1 stated if there was no order indicating to do so then it should not have been done.

During an observation on 7/24/2024 at 9:13 AM, in Medication Cart Station 1, in the presence of RN1, LVN 2 was observed administering one (1) tablet of Tylenol 500 mg to Resident 14. Resident 14 was observed swallowing the tablet whole with a glass of juice.

During an interview on 7/24/2024 at 11:27 PM, with RN 1 and LVN 2, LVN 2 stated that LVN 2 administered one (1) tablet of Tylenol 500 mg to Resident 14 during the morning medication administration on 7/24/2024 at 9:13 AM. LVN 2 acknowledged the physician's order specified to give two (2) tablets (1000 mg). LVN 2 stated LVN 2 failed to administer two (2) tablets as ordered by the physician and underdosed (gave an insufficient amount) Resident 14. LVN 2 stated there was a risk Resident 14 would not see the therapeutic (expected response from a treatment) effect of the Tylenol and continue to be in pain. RN 1 and LVN 2 stated an additional tablet of Tylenol 500 mg will be administered immediately to Resident 14.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0759 During an interview on 7/24/2024 at 12:43 PM, with the Director of Nursing (DON,), the DON stated that Resident 14 did not have a physician order stating to open the Keflex 500 mg capsule and mix with Level of Harm - Minimal harm or applesauce for administration. The DON stated that certain medications should not be opened or crushed as potential for actual harm they can cause adverse effects such as stomach irritation. The DON stated that Resident 14 had an order of Tylenol 1000 mg for Osteoarthritis pain, and not receiving the prescribed amount can lead to uncontrolled Residents Affected - Few pain for the resident. The DON stated that LVN 1 and LVN 2 failed to follow the 5 rights of medication administration to ensure physician orders were followed and the right doses and forms of medications were administered to Resident 14. The DON stated these were considered medication errors.

During an interview on 7/26/2024 at 11:11 AM, with LVN 1, LVN 1 stated that LVN 1 administered opened Keflex 500 mg capsule mixed with applesauce on 7/23/2024 at 12:22 PM to Resident 14, and that there was no physician order instructing LVN 1 to do so. LVN 1 stated this is considered a medication error. LVN 1 stated not all medications could be opened (similar to not all medications can be crushed) and if the wrong medication was opened it may not have the desired effect and could cause adverse effects to the resident. LVN 1 stated LVN 1 failed to follow the facility's medication administration policy and failed to follow physician orders.

During a review of Resident 14's Admission Record (a document containing demographic and diagnostic information,) dated 7/23/2024, the Admission Record indicated Resident 14 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including osteoarthritis (breakdown of bone causing pain and stiffness,) and dermatophytosis (infection of the skin and nails.)

During a review of Resident 14's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], dated 7/23/2024, the MAR indicated Resident 14 was prescribed the following:

1) Tylenol 500 mg tablet to give 2 tablets by mouth two times a day at 8 AM and 4 PM for pain management related to osteoarthritis, starting 5/20/2024. The order indicated the medication should be given as two tablets for a dose of 1000 mg twice a day.

2) Keflex 500 mg capsule to give 1 capsule by mouth three times a day at 8 AM, 12 PM, 4 PM for right second finger infection for 7 days, starting 7/17/2024. The physician order did not specify to open the Keflex capsule and mix the contents with applesauce.

During a review of Resident 14's clinical record, the record contained no documentation that Resident 14 should be given one (1) Tylenol 500 mg tablet and no documentation to mix the contents of Keflex 500 mg capsule with applesauce.

During a review of the facility's policy and procedures (P&P), titled Medication Administration - General Guidelines, dated October 2017, the P&P indicated that Medications are administered as prescribed .

A. Preparation

3) Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0759 B. Administration

Level of Harm - Minimal harm or 2) Medications are administered in accordance with written orders of the attending physician. potential for actual harm

During a review of the facility's P&P, titled Procedures for all Medications, dated April 2008, the P&P Residents Affected - Few indicated: To administer medications in a safe and effective manner.

F. Read medication label before administering.

During a review of the facility's P&P, titled Med Pass, [undated], the P&P indicated:

I.A.2. The 5 Rights

Make sure that meds are administered according to:

b. Right medications

c. Right dose

III.A. Med errors

A med error is a violation in the 5 rights, or in medication regulations; or in approved medication policy or current standard of practice.

C.Survey deficiencies

A survey deficiency is a combination of significant and insignificant med errors that amount to 5% or [NAME] of the total opportunities for error.

VIII.G. Crushed Meds

Meds may be crushed and mixed with applesauce or pudding, per physician order .

During a review of the facility's P&P, titled Crushing Medications, dated March 2023, the P&P indicated that Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49947 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were free of any Residents Affected - Some significant medication errors for three of ten sampled residents (Resident 10, 38, and 76) by:

1. Failing to ensure nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for Resident 10 during

review of insulin care area.

2. Administering insulin to Resident 38 when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) during review of insulin care area.

3. Failing to ensure Treatment Nurse 1 (TN 1) administered the first dose of Keflex (an antibiotic [medication that fights infections caused by bacteria delivered directly into the bloodstream]) immediately or within four hours of receiving a verbal order from the Wound Care Consultant (WCC) for Resident 76 with an active skin infection reviewed during the Infection Control task.

This deficient practice had the potential to result in bruising, pain, and/or lipohypertrophy (lump or accumulation of fatty tissue under skin) to Resident 10, placed Resident 38 at risk for hypoglycemia (a condition when the blood sugar is dangerously low), and had the potential to jeopardize the therapeutic effectiveness of the antibiotic resulting in further complications of Resident 76's infection.

Cross refence to

F-F760.

Findings:

a. During a review of Resident 76's Admission Record, it indicated the facility admitted the resident on 4/4/2023 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm (commonly referred to as cancer [term for a disease in which abnormal cells divide without control and can invade nearby tissues]) of the skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 During a review of Resident 76's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/10/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes Level of Harm - Minimal harm or able to make himself understood. The MDS further indicated the resident requires substantial/maximal potential for actual harm assistance from staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.

Residents Affected - Few During a review of Resident 76's Care Plan (CP) titled, (Resident 76) has unspecified dermatitis. Location: generalized body rash (bilateral upper extremities, chest, back) ., initiated 6/13/2024, the CP indicated goals to promote healing without complications and will show no signs and development of infection. The CP indicated to monitor for signs and symptoms of infection (redness, presence of drainage, odor, pain), to report change in resident's kin condition to physician and resident's family, and to provide treatment as ordered.

During a review of Resident 76's physician orders, the physician orders indicated the following orders:

-Monitor for symptoms and signs of IGAS: cough; sore throat; fever; skin infection (tenderness or pain, heat, swelling, serous drainage [a clear to yellow fluid that leaks out of a wound and may be a sign of infection] at affected site) and document yes/no, (if yes, indicate in the nurse's note and call physician), every shift until 8/17/2024, dated 7/17/2024.

-Keflex oral capsule 500 milligrams (mg, a unit of measurement), give one capsule by mouth one time only for bacterial folliculitis (the hair follicle becomes infected/inflamed and forms a pustule), first dose from the emergency kit (e-kit, emergency drug supplies), dated 7/24/2024.

During an observation and interview on 7/23/2024 at 9:58 a.m., observed Resident 76 in a wheelchair (WC) outside the resident's room. Observed the resident with multiple open skin wounds on the left upper extremity and a clear dried substance crusted on the left dorsal wrist. Certified Nursing Assistant 9 (CNA 9) stated the resident had multiple open wounds on the left arm and he did not know when it started.

a.1. During a review of Resident 76's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis), the MAR indicated on 7/23/2024 for the evening shift (3 p.m. to 7 p.m.), LVN 3 documented the resident did not have any signs or symptoms of IGAS.

During an observation, interview, and record review on 7/24/2024 at 11 a.m., with LVN 3 reviewed Resident 76's progress notes for July 2024. LVN 3 stated she was caring for Resident 76 on 7/23/2024 and 7/24/2024 and was not aware of any issues on the resident's skin. Observed LVN 3 assess Resident 76's left wrist while the resident sat in the WC in the hallway. LVN 3 stated the resident had open wounds with discharge

on the L wrist that she was not aware of. LVN 3 stated she would do skin assessment daily of the resident, but on 7/23/2024 and 7/24/2024 she only scanned the resident while administering his medications. LVN 3 stated she relies on the CNAs to report any skin changes. LVN 3 reviewed the resident progress notes and stated there was no documentation that the resident had a change of condition (COC, decline in a resident's status) on the skin of the left wrist. LVN 3 called TN 1. LVN 3 stated TN 1 stated the resident was seen by

the wound care consultant that morning and would be started on antibiotics for an infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 During an interview on 7/24/2024 at 11:30 a.m., CNA 9 stated Resident 76 had an issue on his left wrist that was progressively getting worse. CNA 9 stated he did not know for how long the resident had the issue, but Level of Harm - Minimal harm or the charge nurses were aware. potential for actual harm

During an interview on 7/24/2024 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated the facility Residents Affected - Few currently has an outbreak (OB, the occurrence of disease cases in excess of normal expectancy) for IGAS.

The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation, the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started.

During an interview and record review on 7/24/2024 at 5:26 p.m., with the IP reviewed Resident 76's Medication Administration Record (MAR) for 7/2024. The IP stated on 7/23/2024 evening shift LVN 3 documented that she monitored Resident 76 for s/s of IGAS and there were no s/s of skin infection present.

The IP stated monitoring a resident's skin includes removing the clothing and completing a head-to-toe skin assessment. The IP stated when LVN 3 did not do a thorough skin assessment on Resident 76, LVN 3 did not identify the new skin issue and it resulted in a delay of the necessary care and treatment for the resident.

During an interview on 7/24/2024 at 8:25 a.m., with LVN 3, LVN 3 stated she did not remove Resident 76's sleeves or clothing to monitor the resident's skin. LVN 3 stated if she would have done a thorough skin assessment on 7/23/2024, she would have identified the change of condition. LVN 3 stated because she did not do a skin assessment and it resulted in a delay in care to the resident and a delay in placing the resident

in isolation. LVN 3 stated things should have been done with more urgency.

During an interview on 7/25/2025 at 9:42 a.m., the IP stated anything new on a resident is a change of condition and should be reported. The IP stated LVN 3 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.

During a review of the facility policy and procedure (P&P) titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, the P&P indicated outbreaks of communicable diseases within the facility are promptly identified and managed. The infection preventionist and director of nursing are responsible for monitoring ill residents and staff and initiating transmission-based precautions as appropriate. The nursing staff are responsible for notifying the director of nursing services of newly symptomatic residents, providing infection surveillance data in a timely manner.

a.2. During an observation and interview on 7/24/2024 at 11 a.m., Licensed Vocational Nurse 3 (LVN 3) stated she was caring for Resident 76. Observed LVN 3 assessed Resident 76 sitting in a WC in the hallway and stated the resident had open wounds with discharge that she was not aware of. LVN 3 called TN 1. LVN 3 stated TN 1 stated the resident was seen by the WCC that morning and would be started on antibiotics for

an infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 During an interview on 7/24/2024 at 1:32 p.m., TN 1 stated she provides daily skin treatments to Resident 76's generalized body rash that includes the bilateral upper extremities (both arms). TN 1 stated the facility Level of Harm - Minimal harm or currently has an OB of IGAS and the public health nurse thinks resident rashes may be related to the OB. TN potential for actual harm 1 stated she noticed on 7/23/2024 that Resident 76's left wrist was irritated and moist. TN 1 stated she did not report to anyone that on 7/23/2024 the resident's wrist was irritated and moist. TN 1 stated Resident 76's Residents Affected - Few left wrist was crustier today when she made rounds with the WCC at 6:30 a.m. and the WCC verbally ordered antibiotics for an infection of Resident 76's left wrist wound. TN 1 stated she was not given a start date for the antibiotics, so she was going to enter the verbal order to give the first dose on 7/25/2024, the next day. TN 1 then stated antibiotics should be given immediately or within two hours of an order. TN 1 stated the antibiotics should have been given by 8:30 a.m. TN 1 stated it was now 1:45 p.m. and the antibiotics had not been administered to Resident 76. TN 1 stated when antibiotics are delayed a wound can get worse.

TN 1 further stated any residents with open wounds that have signs and symptoms of infection are considered possibly contagious and should be placed in contact/droplet isolation. TN 1 stated Resident 76 was not placed in contact/droplet isolation.

TN 1 stated the facility is currently swabbing all open wounds to test for IGAS, but resident 76 was not swabbed.

TN 1 stated she did not notify the IP or Director of Nursing (DON) that Resident 76 had an open skin wound with an infection, place the resident on contact/droplet isolation, or swab the resident's open wound because

she was very busy that morning.

During a review of Resident 76's Skilled Nursing Facility Wound Care Consultant notes, dated 7/24/2024, the notes indicated Resident 76 had an infected wound with scant serous drainage. The notes indicated to start

the resident on Keflex 500 mg, four times a day for seven days.

During an interview on 7/24/2024 at 2:09 p.m., with the IP, the IP stated the facility currently has an OB of IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation, the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started. The IP stated TN 1 did not notify her there were any newly identified residents with open wounds that had signs and symptoms of infection. The IP stated TN 1 should have notified her in the morning regarding Resident 76's wound so she could have assessed the wound, placed

the resident in isolation, swabbed the wound for IGAS, and started the antibiotic treatment because the facility has an OB. The IP stated they want to prevent the OB from spreading to other residents.

During a review of Resident 76's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis), the MAR indicated the following:

-On 7/24/2024 at 3:15 p.m., TN 1 documented the administration of Keflex 500 mg capsule.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 During an interview on 7/24/2024 at 3:17 p.m., with the IP, the IP stated she just assessed Resident 76's left wrist and there is an open wound with serous drainage. The IP stated TN 1 should have identified Resident Level of Harm - Minimal harm or 76's change of condition on 7/23/2024 and again on 7/24/2024 when TN 1 was with the WCC. The IP stated potential for actual harm TN 1 should have notified the IP immediately because there is an OB. The IP stated she spoke with TN 1 and TN 1 stated she did not notify the IP because she was overwhelmed. Residents Affected - Few

During an interview on 7/25/2025 at 9:42 a.m., with the IP, the IP stated anything new on a resident is a change of condition and should be reported. The IP stated TN 1 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.

During an interview and record review on 7/25/2024 at 5 p.m., with the DON, reviewed the facility policies regarding antibiotic medication administration. The DON stated for a new order of antibiotics, the first dose should be given within four hours of receiving the order. The DON stated TN 1 should have asked someone for help when she was making rounds with the WCC and was given a verbal order to start Resident 76 on antibiotics. The DON stated the facility policies do not specifically indicate antibiotics must be started within four hours, but it is a standard of practice.

During a review of the facility policy and procedure (P&P) titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, the P&P indicated outbreaks of communicable diseases within the facility are promptly identified and managed. The infection preventionist and director of nursing are responsible for monitoring ill residents and staff and initiating transmission-based precautions as appropriate. The nursing staff are responsible for notifying the director of nursing services of newly symptomatic residents and providing infection surveillance data in a timely manner.

During a review of the facility provided Group A Streptococcal (GAS) Infections form, undated, the form indicated Group A streptococci are bacteria commonly found in the throat and on the skin. Usually, these bacteria cause strep throat but can cause life threatening skin rashes or other infections. These bacteria are spread by direct contact with nose and throat secretions of someone who has an active infection. The risk of spread is greatest when an individual is ill, such as when people have strep throat or an infected wound.

During a review of the facility provided Centers for Disease Control and Prevention, Decision Tool for investigating Group A Streptococcus Infections in Long-Term Care Facilities (LTCF), undated, it indicated one invasive case of GAS should prompt an epidemiological investigation by the LTCF infection control personnel. Identify additional symptomatic cases by surveying all residents for symptoms of GAS infection. Culture throat or skin lesions of residents as clinically indicated. Residents with suspected or confirmed GAS infection or colonization should be placed on appropriate Transmission-Based Precautions pending culture results: wound- residents with GAS cultured from a wound should remain on contact and droplet precautions until 24 hours after the initiation of effective antibiotic therapy and any wound drainage stops or can be contained by a dressing.

During a review of the facility policy and procedure titled, Infection control 'Isolation Precautions', last reviewed 1/10/2024, the P&P indicated it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 During a review of the facility policy and procedure titled, Organizational Aspects, last reviewed 1/10/2024, indicated the pharmacy provides routine and timely pharmacy services seven days a week and emergency Level of Harm - Minimal harm or pharmacy service 24 hours per day, seven days a week. Medications which should be promptly available, potential for actual harm such as anti-infectives are available within four hours.

Residents Affected - Few During a review of the facility policy and procedure titled, Medication Ordering and Receiving from Pharmacy, last reviewed 1/10/2024, indicated medications and related products are received from the dispensing pharmacy on a timely basis. Stat and emergency medications, the initial dose is obtained from

the emergency kit and administered immediately.

43988

b. During a review of Resident 2's Admission Record, it indicated the facility admitted the resident on 9/29/2022 and readmitted the resident on 1/25/2023 with diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dermatitis (inflammation of the skin with dry skin, redness, and itchiness), and dermatophytosis (also known as ringworm, a fungal infection of the skin that may affect the skin, hair, and nails).

During a review of Resident 2s History and Physical (H&P) dated 2/20/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 2s MDS, dated [DATE REDACTED], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with mobility; substantial/maximal assistance with tub/shower transfers; and supervision or touching assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 2s care plan (CP), the CP indicated:

-Group A Streptococcus Infection, Resident is at risk for sore throat, cough, fever more than 99.6, skin infection; tenderness or pain, heat, swelling, serous drainage at affected site related to exposure initiated 7/12/2024 indicated to utilize appropriate PPE if indicated as one of the interventions.

During an observation on 7/23/2024 at 11:18 a.m. outside Resident 2's room by the door, observed a sign for EBP with instructions on the type of PPE to use during high contact activities with the resident. Observed inside the resident's room CNA 4 without a gown on while applying cream on Resident 2's skin.

During an interview on 7/23/2024 at 11:27 a.m. with CNA 4, CNA 4 stated the sign by the door indicated Resident 2 was placed on EBP and he should be wearing a gown while providing care to the resident as the facility currently has an outbreak for IGAS. CNA 4 stated not wearing a gown can spread the infection among residents and staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0880 During an interview on 7/25/2024 at 9:53 a.m., with the IP, the IP stated that all residents were placed on EBP following an outbreak of IGAS in the facility and staff were in-serviced multiple times on hand hygiene, Level of Harm - Minimal harm or proper donning (put on) and donning (take off) of PPEs, types of isolations, and EBP. The IP stated staff potential for actual harm should wear an isolation gown and gloves after proper hand hygiene during direct patient care or high contact activities for residents on EBP. The IP stated CNA 4 was present during the in-services and CNA 4 Residents Affected - Few should have donned an isolation gown while applying a cream to Resident 2 to prevent spread of infection among other residents and staff.

During an interview on 7/26/2024 at 11:31 p.m., with the DON, the DON stated that all residents were placed

on EBP due to exposure to IGAS infection. The DON stated CNA 4 should have donned an isolation prior to application of cream to Resident 2's skin. The DON stated all staff should wear an isolation gown and gloves

after hand hygiene during close or direct patient care to prevent spread of infection among other residents and staff.

During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed 1/10/2024, the P&P indicated EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs). The policy indicated:

1. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.

o Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to

before entering the room).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and Residents Affected - Few patient care equipment in safe operating condition for one of one sampled resident (Resident 46) investigated during a random observation when Resident 46's bed controller (device used to change the height and angle of the bed) cable was observed with exposed wires.

This deficient practice had the potential to place Resident 46 at risk for injury.

Findings:

During a review of Resident 46's Admission Record, it indicated the facility admitted the resident on 8/26/2019 and readmitted on [DATE REDACTED] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood, and history of falling.

During a review of Resident 46's History and Physical (H&P) dated 3/15/2024, the HP indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated the resident had severe cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During an observation on 7/23/2024 at 10:17 a.m., inside Resident 46's room, Resident 46 was observed in

the wheelchair with the bed controller placed on top of the resident's bed and within reach. Observed the base of the bed controller cable with the white, red, green, and yellow wires exposed.

During a concurrent observation and interview on 7/23/2024 at 10:17 a.m. inside Resident 46's room, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the base of resident's bed controller had exposed wires and further stated it is not safe for the resident to have exposed wires within their reach as it placed the resident at risk for injury from being electrocuted. CNA 1 stated she will notify the Maintenance Supervisor (MS) to change the bed controller.

During an interview on 7/26/2024 at 10:49 a.m., with the Director of Nursing (DON), the DON stated the maintenance department makes rounds every month to check for any malfunctioning equipment in the building. The DON stated the staff are supposed to report any equipment issues to the MS such as a bed control with exposed wires. The DON stated a bed control with exposed wires placed the resident's safety at risk.

During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, last reviewed 1/10/2024, the P&P indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0908 - Maintenance service shall be provided to all areas of the building, grounds, and equipment.

Level of Harm - Minimal harm or - The maintenance department is responsible for maintaining the buildings grounds, and equipment in a safe potential for actual harm and operable manner at all times.

Residents Affected - Few - Maintaining the building in good repair and free from hazards

- Maintaining the heat/cooling system, plumbing fixtures, wiring, etc. in good working order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed ensure resident rooms meet the requirement of 80 square feet (sq feet - a unit of measurement) per resident in multiple resident bedrooms (Rooms 1, 2, 3, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34).

This deficient practice had the potential to result in inadequate usable living space and privacy for the residents and working space for the health caregivers.

Findings:

During a review of the Request for Room Size Waiver letter dated 7/23/2024 submitted by the Administrator,

the letter indicated 19 rooms did not meet the 80 square feet requirement per federal regulation. The letter indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect resident's health and safety and do not impede the ability of the residents in the room to obtain their highest practicable well-being.

The following rooms provided less than 80 square; feet per resident: ,

Rooms # Beds Floor Area Sq. Ft.

1 3 238

2 3 232

4 3 212

5 3 212

6 3 212

8 3 212

10 3 213

12 3 212

14 3 212

16 3 212

17 3 212

18 3 212

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0912 19 3 212

Level of Harm - Potential for 20 3 212 minimal harm 21 3 212 Residents Affected - Some 22 3 212

23 3 212

23 3 212

34 3 212

The minimum square footage for a 3-bed resident room should be 240 sq ft.

During a review of the Resident Council meeting minutes dated 5/21/2024, 6/18/2024, 7/9/2024, and 7/22/2024, the meeting minutes did not indicate there were no concerns brought up by the residents regarding the size of the rooms.

During a concurrent observation and interview with Resident 40 on 7/24/2024 at 6:26 p.m. inside the resident's room, observed Resident 40 moving freely inside the room. Resident 40 stated she can move freely in the room, and she had ample space for her personal belongings.

During interviews with staff on 7/24/2024 and 7/25/2024, there were no concerns regarding the size of the aforementioned rooms.

During a general observation of the mentioned resident rooms on 7/23/2024 to 7/25/2024, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient space for beds, side tables and resident care equipment.

The facility submitted a written request for continued waiver dated 7/23/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the Residents Affected - Many food services department when one (1) fly (a type of insect) was observed flying in the kitchen and landing

on surfaces and yellow cake.

This deficient practice had a potential to result in 78 of 78 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Findings:

During a concurrent observation of the kitchen and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS) on 7/23/2024 at 10:53 a.m., an insect landed on the can opener. The RD stated the insect was a fly. The DS stated the fly could be coming from the breakroom or office when staff opened the door. The DS stated they did not want the fly on the food because it could transmit germs and residents could get sick and an infection.

During concurrent observation in the trayline (area where food was assembled) area and interview with the RD and the DS on 7/23/2024 at 12:34 p.m., a fly landed on a baked good placed on top of the trayline area.

The DS stated the food on top of the trayline area was a yellow cake. The RD stated they would not use the yellow cake and would throw it away instead.

During a review of facility's Policy and Procedure (P&P), titled, Pest Control Policy, dated 1/10/2024, the P&P indicated, The facility shall maintain an effective pest control program. (1) This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of104 555690

F-F849.)

3. Ensure Licensed Vocational Nurse 3 (LVN 3) monitored, identified, and reported to the physician and the Infection Preventionist (IP) Resident 76's open wounds (a break in the skin) with signs and symptoms (s/s) of invasive group A streptococcus (IGAS - a severe and sometimes life-threatening infection that is spread from person to person through respiratory droplets or touching other surfaces contaminated with bacteria that may invade parts of the body where bacteria are not usually found) on the left wrist.

4. Ensure Treatment Nurse 1 (TN 1) identified and reported Resident 76's open wounds with s/s of IGAS on

the left wrist.

These deficient practices had the potential to result in worsening of Resident 76's wound including necrotizing fasciitis (a life-threatening soft tissue infection) and in the spread of IGAS to facility residents, visitors, and staff.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 a. During a review of Resident 68's Admission Record, the facility admitted Resident 68 on 6/30/2022 and readmitted on [DATE REDACTED] with diagnoses including dementia (decline in mental ability severe enough to interfere Level of Harm - Minimal harm or with daily life), type 2 diabetes mellitus (high blood sugar), major depressive disorder (depression, a mood potential for actual harm disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), Vitamin D deficiency (not enough Vitamin D needed for strong bones and teeth), and Residents Affected - Some contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to the right hand, both elbows, and both knees. The Admission Record indicated Resident 68 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/26/2024 with diagnosis of cerebral atherosclerosis (blood vessels in the brain have become blocked by fatty substances).

During a review of Resident 68's care plan for spontaneous (sudden), pathological (caused by disease), stress (tiny breaks in bone) fracture (break in bone), initiated on 6/30/2022 and revised on 3/20/2024, the care plan interventions included to observe Resident 68 for sudden pain, swelling, and guarded movement (cautious with resistance, protecting against pain) of the extremity (arm or leg), handle gently and carefully

during care, encourage mild exercises as tolerated and within joint limitation, and to notify the physician, responsible party, and the Hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) Registered Nurse (Hospice RN) of changes in condition.

During a review of Resident 68's physician orders, dated 4/24/2023, the physician orders indicated for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) to both arms, five times per week as tolerated. A review of another Resident 68's physician orders, dated 12/8/2023, indicated for the RNA to apply both elbow extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and a right-hand roll (material placed in the hand to prevent the fingers from bending into the palm) for one to two hours per day, five times per week. A review of another Resident 68's physician orders, dated 2/13/2024, indicated for the RNA to provide PROM to both legs and apply a right knee extension splint for up to five hours, five times per week.

During a review of Resident 68's physician orders, dated 3/7/2024, the physician orders indicated to give two tablets of acetaminophen (pain medication) 325 milligrams ([mg] unit of weight) by mouth two times per day for pain management. A review of another physician order, dated 3/7/2024, indicated to give 0.25 mg of Morphine Sulfate (pain medication for moderate to severe pain) to Resident 68 by mouth every two hours as needed for moderate to severe pain.

During a review of Resident 68's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/10/2024, the MDS indicated Resident 68 was severely impaired for daily decision making, had ROM limitations in both arms and legs, and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a review of Resident 68's Documentation Survey Report (record of nursing assistant tasks) for RNA in 6/2024, the Documentation Survey Report indicated Resident 68 refused RNA for PROM to both arms and Level of Harm - Minimal harm or legs, application of the right knee extension splint, and application of both arm extension splint and the potential for actual harm right-hand roll on 6/10/2024, 6/18/2024, 6/19/2024, 6/20/2024, 6/25/2024, 6/26/2024, and 6/27/2024.

Residents Affected - Some During a review of Resident 68's Restorative Nursing (RNA) Weekly Summary - Range of Motion (ROM), dated 6/15/2024, 6/22/2024, and 6/29/2024, the RNA Weekly Summary - ROM indicated Resident 68 refused RNA for ROM and nursing (unknown) was notified.

During a review of Resident 68's RNA Weekly Summary - Splint Care, dated 6/15/2024, 6/22/2024, and 6/29/2024, the RNA Weekly Summary - Splint Care indicated Resident 68 refused to wear the right-hand roll, right elbow extension splint, and the right knee splint and nursing (unknown) was notified.

During a review of the RNA Monthly Meeting notes, dated 6/28/2024, the RNA Monthly Meeting notes indicated Resident 68 refused participating in RNA, had pain, and held the arm (unspecified) not wanting the RNA to move the arm.

During a review of Resident 68's Documentation Survey Report (record of nursing assistant tasks) for RNA in 7/2024, the Documentation Survey Report indicated Resident 68 refused RNA for PROM to both arms and legs, application of the right knee extension splint, and application of both arm extension splint and the right-hand roll on 7/9/2024, 7/10/2024, 7/11/2024, 7/16/2024 7/17/2024, and 7/18/2024. The Documentation Survey Report for RNA was blank for 7/7/2024, 7/8/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/22/2024.

During a review of Resident 68's Restorative Nursing (RNA) Weekly Summary - ROM, dated 7/6/2024, 7/13/2024, and 7/20/2024, the RNA Weekly Summary - ROM indicated Resident 68 refused RNA for ROM and nursing (unknown) was notified.

During a review of Resident 68's RNA Weekly Summary - Splint Care, dated 7/6/2024, 7/13/2024, and 7/20/2024 the RNA Weekly Summary - Splint Care indicated Resident 68 refused to wear the right-hand roll, right elbow extension splint, and the right knee splint and nursing (unknown) was notified.

During a review of Resident 68's Hospice Skilled Nursing Visit Note, dated 7/15/2024 written by Hospice RN 1, the Hospice Skilled Nursing Visit Note indicated the facility's License Vocation Nurse (LVN) 1 notified Hospice RN 1 regarding Resident 68's right arm swelling and increased pain especially with movement. The Hospice Skilled Nursing Visit Note indicated Hospice RN 1 observed Resident 68s right arm which had whole arm swelling and pain with movement when gentle ROM was attempted. The Hospice Skilled Nursing Visit Note indicated Hospice RN 1 called Resident 68's Responsible Party (RP 1) to discuss observations

during the visit, including worsening pain with movement in the right arm that prevents ROM, elevation of the arm, and adjustment to Resident 68's pain medication.

During a review of Resident 68's physician orders, dated 7/15/2024, the physician orders indicated to discontinue Resident 68's two tablets of acetaminophen 325 mg by mouth two times per day. The physician order, dated 7/15/2024, indicated for Resident 68 to start taking one tablet of Norco (medication used to treatment moderate to severe pain) which included 5 mg of hydrocodone (pain medication used to treatment moderate to severe pain) and 325 mg of acetaminophen (Norco 5/325 mg), two times per day routinely, for pain management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a concurrent observation and interview on 7/23/2024 at 3:30 p.m. with Certified Nursing Assistant (CNA) 8 in the bedroom, Resident 68 was sitting up in a reclining wheelchair. Resident 68 was using the left Level of Harm - Minimal harm or arm to hold onto the right arm. CNA 8 stated Resident 68 had pain and swelling in the right elbow but had potential for actual harm not fallen or had any injury. CNA 8 attempted to lift Resident 68's right arm but Resident 68 immediately used the left arm to grab and guard the right arm, had a facial wince (gesture in the face of pain), and had Residents Affected - Some tears in the left eye. CNA 8 stated Resident 68 appeared to be in 10 out of 10 pain (pain scale from zero [0], indicating no pain, to 10, indicating the worst pain possible) in the right arm because Resident 68's eye was tearing up. CNA 8 stated Resident 68 complained of right elbow pain for one to two weeks.

During an interview on 7/24/2024 at 7:47 a.m. with Restorative Nursing Aide (RNA) 3, RNA 3 stated the nurse (unknown) was giving Resident 68 pain medication prior to the RNA session this morning. RNA 3 stated Resident 68 was seen yesterday evening (7/23/2024) for RNA. RNA 3 stated Resident 68 did not tolerate the exercises to the right arm yesterday and did not apply the right arm splints due to Resident 68's right elbow pain and swelling. RNA 3 stated Resident 68 used the left arm to guard and hold onto the right arm. RNA 3 stated Resident 68 did not want anyone to touch her right arm due to the pain for the past month. RNA 3 stated Resident 68's right arm pain was reported to the Director of Rehabilitation (DOR) and

the Director of Staff Development (DSD) during the monthly RNA Meeting.

During an observation on 7/24/2024 at 8:24 a.m. with RNA 3 in the bedroom, Resident 68 was lying in bed with swelling throughout the right arm compared to the left arm. RNA 3 stood on the left side of the bed and performed exercises to Resident 68's left shoulder, elbow, and hand. RNA 3 stood on the right side of the bed, lifted the right arm at the shoulder joint, and attempted to extend the elbow. Resident 68 immediately held onto the right arm using the left hand and flexed (bent) the body as a pain response. RNA 3 stated Resident 68 was in pain.

During an interview on 7/24/2024 at 9:15 a.m. with CNA 8, CNA 8 stated LVN 1 and the DSD were aware of Resident 68's right arm pain and Resident 68 was receiving pain medication.

During a concurrent interview and record review on 7/24/2024 at 10:25 a.m. with the DSD, the RNA Monthly Meeting notes, dated 6/28/2024, were reviewed. The DSD stated the RNA reported Resident 68 had pain and refused RNA. The DSD stated she saw Resident 68 the next day and observed Resident 68 had swelling in the right arm and pulled the right arm away due pain when the DSD attempted to move the right arm. The DSD stated Resident 68 did not have any previous reports of pain in the right arm.

During a concurrent interview and record review on 7/24/2024 at 10:42 a.m. with the DSD, Resident 68's Progress Notes, dated 6/1/2024 to 7/24/2024, and Change of Condition (COC) Assessment Forms were reviewed. The DSD stated the primary physician should be notified if a resident (in general) was in pain and refusing RNA sessions since it was a change of condition. The DSD reviewed Resident 68's Progress Notes and stated there was no documentation Resident 68's physician (MD 1) or the Hospice RN 1 was notified of Resident 68's change of condition, including right arm pain and refusing RNA. The DSD reviewed Resident 68's COC Assessment Forms and stated a COC Assessment Form was not completed for Resident 68's refusal to participate in RNA and increased pain to the right arm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a concurrent interview and record review on 7/24/2024 at 11:38 a.m. with the Director of Nursing (DON), Resident 68's Progress Notes, dated 6/1/2024 to 7/24/2024, and Change of Condition (COC) Level of Harm - Minimal harm or Assessment Forms were reviewed. The DON stated the facility provided all treatments to residents on potential for actual harm hospice, including Resident 68. The DON stated the process when a resident (in general) refused RNA included the RNA informing the licensed nurse, who would gather more information and assess the resident. Residents Affected - Some The DON stated Resident 68's refusal to participate in RNA and right arm pain was a change of condition that should have been reported to MD 1. The DON stated Resident 68's arm contractures increased Resident 68's risk for injury. The DON stated Resident 68 could be experiencing right elbow pain due to the contracture or could have an injury. The DON reviewed Resident 68's Progress Notes, dated 6/1/2024 to 7/24/2024, and the COC Assessment Forms. The DON stated Resident 68's clinical record did not include a COC Assessment Form and the Progress Notes did not indicate Resident 68 had right arm pain and refused RNA. The DON stated the licensed nurses should have completed documentation indicating Resident 68's right arm pain, refusal to participate in RNA, and a COC Form Assessment, which would have included notification to MD 1. The DON stated Resident 68's change of condition should have been monitored and addressed as a team, including the physician, nursing, and the hospice team.

During a telephone interview on 7/25/2024 at 8:11 a.m. with Resident 68's Responsible Party (RP 1), RP 1 stated Hospice RN 1 usually called RP 1 regarding Resident 68's care. RP 1 stated the facility did not inform RP 1 that Resident 68 had right arm pain and refused exercises. RP 1 stated Hospice RN 1 contacted RP 1 about Resident 68's right arm swelling and changing medications but was not informed Resident 68 had right arm pain and refused exercises. RP 1 felt uncomfortable that the facility did not contact RP 1 directly and wanted to know the cause of Resident 68's right arm pain.

During an interview on 7/25/2024 at 12:04 p.m. with Hospice RN 1, the Hospice physician (Hospice MD 1), and the DON, the Hospice RN 1 stated LVN 1 reported Resident 68 had more swelling, stiffness, and pain in right arm on 7/15/2024. Hospice RN 1 stated Resident 68 did have with more body stiffness and pain during

the assessment on 7/15/2024. Hospice RN 1 stated Hospice RN 1 called RP 1 about the recommendation to adjust Resident 68's pain medication to Norco 5/325 mg, which Hospice MD 1 prescribed. Hospice MD 1 stated Resident 68's new onset pain and swelling could be associated with injury but would not recommend any tests since Resident 68 was on hospice care.

During an interview on 7/25/2024 at 1:00 p.m. with the DON, the DON reviewed the facility's policy and procedure (P&P), titled Change of Condition. The DON stated the facility did not follow the P&P since the facility did not contact MD 1 and RP 1.

During a concurrent interview and record review on 7/25/2024 at 5:29 p.m. with the DON, the DON reviewed Resident 68's Documentation Survey Report for 6/2024 and 7/2024. The DON stated the licensed nurse should have completed Resident 68's COC Assessment Form on 6/20/2024, which was Resident 68's fourth RNA refusal. The DON stated Resident 68's COC Assessment would have included communication to the DON, the hospice team, MD 1, and RP 1. The DON stated the DON knew about Resident 68's increased pain, inability to tolerate exercises with RNA, and increase in pain medication to Norco 5/325 mg on 7/15/2024 but did not further investigate the reason for Resident 68's need for increased pain medication.

The DON stated the facility did not contact RP 1 because Hospice RN 1 called RP 1 on the facility's behalf.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a concurrent interview and record review on 7/26/2024 at 11:30 a.m. with LVN 1, Resident 68's MAR for 6/2024 and Progress Notes, dated 6/1/2024 to 7/24/2024, were reviewed. LVN 1 stated either the CNA Level of Harm - Minimal harm or (unknown) or the Hospice CNA (unknown) informed LVN 1 that Resident 68 had pain the right arm which potential for actual harm was new for Resident 68. LVN 1 stated Resident 68 moaned and grimaced with movement to the right arm

on 6/21/2024 and administered Morphine. LVN 1 reviewed Resident 68's Progress Notes and stated LVN 1 Residents Affected - Some contacted Resident 68's hospice when the Morphine was administered and should have documented the communication with the hospice team in Resident 68's Progress Note. LVN 1 stated Resident 68 did not have any pain if lying in bed but did have pain when moving Resident 68's right arm. LVN 1 stated the change of condition documentation, which included notifying the RN to further assess the resident, informing

the resident's primary physician, and contacting the responsible party, was not completed for Resident 68's right arm pain and swelling because Resident 68 was on hospice. LVN 1 stated the facility educated LVN 1 to communicate with the hospice team if Resident 68 had any changes in condition. LVN 1 stated a COC Assessment Form should have been completed for Resident 68's right arm pain and swelling, which should have been monitored for 72 hours. LVN 1 stated she did not know Resident 68 refused RNA sessions.

During a concurrent interview and record review on 7/26/2024 at 12:01 p.m. with LVN 1 and RNA 3, Resident 68's RNA Weekly Summary - ROM and Splint Care, dated 6/15/2024, 6/22/2024, and 6/29/2024, were reviewed. RNA 3 reviewed Resident 68's RNA Weekly Summaries, which indicated RNA 3 informed

the licensed nurse. RNA 3 stated LVN 1 was not informed about Resident 68's refusal to participate in ROM and application of splints and did not remember which licensed nurse was informed.

During a review of the facility's undated P&P titled, Change of Condition, the P&P indicated the facility ensured proper assessment and follow-through for any resident with a change in condition. The P&P indicated all changes of condition in a resident shall be handled promptly, which included prompt notification of the resident's physician, completion of the nursing report, daily assessment of the resident, and documentation of the change of condition.

44244

b. During a review of Resident 76's Admission Record, it indicated the facility admitted the resident on 4/4/2023 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm (commonly referred to as cancer [term for a diseases in which abnormal cells divide without control and can invade nearby tissues]) of skin.

During a review of Resident 76's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/10/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident requires substantial/maximal assistance from staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a review of Resident 76's Care Plan (CP) titled, (Resident 76) has unspecified dermatitis. Location: generalized body rash (bilateral upper extremities, chest, back) ., initiated 6/13/2024, the CP indicated goals Level of Harm - Minimal harm or to promote healing without complications and will show no signs and development of infection. The CP potential for actual harm indicated to monitor for signs and symptoms of infection (redness, presence of drainage, odor, pain), to report change in resident's kin condition to physician and resident's family, and to provide treatment as Residents Affected - Some ordered.

A review of Resident 76's physician orders indicated the following orders:

-Monitor for symptoms and signs of IGAS: cough; sore throat; fever; skin infection (tenderness or pain, heat, swelling, serous drainage [a clear to yellow fluid that leaks out of a wound and may be a sign of infection] at affected site) and document yes/no, (if yes, indicate in the nurse's note and call physician), every shift until 8/17/2024, dated 7/17/2024.

During an observation and interview on 7/23/2024 at 9:58 a.m., with Certified Nursing Assistant 9 (CNA 9) observed Resident 76 in a wheelchair (WC) outside the resident's room. Observed the resident with multiple open skin wounds on the left upper extremity and a clear dried substance crusted on the left dorsal wrist. CNA 9 stated the resident had multiple open wounds on the left arm and he did not know when it started.

b.1. During a review of Resident 76's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis), the MAR indicated on 7/23/2024 for the evening shift (3 p.m. to 7 p.m.), LVN 3 documented the resident did not have any signs or symptoms of IGAS.

During an observation, interview, and record review on 7/24/2024 at 11 a.m., with LVN 3, reviewed Resident 76's progress notes for July 2024. LVN 3 stated she was caring for Resident 76 on 7/23/2024 and 7/24/2024 and was not aware of any issues on the resident's skin. Observed LVN 3 assess Resident 76's left wrist while the resident sat in the WC in the hallway. LVN 3 stated the resident had open wounds with discharge

on the L wrist that she was not aware of. LVN 3 stated she should do a skin assessment daily of the resident, but on 7/23/2024 and 7/24/2024 she only scanned the resident while administering his medications. LVN 3 stated she relies on the CNAs to report any skin changes. LVN 3 reviewed the resident progress notes and stated there was no documentation that the resident had a change of condition (COC, decline in a resident's status) on the skin of the left wrist.

During an interview on 7/24/2024 at 11:30 a.m., with CNA 9, CNA 9 stated Resident 76 had an issue on his left wrist that was progressively getting worse. CNA 9 stated he did not know for how long the resident had

the issue, but the charge nurses were aware.

During an interview on 7/24/2024 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated the facility currently has an Outbreak (OB, the occurrence of disease cases in excess of normal expectancy) for IGAS.

The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation (used to help prevent the spread of infectious agents that spread by direct or indirect contact with a resident or a resident's environment), the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During an interview and record review on 7/24/2024 at 5:26 p.m., with the IP, reviewed Resident 76's Medication Administration Record (MAR) for 7/2024. The IP stated on 7/23/2024 evening shift LVN 3 Level of Harm - Minimal harm or documented that she monitored Resident 76 for s/s of IGAS and there were no s/s of skin infection present. potential for actual harm The IP stated monitoring a resident's skin includes removing the clothing and completing a head-to-toe skin assessment. The IP stated when LVN 3 did not do a thorough skin assessment on Resident 76, LVN 3 did Residents Affected - Some not identify the new skin issue and it resulted in a delay of the necessary care and treatment for the resident.

During an interview on 7/24/2024 at 8:25 a.m., LVN 3 stated she did not remove Resident 76's sleeves or clothing to monitor the resident's skin. LVN 3 stated if she would have done a thorough skin assessment on 7/23/2024, she would have identified a change of condition. LVN 3 stated because she did not do a skin assessment, it resulted in a delay in care to the resident and a delay in placing the resident in isolation. LVN 3 stated things should have been done with more urgency.

During an interview on 7/25/2025 at 9:42 a.m., with the IP, the IP stated anything new on a resident is a change of condition and should be reported. The IP stated LVN 3 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.

During a review of the facility policy and procedure (P&P) titled, Change of Condition, last reviewed 1/10/2024, the (P&P) indicated the purpose of the policy was to ensure proper assessment and follow through for any resident with a change of condition. A change of condition is a sudden or marked difference

in resident's drainage from a wound (anything abnormal), open or red areas, rashes, or skin conditions (swelling or discoloration). All changes of condition in a resident shall be handled promptly. The physician shall be called promptly. Documentation of change in condition shall be performed by the licensed nurse accordingly and a change of condition will be completed as indicated.

[NAME] a review of the facility policy and procedure (P&P) titled, Charting and Documentation, last reviewed 1/10/2024, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented

in the resident's medical record. The record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, and the notification of family, physician or other staff if indicated.

b.2.During an interview on 7/24/2024 at 1:32 p.m., with TN 1, TN 1 stated she provides daily skin treatments to Resident 76's generalized body rash that includes the bilateral upper extremities (both arms). TN 1 stated

the facility currently has an OB of IGAS and the public health nurse thinks the resident's rashes may be related to the OB. TN 1 stated she noticed on 7/23/2024 that Resident 76's left wrist was irritated and moist. TN 1 stated she did not report to anyone that the resident's wrist was irritated and moist. TN 1 stated Resident 76's left wrist was crustier today when she made rounds with the Wound Care Consultant (WCC) at 6:30 a.m. and the WCC verbally ordered antibiotics for an infection of Resident 76's left wrist wound. TN 1 stated any residents with open wounds that have signs and symptoms of infection are considered possibly contagious and should be placed in contact/droplet isolation. TN 1 stated she did not notify the IP or DON that Resident 76 had an open skin wound with an infection because she was very busy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a review of Resident 76's Skilled Nursing Facility Wound Care Consultant notes, dated 7/24/2024, it indicated Resident 76 had an infected wound with scant serous drainage. The notes indicated to start the Level of Harm - Minimal harm or resident on Keflex (a medication that treats infections) 500 milligrams (mg-unit of measurement), four times a potential for actual harm day for seven days.

Residents Affected - Some During an interview on 7/24/2024 at 2:09 p.m., with the IP, the IP stated the facility currently has an OB of IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation, the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started. The IP stated TN 1 did not notify her there were any newly identified residents with open wounds that had signs and symptoms of infection. The IP stated TN 1 should have notified her in the morning regarding Resident 76's wound so she could have assessed the wound, placed

the resident in isolation, swabbed the wound for IGAS, and started the antibiotic treatment because the facility has an OB. The IP stated they want to prevent the OB from spreading to other residents.

During an interview on 7/24/2024 at 3:17 p.m., with the IP, the IP stated she just assessed Resident 76's left wrist and there is an open wound with serous drainage. The IP stated TN 1 should have identified Resident 76's change of condition on 7/23/2024 and again on 7/24/2024 when TN 1 was with the WCC. The IP stated TN 1 should have notified the IP immediately because there is an OB. The IP stated she spoke with TN 1 and TN 1 stated she did not notify the IP because she was overwhelmed.

During an interview on 7/25/2025 at 9:42 a.m., with the IP, the IP stated anything new on a resident is a change of condition and should be reported. The IP stated TN 1 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.

During a review of the facility policy and procedure titled, Change of Condition, last reviewed 1/10/2024, the P&P indicated the purpose of the policy was to ensure proper assessment and follow through for any resident with a change of condition. A change of condition is a sudden or marked difference in resident's drainage from a wound (anything abnormal), open or red areas, rashes, or skin conditions (swelling or discoloration). All changes of condition in a resident shall be handled promptly. The physician shall be called promptly. Documentation of change in condition shall be performed by the licensed nurse accordingly and a change of condition will be completed as indicated.

During a review of the facility policy and procedure titled, Charting and Documentation, last reviewed 1/10/2024, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented

in the resident's medical record. The record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, and the notification of family, physician or other staff if indicated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0580 During a review of the facility policy and procedure titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, the P&P indicated outbreaks of communicable diseases within the facility are promptly Level of Harm - Minimal harm or identified and managed. The infection preventionist and director of nursing are responsible for monitoring ill potential for actual harm residents and staff and initiating transmission-based precautions as appropriate. The nursing staff are responsible for notifying the director of nursing services of newly symptomatic residents and providing Residents Affected - Some infection surveillance data in a timely manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on observation, interview, and record review the facility failed to ensure the residents were free from Residents Affected - Some any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one out of one sampled resident (Resident 46) investigated

during a random observation by:

1. Failing to obtain an appropriate physician order for the use of bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure).

2. Failing to assess Resident 46 quarterly for continued use of the bed pad alarm per facility policy and procedure.

These deficient practices Resident 46 at risk for unnecessary prolonged use of restraints, restriction from freedom of movement which can lead to a decline in functioning.

Findings:

During a review of Resident 46's Admission Record, the facility admitted the resident on 8/26/2019 and readmitted on [DATE REDACTED] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood, and history of falling.

During a review of Resident 46's History and Physical (H&P) dated 3/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated the resident had severe cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 46 used a bed alarm.

During a review of Resident 46's Order Summary Report, it indicated the following physician's order dated 7/29/2022:

- Non-Restraint. Apply pad alarm in bed as nursing intervention to alert staff for unassisted transfer and attempting to walk. Nursing staff to check proper placement and function every shift.

During a review of Resident 46's care plan (CP), the CP indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0604 1. Risk for falls or injury related but not limited to dementia, generalized weakness, history of falls, and impaired cognition initiated on 7/4/2023 and a goal to reduce falls and injury daily with a target date Level of Harm - Minimal harm or 8/14/2024. The care plan indicated to apply bed pad alarm to alert staff for unassisted transfer and potential for actual harm attempting to walk ad nursing staff to check proper placement and function every shift as one of the interventions. Residents Affected - Some 2. Falling Star program: At risk for falls related to balance deficit, bladder/bowel dysfunction, cognitive impairment, history of falls, etc. initiated on 7/23/2024 and a goal to reduce risk for fall and /or injury thru appropriate interventions daily with a target date 8/14/2024, indicated bed pad alarm as one of the interventions.

During a review of Resident 46's Fall Risk Assessments dated 5/16/2024, 2/12/2024, and 11/16/2023, it indicated the resident is a high risk for falls.

During a review of resident 46's Restraint - Physical (Quarterly/Annual Evaluation), it indicated the facility reassessed the resident for continued use of the bed pad alarm on 2/12/2024, 11/30/2023, and 8/31/2023. There was no documented evidence Resident 46 was reassessed on 5/2024.

During a concurrent observation and interview on 7/25/2024 at 10:34 a.m. with Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) inside Resident 46's room, observed Resident 46 constantly moving in bed from left to right. RN 2 stated the bed pad alarm will trigger a sound when it detected a change

in pressure when Resident 46 was moving from side to side. RN 2 stated the bed pad alarm was a nursing intervention and not considered a restraint.

During a concurrent interview and record review on 7/26/2024 at 12:20 p.m., reviewed Resident 46's physician's order for bed alarm, informed consent, care plans, and restraint assessments with the Director of Nursing (DON). The DON stated the bed pad alarm was a nursing intervention to help prevent Resident 46 from rolling out of bed by accident and sustain injury. The DON stated the bed pad alarm is not considered a restraint by the facility as indicated in the physician's order. However, the DON stated the bed pad alarm is a restraint as it restricts the resident's movements because when the resident moves, the alarm will sound.

The DON stated the physician's order should have indicated the bed pad alarm as a restraint. The DON verified there was no documented evidence of a restraint assessment/reassessment on 5/2024. The DON stated restraint assessments are supposed to be completed quarterly, annually, and as needed to evaluate necessity for continued use of the bed pad alarm.

During a review of the facility's policy and procedure titled, Physical Restraints, last reviewed 1/10/2024, indicated physical restraint assessment and use shall be managed accordingly. The policy indicated the following:

1. The licensed nurse shall be responsible for obtaining an order form the attending physician, which is to include:

- Specific type of restraint.

- Purpose of the restraint.

- Time and place of application.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0604 - Approaches to prevent decreased functioning when applicable.

Level of Harm - Minimal harm or - Informed consent obtained from resident or from surrogate decision-maker. potential for actual harm

During a review of the facility's policy and procedure titled, Use of Restraints, last reviewed 1/10/2024, Residents Affected - Some indicated retrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive method of restraints, or total restraint elimination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 49947 potential for actual harm Based on interview and record review the facility failed to implement policies and procedures (P&P) related Residents Affected - Few to screening (sometimes called background check - a process a person or company uses to verify that an individual is who they claim to be and do not possess a criminal record) procedures by failing to conduct a background check screening prior to employment of one of seven staff members (Restorative Nursing Assistant 1, [RNA 1] ) investigated under the sufficient and competent nurse staffing facility task.

This failure placed the residents at risk for abuse, neglect, and exploitation, and misappropriation of resident property for approximately nine months.

Findings:

During a concurrent interview and record review on 7/25/2024 at 3:30 p.m. with the Director of Staff Development (DSD), reviewed Restorative Nursing Aides (RNA - Certified Nursing Assistants [CNA] with specialized training to help residents regain their physical function and quality of life after illness or injury) 1's employee file. The DSD stated RNA 1 was hired on 4/9/2019 and did not have a background check screening until 1/15/2022. The background check came back with a criminal record of driving with a suspended license, misdemeanor. The DSD further stated she was unsure why the background check was completed late, and the delay put the residents at risk.

During an interview on 7/25/2024 at 6:40 p.m. with the Director Of Nursing (DON), the DON stated background checks must be completed prior to employment to ensure the safety of the residents and staff.

The DON further stated RNA 1 should not have started working until the background check was completed and that facility's policy was not followed.

During a review of the facility's policy and procedure (P&P) titled, Hiring Process, last reviewed 1/10/2024,

the P&P indicated prior to hiring of any employee, facility shall ensure provisions covering employment screening for potential history of abuse, neglect, or mistreatment of residents.

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last reviewed 1/10/2024, the P&P indicated employee background checks must be conducted to prevent abuse, neglect, exploitation and misappropriation of residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 49947

Residents Affected - Some Based on interview and record review the facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes to one out of three sampled residents (Resident 70) investigated during review of behavioral/emotional care area by failing to develop a care plan that addressed

the resident's behavior of disrobing (the act of removing clothing).

The deficient practice had violated Resident 70's right to maintain their highest practicable psychosocial well-being.

Cross reference to

F-F880.

Findings:

1. During a review of Resident 10's Admission Record, it indicated the facility admitted the resident on 3/10/2023, with diagnoses including, but not limited to, type 2 diabetes mellitus (DM - a disease that occurs when the glucose, also called blood sugar, is too high) with unspecified complications, and long-term use of insulin.

During a review of Resident 10's History and Physical (H&P), dated 3/4/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/13/2024, the MDS indicated the resident had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and required moderate assistance with eating, oral hygiene, and upper body dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 During a review of Resident 10's Order Summary Report, printed on 7/25/2025, the report indicated Resident 10 had an order increase on 7/4/2024 for Lantus (long-acting insulin) SoloStar Subcutaneous (SQ - into the Level of Harm - Minimal harm or fatty layer under the skin) Solution Pen-injector (a device used to administer medication into the body potential for actual harm through a needle) 100 unit per milliliters (unit/ml, a unit of fluid volume) from 12 to 14 units: inject 14 unit SQ at bedtime (HS). Hold if BS is less than 110. May give orange juice for BS less than 60. Rotate site. Residents Affected - Some

During a review of Resident 10's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for 5/2024-7/2024, indicated Lantus SoloStar SQ Solution Pen-injector; inject 14 units SQ at HS was administered on:

5/7/2024 at 8:00 p.m. on the left lower quadrant

5/8/2024 at 8:00 p.m. on the left lower quadrant

5/12/2024 at 8:00 p.m. on the abdomen

5/13/2024 at 8:00 p.m. on the abdomen

5/14/2024 at 8:00 p.m. on the abdomen

5/17/2024 at 8:00 p.m. on the right lower quadrant

5/18/2024 at 8:00 p.m. on the right lower quadrant

5/24/2024 at 8:00 p.m. on the left lower quadrant

5/25/2024 at 8:00 p.m. on the left lower quadrant

6/2/2024 at 8:00 p.m. on the abdomen

6/3/2024 at 8:00 p.m. on the abdomen

6/8/2024 at 8:00 p.m. on the abdomen

6/9/2024 at 8:00 p.m. on the abdomen

6/10/2024 at 8:00 p.m. on the abdomen

6/11/2024 at 8:00 p.m. on the abdomen

6/19/2024 at 8:00 p.m. on the left lower quadrant

6/20/2024 at 8:00 p.m. on the left lower quadrant

7/3/2024 at 8:00 p.m. on the left arm

7/4/2024 at 8:00 p.m. on the left arm

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 7/5/2024 at 8:00 p.m. on the left lower quadrant

Level of Harm - Minimal harm or 7/6/2024 at 8:00 p.m. on the left lower quadrant potential for actual harm 7/12/2024 at 8:00 p.m. on the left lower quadrant Residents Affected - Some 7/13/2024 at 8:00 p.m. on the left lower quadrant

7/18/2024 at 8:00 p.m. on the left lower quadrant

7/19/2024 at 8:00 p.m. on the left lower quadrant

7/21/2024 at 8:00 p.m. on the left arm

7/22/2024 at 8:00 p.m. on the left arm

During a concurrent interview and record review on 7/24/2024, at 3:00 p.m., with Registered Nurse (RN) 3, reviewed the Order Summary Report and the MAR of Resident 10 with RN 3. RN 3 stated there were multiple instances where the injection sites of the insulin were not rotated from 5/2024 to 7/2024. RN 3 stated

the sites of insulin administration should be rotated to prevent bruising, hardening of the skin injection sites, and lipodystrophy (abnormal distribution of fat). RN 3 also stated the failure to follow the physician's order to rotate the insulin administration site is considered a medication error.

During a review of the facility's Policy and Procedure (P&P) titled, Medication Error, last reviewed on 1/10/2024, the P&P indicated the facility will follow the medication administration P&P to avoid any medication errors including wrong route of administration.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 1/10/2024, the P&P indicated to select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior and lateral areas of the thighs and abdomen. Avoid the are approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area.

During a review of the facility provided FDA Label for Lantus SoloStar, undated, it indicated to rotate injection sites within the same area you choose each time form one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis (skin with lumps). Do not use the same spot for injection.

2. During a review of Resident 38's Admission Record, it indicated the facility admitted the resident on 2/20/2019, with diagnoses including, but not limited to, type 2 diabetes mellitus without complications.

During a review of Resident 38's H&P, dated 2/13/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 During a review of Resident 38's MDS, dated [DATE REDACTED], the MDS indicated the resident was severely cognitively impaired. The MDS indicated Resident 38 is dependent on eating, toileting, showers, dressing, Level of Harm - Minimal harm or personal hygiene, and mobility. potential for actual harm

During a review of Resident 38's Order Summary Report, printed on 7/25/2024, the Order Summary Report Residents Affected - Some indicated an order for Basaglar (long-acting insulin) KwikPen Solution Pen-Injector 100 u/ml.: inject 4 units SQ one time a day. Rotate site; hold for BS less than 90.

During a review of Resident 38's Care Plan (CP) focused on hypoglycemia related to DM, revised on 1/28/2024, the CP indicated to administer the medications as ordered.

During a review of Resident 38's MAR for 4/2024 to 7/2024, the MAR indicated:

Basaglar KwikPen Solution Pen-Injector 100 u/ml.: inject 4 units SQ one time a day. Rotate site; hold for BS less than 90, was administered on:

a. 4/1/2024 at 8:00 a.m. on the right arm with a BS of 89.

b. 7/2/2024 at 8:00 a.m. on the right lower quadrant with a BS of 80.

During a concurrent interview and record review on 7/24/2024, at 2:30 p.m. with Licensed Vocational Nurse (LVN) 3, reviewed the Order Summary Report and the MAR of Resident 38 with LVN 3. LVN 3 stated, she gave the resident insulin with BS below 90, when it should have been held to prevent the BS from going down even lower.

During an interview on 7/25/2024, at 6:25 p.m., with the Director of Nursing (DON), the DON stated the orders must be double checked; the parameters the physician ordered must always be followed to prevent hypoglycemia. The DON further stated not following the physician ordered parameters during administration of insulin constitutes a medication error.

During a review of the facility's P&P titled, Medication Error, last reviewed on 1/10/2024, indicated the facility will follow the medication administration P&P to avoid any medication errors including failure to follow parameters for specific medications.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 1/10/2024, the P&P indicated to check the order for the amount of insulin and the blood sugar parameter per physician order.

44244

3. During a review of Resident 76's Admission Record, it indicated the facility admitted the resident on 4/4/2023 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm (commonly referred to as cancer, term for a disease in which abnormal cells divide without control and can invade nearby tissues) of the skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 During a review of Resident 76's MDS 6/10/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the Level of Harm - Minimal harm or resident requires substantial/maximal assistance from staff for oral hygiene, toileting, bathing, dressing, potential for actual harm personal hygiene, and mobility.

Residents Affected - Some During a review of Resident 76's CP titled, (Resident 76) has unspecified dermatitis. Location: generalized body rash (bilateral upper extremities, chest, back) ., initiated 6/13/2024, the CP indicated goals to promote healing without complications and will show no signs and development of infection. The CP indicated to monitor for signs and symptoms of infection (redness, presence of drainage, odor, pain), to report change in resident's kin condition to physician and resident's family, and to provide treatment as ordered.

During a review of Resident 76's Skilled Nursing Facility Wound Care Consultant notes, dated 7/24/2024, the Wound Care Consultant Notes indicated Resident 76 had an infected wound with scant serous drainage.

The notes indicated to start the resident on Keflex 500 mg, four times a day for seven days.

During a review of Resident 76's physician orders, the orders indicated the following orders:

-Keflex oral capsule 500 milligrams (mg, a unit of measurement), give one capsule by mouth one time only for bacterial folliculitis (the hair follicle becomes infected/inflamed and forms a pustule), first dose from the emergency kit (e-kit, emergency drug supplies), dated 7/24/2024.

-Monitor for symptoms and signs of Group A Streptococcus (IGAS, a severe and sometimes life threatening infection in which the bacteria have invaded parts of the body where bacteria are not usually found, such as

the blood, deep muscle and fat tissue): cough; sore throat; fever; skin infection - tenderness or pain, heat, swelling, serous drainage at affected site and document yes/no, (if yes, indicate in the nurse's note and call physician), every shift until 8/17/2024, dated 7/17/2024.

During a review of Resident 76's MAR, the MAR indicated the following:

-On 7/24/2024 at 3:15 p.m., TN 1 documented the administration of Keflex Oral Capsule 500 mg capsule.

During an observation on 7/23/2024 at 11:40 a.m., observed Resident 76 sitting in a wheelchair in the hallway outside the resident's room. Observed the resident with multiple open wounds on the left arm and a clear dry crusted substance on the left wrist.

During an observation and interview on 7/24/2024 at 11 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she was caring for Resident 76. LVN 3 assessed Resident 76 and stated the resident had open wounds with discharge that she was not aware of. LVN 3 called TN 1. LVN 3 stated TN 1 stated the resident was seen by the wound care consultant that morning and would be started on antibiotics for an infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 During an interview on 7/24/2024 at 1:32 p.m., TN 1 stated the facility currently has an Outbreak (OB, the occurrence of disease cases in excess of normal expectancy) of IGAS. TN 1 stated Resident 76's left wrist Level of Harm - Minimal harm or was crustier today when she made rounds with the WCC at 6:30 a.m. and the WCC verbally ordered potential for actual harm antibiotics for a skin infection on Resident 76's left wrist. TN 1 stated she was not given a start date for the antibiotics, so she was going to enter the verbal order to give the first dose on 7/25/2024, the next day. TN 1 Residents Affected - Some then stated antibiotics should be given immediately or within two hours of an order. TN 1 stated the antibiotics should have been given by 8:30 a.m. TN 1 stated it was now 1:45 p.m. and the antibiotics had not been administered to Resident 76. TN 1 stated when antibiotics are delayed a wound can worsen.

During an interview on 7/24/2024 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated the facility currently has an OB for IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should be tested to confirm or rule out as IGAS, the primary physician should be notified, and treatment should be started. The IP stated TN 1 did not notify her there are any newly identified residents with open wounds that have signs and symptoms of infection. The IP stated TN 1 should have notified her in the morning regarding Resident 76's wound and started the antibiotic treatment because the facility has an OB. The IP stated when the WCC gave a verbal order for antibiotics, the antibiotics should have been started within four hours because the resident has an infection, they want to stop the infection from worsening, and to prevent the OB from spreading to other residents.

During an interview and record review on 7/25/2024 at 5 p.m., with the DON reviewed the facility policies regarding antibiotic medication administration and antibiotic stewardship. The DON stated for a new order of antibiotics, the first dose should be given within four hours of receiving the order. The DON stated TN 1 should have asked someone for help when she was making rounds with the WCC and was given a verbal order to start Resident 76 on antibiotics. The DON stated the facility policies do not specifically indicate antibiotics must be started within four hours, but it is a standard of practice. The DON stated the antibiotic was available in the facility e-kit and should have been given to Resident 76 as soon as possible and not the following day. The DON stated it was a medication error to delay the initial dose of antibiotics.

During a review of the facility P&P titled, Physician Orders and Telephone Orders, last reviewed 1/10/2024,

the P&P indicated all orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Methods of obtaining orders may be verbal. All orders must indicate

the date and time received and must be noted by the professional staff taking the order.

During a review of the facility P&P titled, Organizational Aspects, last reviewed 1/10/2024, the P&P indicated

the pharmacy provides routine and timely pharmacy services seven days a week and emergency pharmacy service 24 hours per day, seven days a week. Medications which should be promptly available, such as anti-infectives are available within four hours.

During a review of the facility P&P titled, Medication Ordering and Receiving from Pharmacy, last reviewed 1/10/2024, the P&P indicated medications and related products are received from the dispensing pharmacy

on a timely basis. Stat and emergency medications, the initial dose is obtained from the emergency kit and administered immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0760 During a review of the facility P&P titled, Medication Orders, last reviewed 1/10/2024, the P&P indicated medications are administered only upon the clear, complete, and signed order of a person lawfully Level of Harm - Minimal harm or authorized to prescribe. Each medication is documented in the resident's medical record with the date, time, potential for actual harm and signature of the person receiving the order. The nurse on duty at the time the order is received enters it

on the physician order sheet/telephone sheet. If the order is from a prescriber other than the attending Residents Affected - Some physician, the order is verified with the current attending physician. Emergency/STAT medicine order is scheduled to be given within the legally specified time.

During a review of the facility P&P titled, Antibiotic Stewardship - Orders for Antibiotics, last reviewed 1/10/2024, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program in conjunction with the facilities general policy for medication utilization and prescribing. If an antibiotic is indicated, providers will provide complete antibiotic orders.

Before a nurse removes an antibiotic from the emergency supply of medication, he or she will report the use to the infection preventionist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that Residents Affected - Some conserved flavor and appearance when the broccoli was mushy, overcooked and did not have a garlic flavor.

This deficient practice placed 21 of 78 facility residents on regular consistency texture (texture with no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Findings:

A review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 7/23/2024, indicated regular texture diet included the following food items on the tray:

-Roast Turkey 3 ounces (oz, unit of measurement)

-Gravy 1 oz

-Bread stuffing 2.7 oz

-Broccoli with garlic 1/2 cup (c, household measurement)

-Wheat roll 1 piece

-Glazed apple square 1 pc, except for the following diets: consistent carbohydrate diet (CCHO, diet that had

the same amount of carbohydrates per meal).

During a trayline (an area where food was assembled) observation on 7/23/2024 at 12:20 p.m., the broccoli

in the steam table looked overcooked and mushy.

During a test tray conducted with the Dietary Supervisor (DS) and Registered Dietitian (RD) on 7/23/2024 at 12:51 p.m. for regular diet (diet with no restrictions), broccoli was mushy, overcooked and no garlic flavor. DS stated the broccoli was mushy, overcooked, soft and it was served to everybody including soft diet textures. The DS stated the broccoli had no garlic flavor after tasting it. RD stated overcooked vegetables could lose its nutrients and flavor and as a potential outcome, residents would not get the proper nutrients

they were supposed to get.

During a review of the facility's diet manual titled Regular diet dated 2020, it indicated The regular diet is designed to meet the nutritional needs of residents who do not need dietary modification or restrictions.

A review of the facility's recipe titled Recipe: Broccoli with Garlic dated week 4, Tuesday, 2024 indicated the recipe contained the following ingredients:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0804 -Broccoli, fresh 12 pounds (lbs., unit of measurement) or frozen 15 lbs.

Level of Harm - Minimal harm or -Margarine, melted 1 1/8 c. potential for actual harm -Garlic powder 1 1/2 - 3 tablespoon (tbsp, household measurement). Residents Affected - Some

During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 1/10/2024, the P&P indicated POLICY. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Procedure: (1) All food will be prepared by methods that preserve nutritive value, flavor, and appearance and will be attractively served at the proper temperature and in a form that meet the individual needs of the resident. (6) Prepare foods as close as possible to serving time in order to preserve the nutritive value, freshness, and to prevent overcooking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Some Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when:

1. Resident (Resident 33) on vegan (a diet containing plant and plant products only), lactose free diet (diet that consist of food with no lactose, a type of sugar in milk, found in milk, cheese and dairy products) received grilled cheese and bread stuffing containing eggs, poultry seasoning, low sodium chicken stock and lactose on her lunch tray.

2. Fifteen (15) of 78 residents on puree diet (food with smooth, pudding like consistency) had parsley flakes

on top of puree foods as garnish.

These deficient practices had the potential to cause weight loss and frustrations (Resident 33), coughing, choking (to keep from breathing the normal way) and death for residents on puree diets.

Findings:

1. During a review of Resident 33's Admission Record, it indicated the facility admitted the resident on 2/23/2020 with diagnoses including unspecified dementia (a form of mild or mixed dementia characterized with a mild cognitive impairment), iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells) and chronic kidney disease stage 3 (a reduced in kidney function associated loss of kidney function overtime).

During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/30/2024, the MDS indicated Resident 33 had severe cognitive impairment (unable to reason and make their own decision) and able to eat with set-up or clean-up assistance.

During a review of Resident 33's diet order by physician, dated 6/17/2024, the physician order indicated Mechanical soft diet (foods that are soft and chopped), vegetarian diet, nectar/mildly thick (a fluid which flows off a spoon but slower than thin liquids) Additional directions: vegetarian diet, inner lip plate for all meals.

During a review of Resident 33's care plan (CP) initiated 5/30/2024, the CP indicated Resident is at risk for alteration in nutritional status and interventions included mechanically altered diet, lactose free milk. Adhere to food preferences. Resident requests grilled cheese sandwich.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0805 During concurrent trayline observation (an area where resident's foods were assembled) and interview with Registered Dietitian (RD) and DS on 7/23/2024 at 12:40 p.m., Resident 33's meal ticket indicated a diet of Level of Harm - Minimal harm or order of mechanical soft, regular diet, fluids-nectar mildly thick. Adaptive Equipment: lip late. Notes: VEGAN, potential for actual harm lactose free. Resident 33's tray contained grilled cheese, bread stuffing, broccoli, nectar thickened milk, juice, and water. The RD stated the tray was wrong because Resident 33 was not supposed to get grilled Residents Affected - Some cheese due to resident was on vegan diet per diet ticket. The DS stated Resident 33 requested grilled cheese all the time and the diet needed to be changed to a vegetarian diet. The DS stated the meal ticket needed to reflect vegetarian diet instead of Vegan diet, however, she was not sure and needed to double check. The DS stated vegan diet should not receive dairy, milk, and cheese. The DS stated the resident was

on a lactose free diet hence cheese should not be served on to the resident. The DS stated the potential outcome of not updating resident's diet ticket would be residents might not eat and could cause weight loss, frustrations, and complaints.

During a review of the facility's recipe titled Bread Dressing dated week 4, Tuesday 2024, the recipe indicated ingredients included poultry seasoning and low sodium chicken stock.

During a review of the facility's diet manual titled Vegetarian and Vegan Diet dated 2020, the diet manual indicated There are four general categories of adequate vegetarian diets: (1) Vegans use vegetables, salads, legumes, tofu, fruits, whole grains, nuts, and seeds. Excluded all animal products. (2) Lacto-ovo-vegetarians use the above plus dairy products (milk, butter, cheese, yogurt, and eggs (3) lacto-vegetarians use dairy items but not eggs.

During a review of the facility's diet manual titled Lactose Restricted Diet dated 2020, the diet manual indicated Description: This diet provides a restricted intake of lactose in the dietetic management of patients exhibiting lactose intolerance. Words that may indicate lactose in food: milk, lactose, margarine, butter, milk solids, curds, sweet cream, whey, cheese flavors and sour cream. Read labels carefully. Food to be avoided included cheese.

During a review of facility's policies and procedure (P&P) titled Resident Food Preferences revised 1/10/2024, the P&P indicated Procedure: Dietary Service Supervisor (DSS) will meet with resident or representative to go over food preferences, allergies, likes and dislikes upon admission and as needed. The DSS will update meal ticket according to resident food preferences, diet order and nourishments.

During a review of facility's P&P titled Menu, dated 1/10/2024, the P&P indicated (7) Individual resident trays will have a meal ticket which identifies the residents name, room number, diet order. Also sated on the card:

-Portion size.

-Food preferences

-Beverage preferences

-Allergies

-Nourishment order if applicable

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0805 Meal tickets are periodically checked by the Dietary Services Supervisor and/or Consultant Dietitian for accuracy. Level of Harm - Minimal harm or potential for actual harm 2. During a review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 7/23/2024, the menu spreadsheets indicated puree diet included Residents Affected - Some the following food items on the tray:

-Puree Roast Turkey 1/2 cup (c, household measurement)

-Gravy 1 oz (if needed)

-Puree Bread stuffing 2.7 ounces with gravy (oz, a unit of measurement)

-Puree Broccoli with garlic 2.7 oz

-Puree Wheat roll 2.7 oz

-Puree Glazed apple square 2.7 oz, except for the following diets: consistent carbohydrate diet (CCHO, diet that had the same amount of carbohydrates per meal).

During a trayline observation on 7/23/2024 at 12:20 p.m., staff used parsley flakes for puree diet garnishing.

During a test tray for puree diet tray conducted with the DS and the RD on 7/23/2024 at 12:51 p.m., the puree turkey, puree stuffing had parsley flakes garnish. The RD stated there was a lot of parsley flakes as a garnish that would produce lumps that would have a potential outcome of aspiration-to-aspiration risk residents. The RD stated puree diets were allowed to use parsley flakes per the facility policy.

During a review of the facility's diet manual titled Regular Pureed Diet dated 2020, the diet manual indicated Description: The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes, etc. Food allowed included: raw vegetable- pureed, cooked vegetables-pureed.

During a review of facility's P&P titled Food Preparation dated 1/10/2024, the P&P indicated Foods will be cut, chopped, ground, or pureed to meet individual needs of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:

a. Walk-in refrigerator shelves were chipped and cracked.

b. Freezer one (1) and two (2) bottom shelves had dried up pink liquid, and dust buildup.

c. One (1) dented can was stored with non-dented cans.

d. Knife container had dust and sticky residue.

e. One scoop had sticky and dirt debris was stored with the clean scoops.

f. Scoop handles storage was not in one direction.

g. Clean storage area for pots and pans had dust, crumbs, food residues and dried up food.

h. Mixer had dirt and food buildup.

i. Food carts used for lunch service had dried up milk spill and tape residues.

j. Resident's food from home in the resident's refrigerator had no label and no received date.

These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 78 of 78 medically compromised residents who received food and ice from the kitchen.

Findings:

a. During an initial kitchen tour observation on 7/23/2024 at 8:13 a.m. in the walk-in refrigerator, shelves was chipped and cracked.

During a concurrent observation of the walk-in refrigerator shelves and interview with Dietary Supervisor (DS) on 7/23/2024 at 8:41 a.m., the DS stated it was not okay that the paint of the shelves were coming off.

The DS stated it did not look good and bacteria could live there and grow because it's a place to store food. DS stated the shelves surface should be smooth to prevent cross-contamination.

During a review of facility's Policies and Procedures (P&P) titled Sanitizing Equipment and Surfaces dated 1/10/2024, the P&P indicated (6) Dietary staff should ensure that all the equipment, shelves, utensils, and surface area are clean and in good condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0812 During a review of Food Code 2017 , the P&P indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, Level of Harm - Minimal harm or and similar imperfections. potential for actual harm b. During an initial kitchen tour observation of the reach-in freezer one (1) on 7/23/2024 at 8:22 a.m., the Residents Affected - Many bottom shelves had dried up pink liquid and dirt debris.

During an initial kitchen tour observation of the reach-in freezer two (2) on 7/23/2024 at 8:25 a.m., the bottom shelves had dirt and tape debris.

During a concurrent observation of the reach-in freezer 1 and 2 and interview with DS on 7/23/2024 at 8:36 a. m., DS stated the freezers had dirt and it was not supposed to be there. DS stated they cleaned the refrigerator daily when its dirty and deep clean it every Wednesdays. DS stated the spills, dust build up, sticker and label residues were not acceptable as it could attract germs. DS stated residents could get sick with diarrhea, vomiting, upset stomach and food poisoning as potential outcome.

During a review of facility's P&P titled Sanitation and Infection Control dated 1/10/2024 indicated Food service employees will follow infection control policies to ensure the department operates under sanitary condition at all times.

During a review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.

c. During a concurrent observation of the dry storage area and interview with the DS on 7/23/2024 at 8:49 a. m., the DS stated there was one dented can along with undented cans. The DS stated there was a separate area for dented cans because they could not sure the dented cans as it was dangerous due to metal inside

the can that could cause botulism (a serious illness caused by toxin that attacks the body's nerves). The DS stated when the can metal part was broken it would start to create or grow bacteria. The DS stated residents could die from it if they eat the food from dented cans as a potential outcome. The DS stated it was important to separate dented cans from non-dented cans to avoid using the product accidentally. The DS stated they needed to return cans that were dented even if it only had a little dent.

During a review of facility's P&P titled Storage of Canned and Dry Goods dated 1/10/2024, the P&P indicated 10. Canned items should be inspected for damage such as dented, leaking or bulging cans. These items will be stored separately in the designated area-DENTED CANS for return to the vendor or disposed of properly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0812 During a review of Food Code 2017, it indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Level of Harm - Minimal harm or Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101. potential for actual harm 11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to Residents Affected - Many conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

d. During a concurrent observation of the knife container and interview with the DS on 7/23/2024 at 10:38 a. m., the DS stated the knife container had a sticky and dirt residue. DS stated staff cleaned the knife container every Wednesday and it was important to maintain the cleanliness for infection control.

e. During a concurrent observation of the scoop drawer and interview with the Registered Dietitian (RD) on 7/23/2024 at 10:49 a.m., a scoop with purple handle had sticky residue. RD stated the scoop had grease build up and it was stored along with the clean ones that could contaminate the rest. The RD stated it needed to be cleaned to prevent cross-contamination.

During a review of Food Code 2017, it indicated 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.

f. During a concurrent observation of the scoop drawer and interview with the RD and the DS on 7/23/2024 at 10:49 a.m., the scoops used for trayline were stored in a cabinet with the handles in different direction.

The RD stated the scoop storage as not organized but the storage was sanitary. The RD stated they follow

the Retail Food Code but needed to check why the practice of storing the scoop handle in different direction was not a good practice.

During a review of Food Code 2017, it indicated 4-904.11 Kitchenware and Tableware (A) Single-service and Single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented.

g. During a concurrent observation of the clean pots and pans storage area by the trayline and interview with

the RD and the DS on 7/23/2024 at 11:04 a.m., the clean area had dust, crumbs, and other food debris. The RD stated there were crumbs in the pots and pans storage and needed to be cleaned to prevent cross-contamination. DS stated they would clean it today.

h. During a concurrent observation of the mixer and interview with the RD and the DS on 7/23/2024 at 11:08 a.m., the RD stated the mixer had dried up dirt. The DS stated they did not use the mixer always however it needed to be cleaned after each use. The DS sated they also needed to cover the mixer when not in sue as there was dust and dried up food residue. The DS stated it was important to clean the mixer as dirt could get into the food and residents could get sick when they ate the food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0812 During a review of Food Code 2017, it indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Level of Harm - Minimal harm or Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use potential for actual harm after cleaning.

Residents Affected - Many i. During concurrent observation of the food carts and interview with DS on 7/23/2024 at 11:18 a.m., the food carts had white dirt spill and tape residues. DS stated four (4) of 4 carts had dried up milk spill and needed to be cleaned to prevent cross-contamination. DS stated residents could get sick if the carts were not cleaned

after each meal.

During a review of facility's P&P titled Cleaning Schedule dated 1/10/2024, the P&P indicated All areas and equipment should be cleaned daily. The assigned dietary personnel will deep clean the area equipment assigned for them that day using the dietary cleaning schedule. Daily cleaning schedule weekly checklist: refrigerators, freezers, tray carts and mixer.

j. During concurrent observation of the resident's refrigerator and interview with the Director of Nursing (DON) and the RD on 7/24/2024 at 9:10 a.m., a bottle of yogurt had no name and received date. The DON sated this was clearly their mistake that there was no name and label on the yogurt. The DS stated it was important to label food from the outside so that they would know who it belongs to and ensure diet correctness and meal restrictions of the residents. The DON stated they label outside food with name, received date and three (3) days self-life. The DS stated they follow labeling and dating policies from dietary.

The RD stated it was important to label outside food to ensure correctness of diet texture and allergies of the residents. The RD stated allergic reactions and chocking as a potential outcome of not labeling outside food.

During a review of facility's P&P titled Resident's Refrigerator/Freezer Storage dated 1/10/2024, the P&P indicated (6) All items should be properly covered, dated, and labeled. Food items should have appropriate dates: delivery date-when received; open date-opened containers of PHF.

During a review of Food Code 2017, it indicated 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441 potential for actual harm Based on observation, interview, and record review the facility failed to have a policy regarding the use and Residents Affected - Many storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought

in by family and other visitors beyond one (1) mealtime.

This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 78 of 78 facility residents.

Findings:

During a review of the facility's Policies and Procedures (P&P) titled Food from Outside Sources dated [DATE REDACTED], the P&P indicated Policy: Food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders. Procedure:

1. While it is preferred that families and/or friends do not bring foods or beverages into the facility, it is within resident's rights to allow the resident to eat outside food, especially if an individual is eating poorly. If outside food is brought in, the facility is not liable for any food safety and infection control concerns.

2. If a resident, family member, or friend wants to bring the resident an outside food or beverage, the resident, family member, or friend should talk with the charge nurse and or Dietary Services Supervisor and or food service manager to determine if the outside food or beverage is within the resident's prescribed diet.

3. The charge nurse must be notified if any outside food or beverage is brought in. It is recommended that only enough food/beverage be brought for the visit/meal with the resident. The staff will discard any leftovers.

During concurrent interview with the Registered Dietitian (RD) and facility document review of the food from

the outside sources policy on [DATE REDACTED] at 8:55 a.m., the RD stated they tell the residents that they could bring food from the outside though it was not recommended for them due to food safety. The RD stated they label, date, and put the food from the outside in the resident's refrigerator. The RD stated they only keep the food for 72 hours and discard the rest of the food. The RD stated the residents might not comply with the policy if food that were not expired were thrown away and it could cause them to get upset. The RD stated the policy did not indicate safe food storage guidelines.

During concurrent interview with the Director of Nursing (DON) and facility food from the outside sources policy review on [DATE REDACTED] at 9:10 a.m., the DON stated their policy regarding food from home were as follows:

1. Staff checked what was type of food families/friends are bringing in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0813 2. They encourage the family to bring food just enough for the day. However, it was important to have food from home because the residents miss their home cooked foods. Level of Harm - Minimal harm or potential for actual harm The DON stated the food from outside sources policy was very general, had no guidance for food storage and needed to be revised as it indicated staff will discard any leftovers. The DON stated she learned from Residents Affected - Many dietary that they could only keep food from outside for 72 hours and the rest would be discarded. The DON stated family and residents would find the foods and could cause emotional change in behavior and weight loss as a potential outcome.

During a review of facility's P&P titled Resident's Refrigerator/Freezer Storage dated [DATE REDACTED], the P&P indicated 5. Leftover food or unused portions of packaged foods should be discarded. No food will be stored beyond 72 hours from received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly Residents Affected - Many by not maintaining the trash area free from trash, plastic utensils, other dirt debris and liquid drippings from

the garbage bin.

This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 78 of 78 facility residents.

Findings:

During a concurrent observation of the dumpster (a large metal trash container designed to be emptied into a truck) area outside of the facility and interview with the Dietary Supervisor (DS) on 7/24/2024 at 8:20 a.m.,

the bottom of the blue dumpster had soiled plastic spoon and fork, trash, and liquid drippings from dumpster.

The DS stated the trash surroundings was not clean.

During a concurrent observation of the trash area and interview with the Maintenance Supervisor (MS) on 7/24/2024 at 8:22 a.m., the MS stated he was the one cleaning the trash area and brought the blower last Saturday to blow away the leaves. The MS stated they do not use water pressure to clean. The MS stated it was important to maintain the cleanliness of the trash's surroundings to prevent the spread of infection. The MS stated he did not know if the garbage area was clean or not clean.

During a concurrent observation of the trash area and interview with the Housekeeping Supervisor (HKS) on 7/24/2024 at 8:30 a.m., the HKS stated he cleaned the trash surroundings this morning but did not get to the bottom of the trash bin. The HKS stated the trash area had trash and liquid drippings. HKS stated they needed to keep the trash surroundings clean for the prevention of spread of infection.

During a record review of the facility's policies and procedures (P&P) titled Waste Control and Disposal dated 1/10/2024, the P&P indicated (6) Outside garbage bin should be kept closed at all times and surrounding area must be kept clean.

During a review of Food Code 2017, it indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

During a review of Food Code 2017, it indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of104 555690 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555690 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

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)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 36943

Residents Affected - Few Based on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) to one of three sampled residents (Resident 68) receiving hospice care by failing to officially designate the facility's staff member responsible for coordinating hospice services in the facility's policy and ensure the facility's licensed staff were aware of the facility's designated coordinator for hospice care.

These failures that the potential to prevent Resident 68 from receiving well-coordinated and comprehensive hospice services.

Cross reference to