Alameda Care Center
ALAMEDA CARE CENTER in BURBANK, CA — inspection on July 26, 2024.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
555690
Form Approved OMB
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
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.
555690
Form Approved OMB
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
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.
555690
Form Approved OMB
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
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.
555690
Form Approved OMB
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
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.
555690
Form Approved OMB
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
During a review of Resident 68's Admission Record, the facility admitted Resident 68 on 6/30/2022 and readmitted on [DATE] with diagnoses including dementia (decline in mental ability severe enough to interfere
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
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.
555690
Form Approved OMB
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
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.
555690
Form Approved OMB
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