Alameda Care Center

all call lights should be within resident reach for safety and prompt assistance with their needs.

The

indicated a purpose to assure residents receive prompt assistance.

The policy indicated: o All staff shall know how to place a call light for a resident and how to use the call light system. o Ensuring that the call light is within the resident's reach when in his/her room or when on the toilet. o Monitoring the lights and making sure that the lights are answered promptly, regardless of who is assigned to each resident.

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Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

record in a section of the record that is retrievable by any staff. If the resident has executed an AD, or

resident's wishes are communicated to the resident's direct care staff and physician by placing the

A review of the facility policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024, the P&P indicated federal and state law guarantee certain basic rights to all residents of the facility.

These rights include the resident's right to self-determination.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

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 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.

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Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

1/10/2024, indicated retrained individuals shall be reviewed regularly (at least quarterly) to determine

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During a review of the facility's policy and procedure (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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During a review of the facility's Job Description for CNA dated 1/27/2022, it indicated the essential duties and responsibilities include the following but not limited to: Observe resident's skin and documentations and report skin conditions.

Responsible for skin management that includes drying of skin and application of lotions, ointments, etc. ad indicated.

During a review of the facility's policy and procedure (P&P) titled, Physician Orders and Telephone Orders, last reviewed 1/10/2024, the P&P indicated physician orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorized to prescribe for and treat human illness.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During an interview and record review on 7/25/2024 at 1 p.m., with Registered Nurse 2 (RN 2) reviewed Resident 68's Current Vital Sign form, dated 7/5/2024. RN 2 stated the LALM mattress is set according to the resident's weight and if the resident's weight is 77 lbs., then the LALM pump should be set to 100 lbs. RN 2 stated it was important to set the correct weight because the LALM is used for bedridden residents to prevent pressure ulcers. RN 2 stated when Resident 68's LALM was set to over 200 lbs. the LALM was incorrectly set.

During a review of the facility provided LALM 1 Operation Manual, undated, it indicated the LALM 1 is designed for prevention, treatment, and management of pressure ulcers.

Users can adjust air mattress to desired firmness according to the patient's weight or the suggestion from a health care professional.

During a review of the facility policy and procedure (P&P) titled, Pressure-Reducing Mattress, last reviewed 1/10/2024, the P& indicated the objective of the policy was to provide the mattress that will prevent and/or minimize pressure on the skin and to provide comfort if resident prefers.

During a review of the facility policy and procedure titled, Prevention of Pressure Injuries, last reviewed 1/10/2024, the P&P indicated the purpose of the policy was to ensure that all residents will receive the proper care based on their assessment to reduce the risks for pressure injuries.

Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice.

During a review of the facility policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last viewed 1/10/2024, the P&P indicated the facility will assist with wound risk assessment to identify factors to ensure that all residents will receive necessary treatment and services to prevent skin breakdown and promote wound healing.

The facility will implement measures for skin maintenance that may include providing a special device if needed.

The pressure relieving device may include a LALM.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During an observation on 7/25/2024 at 9:17 a.m. with Restorative Nursing Aide 3 (RNA 3) in the

device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 69's waist. RNA 3 held onto Resident 69's hands to assist Resident 69 with transferring from sit to stand. Resident 69 walked down the facility's hallways with RNA 3's HHA.

During an interview on 7/26/2024 at 8:32 a.m. with the Director of Staff Development (DSD), the DSD stated a blank box in the Documentation Survey Report for RNA indicated the treatment was not completed.

During a concurrent interview and record review on 7/26/2024 at 9:27 a.m. with the DSD, Resident 69's Documentation Survey Reports for RNA were reviewed, including 11/2023, 1/2024, 3/2024, and 4/2024.

The DSD stated Resident 69 was not seen for ambulation, three times per week, in accordance with Resident 69's physician orders.

The DSD stated Resident 69 had the potential to decline in mobility without the provision of RNA treatment.

During a review of the facility's undated policy and procedure(P&P) titled, Restorative Nursing Program, the P&P indicated the RNA program maintained the resident's functional ability and reduce further decline.

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Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During an interview on 7/24/2024 at 11:38 a.m. with the Director of Nursing (DON), the DON stated Resident 68's contractures increased Resident 68's risk for injury.

During a concurrent interview and record review on 7/24/2024 at 12:25 p.m. with the DON, Resident 68's MDS was reviewed.

The DON stated Resident 68 was dependent for all activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) including bed/chair-to-bed transfers.

The DON stated Resident 68 should be transferred with two persons - one person carrying the resident's upper body and the second person carrying the lower body.

During an interview on 7/25/2024 at 5:29 p.m. with the DON, the DON stated the facility usually used two persons to physically transfer each resident to different surfaces and did not routinely use a mechanical lift.

The DON stated physically transferring Resident 68, who already had right arm swelling and pain, could potentially increase Resident 68's pain and risk for injury.

During a review of the facility's undated policy and procedure (P&P) titled, Accident/Incident Prevention, the P&P indicated the facility strived to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, identify each resident at risk for accidents/incidents, and provide care plans with procedures to prevent accidents.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During a review of the facility's RNA job description, last reviewed on 1/10/2024, it indicated the RNA performs restorative nursing approaches on residents to assist the resident in reaching their maximum potential mobility.

The RNA duties and responsibilities included range of motion, daily and weekly documentation for residents in the program, assistance with walking and transfers, activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive), placement of restorative devices and equipment such as wheelchairs and walkers, positioning, and restorative feeding program (individualized assistance to residents during mealtimes).

During a concurrent interview and record review on 7/25/2024 at 3:30 p.m. with the Director of Staff Development (DSD), reviewed RNA 1, 2, and 3's employee files:

• RNA 1 was hired on 4/9/2019 and did not have a PE for 2019, 2022 and 2023.

The DSD stated she was responsible for conducting the PE on all RNAs and CNAs and she does not know why the PE's were not done.

• RNA 2 was hired on 4/18/2022 and did not have a PE for 2022 and 2023.

The DSD stated, she must have overlooked it, when asked why the PEs were not completed.

• RNA 3 was hired on 7/4/2015 and did not have a PE for 2015, 2016, 2017, 2019, 2022, and 2023.

The DSD stated that she must have overlooked it and did not get a chance to complete them.

The DSD stated it is important to complete a PE every 12 months to ensure staff knows how to complete their job functions as well as provide the best care for the residents.

During an interview on 7/25/2024 at 6:40 p.m. with the Director Of Nursing (DON), the DON stated PEs must be completed annually to reevaluate staff; if they are still performing the same, as this can possibly lead to mistakes, errors, and failure to provide the correct care.

During a review of the facility's policy and procedure (P&P) titled, Employee Evaluation Policy, last reviewed 1/10/2024, the P&P indicated employees are evaluated annually and as needed based on performance.

Employees who need immediate improvement may be evaluated more frequently.

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Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

minimal harm Certified Nurse Aides

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

During a concurrent interview and record review on 7/25/24 at 9:15am with the Director of Staff

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

destroyed in the presence of two licensed nurses, and the disposal documented on the accountability

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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:

• Excessive dose
• Excessive duration
• 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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

Review of the facility's P&P titled Psychotherapeutic Medications, dated July 2024, the P&P indicated to Evaluate the resident's response to psychotropic medication therapy to determine that the medications are appropriate, and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.

The licensed nurse will assess resident to ensure: D.

Actual behavior with goals and approaches on care plan K.

Attempt Gradual Dose Reduction unless clinically contraindicated, at least twice in first year and yearly thereafter.

L.

System I pace to document explanation of repeated behavior on MAR with notification of physician and reevaluation for intervention.

M.

The pharmacist will complete monthly drug regimen review and give recommendations as indicated and the facility will follow up with the recommendations.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

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 authorized to prescribe.

Each medication is documented in the resident's medical record with the date, time, 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 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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

appearance, and nutritional value.

Procedure: (1) All food will be prepared by methods that preserve

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

the manufacturer determined the use-by date based on food safety.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

learned from dietary that they could only keep food from outside for 72 hours and the rest would be

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

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Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

was.

facility's P&P titled, Hospice Program, was reviewed.

The ADM stated the facility's hospice

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.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

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, proper donning (put on) and donning (take off) of PPEs, types of isolations, and EBP.

The IP stated staff 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 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:

• 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).

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

The maintenance department is responsible for maintaining the buildings grounds, and equipment in a

- Maintaining the building in good repair and free from hazards - Maintaining the heat/cooling system, plumbing fixtures, wiring, etc. in good working order.

555690 07/26/2024

Alameda Care Center 925 W.

Alameda Ave.

Burbank, CA 91506

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.

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.

555690 07/26/2024

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, 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