Alameda Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

room. CNA 1 stated she (CNA 1) left Resident 1 in the entrance of the dining room and did not take Resident 1 all the way to the dining room table. CNA 1 stated she (CNA 1) then clocked out and on her (CNA 1) way out CNA 1 saw Resident 1.During an interview on 11/13/2025 at 3:40 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 had a fall in the dining room. The DSD stated CNA 1 was going to clock out and saw Resident 1 in the hallway and placed Resident 1 into the dining room for activities and left Resident 1 in the dining room by doorway then CNA 1 clocked out and while clocking out and passed by dining room saw Resident 1 on the floor. During a concurrent interview and record review on 11/13/2025 at 4:38 p.m., Resident 1's EMR was reviewed with the Director of Nursing (DON). The DON stated on 11/6/2025 at 3 p.m. she (DON) was leaving her office which is located across the dining room when she (DON) saw Resident 1 on the floor on her right side in a fetal position. The DON stated when a fall occurs, staff should create a COC. The DON stated the COC for Resident 1's fall was created only today (11/13/2025). The DON reviewed COC Assessment Form, dated 11/6/2025, and the DON stated it indicated it was created on 11/13/2025 at 10:56 a.m. The DON stated Resident 1's COC should have been done on the same day or it can be an hour later but should be done during the shift and care plan and the rest of the forms can be done the following day. The DON was not able to provide documented evidence the MD and the RR were notified on 11/6/2025. The DON stated not documenting the COC can result to not providing the appropriate interventions and/or not following the plan of care. The DON stated monitoring should be specific to the COC. The DON stated there was no 72 hours monitoring for the fall. The DON stated COC monitoring should be per shift for 72 hours after a new COC and since this was not documented it did not occur. The DON stated the care plans were also not done until today (11/13/2025).

During a review of the facility's Policy and Procedures (P&P) title, Change of Condition, last review date of 1/29/2025, the P&P indicated a change of condition is a sudden or marked difference in resident. All changes of condition in a resident shall be handled promptly. E. Documentation of change in condition shall be performed by the Licensed Nurse accordingly:1. Documentation for at least 72 hours, or longer if condition change warrants.2. Using appropriate form for daily charting.3. Documentation vital sign each shift.4. Care plan evident.8. COC/SBAR will be completed as indicated. During a review of the Facility P&P titled, Incident and Accidents, last review date of 1/29/2025, the P&P indicated charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report. 11.

Nursing assessment and documentation of incident onb. Nurses notes to include:i. complete body checkii. documentation of resident's activities prior to incidentiii. MD notifiediv. MD orders carried outv. Family notified12. Nursing assessment and documentation of incident on:c. care plan entryd. investigation of incident/falle. documentation of conclusion and steps taken to prevent recurrence completed within five (5) days f. in-service as related to incident g. Post Fall Assessment completed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on the floor. CNA 1 stated she (CNA 1) did not push Resident 1 but was told on 11/7/2025 by the Administrator (Adm) that she (CNA 1) was suspended pending investigation because the facility thought it was an alleged abuse. CNA 1 stated she informed the facility that AA 1 was going around telling everyone that she (CNA 1) pushed Resident 1. CNA 1 stated on 11/12/2025 she (CNA 1) was terminated and was told this is what is best. During an interview on 11/13/2025 at 3:40 p.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was suspended by the Adm because CNA 1 placed Resident 1 into the dining room and left Resident 1 in the dining room by the doorway. DSD stated CNA 1 then clocked out and when passing by the dining room saw Resident 1 on the floor. The DSD stated the Adm informed CNA 1 she would be suspended pending investigation because staff were saying CNA 1 had basically pushed Resident 1 into the dining room causing Resident 1 to fall. The DSD stated because it was alleged that Resident 1 was pushed that was why Adm wanted to investigate the allegation of pushing and see what the staff meant by that. The DSD stated AA 1 was the one alleging CNA 1 pushed Resident 1 into

the dining room. The DSD stated pushing, if intentional and aggressive would be considered abuse. During

an interview on 11/13/2025 at 4:22 p.m. with the Adm, the Adm stated the CCTV footage for 11/6/2025 was reviewed but Adm did not keep the footage because the footage gets erased automatically after five days.

The Adm stated on 11/6/2025 at 3 p.m. the footage showed CNA 1 bringing Resident 1 inside the dining room and pushed Resident 1 who was in the wheelchair. The Adm stated CNA 1 was observed leaving to clock out and Resident 1 then stood up and fell. The Adm stated AA 1 said CNA 1 pushed Resident 1. The Adm stated she (Adm) spoke to AA 1 and asked why AA 1 was gossiping saying CNA 1 pushed Resident 1 if AA 1 did not see how Resident 1 fell. The Adm stated AA 1 said she (AA 1) did not see Resident 1 fall.

The Adm stated because AA 1 said CNA 1 pushed Resident 1, CNA 1 was suspended. The Adm stated the allegation from AA 1 that Resident 1 was a pushed is a form of abuse. The Adm stated she (Adm) did not report the alleged abuse because Resident 1 had no injuries. During an interview on 11/13/2025 at 4:45 p.m. with the Adm, the Adm stated she did not keep the video footage because she did not think it was anything like abuse. The Adm stated the word push came up but not sure when we were aware of the word push was being used, AA 1 was heard saying that Resident 1 was pushed, and Adm stated maybe a day or two after was told to her (Adm) that Resident 1 was pushed and no one reported it. The Adm stated this was more of a hearsay. The Adm stated when hearing the word push there is a concern for abuse. The Adm stated any abuse allegations must be reported within 2 hours. The Adm stated this allegation was not reported. The Adm stated it was not reported because no one reported it to us (Adm) directly and it was just a hearsay. During a review of the facility's P&P titled, Abuse & Mistreatment of Residents, last reviewed

on 1/29/2025, the P&P indicated facility shall ensure reporting of all alleged and substantiated violation to

the state agency and all other agencies as required, and take all necessary corrective action based on the results of the investigation. Knowledge of an incident that reasonable appears to be a physical abuse or reasonably suspects abuse, shall be reported the known or suspected instance of abuse by telephone immediately or as soon as practically possible, and by written report sent within two (2) working days, to the local Ombudsmen and the local law enforcement agency shall report any case of known or suspected abuse to the State Department of Health Services. During a review of the Facility P&P titled, Close-Circuit TV's, last reviewed on 1/29/2025, the P&P indicated videotape will be kept for five (5) days and then destroyed unless the video content is needed for legal or other purposes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

while clocking out and passed by dining room saw Resident 1 on the floor. During a concurrent interview and record review on 11/13/2025 at 4:38 p.m., Resident 1's EMR was reviewed with the Director of Nursing (DON). The DON stated on 11/6/2025 at 3 p.m. she (DON) was leaving her office which is located across

the dining room when she (DON) saw Resident 1 on the floor on her right side in a fetal position. During a concurrent interview and record review on 11/13/2025 at 4:38 p.m., Resident 1's EMR was reviewed with

the Director of Nursing (DON). The DON stated on 11/6/2025 at 3 p.m. she (DON) was leaving her office which is located across the dining room when she (DON) saw Resident 1 on the floor on her right side in a fetal position. The DON stated when a fall occurs, staff should create a COC. The DON stated the COC for Resident 1's fall was created only today (11/13/2025). The DON reviewed COC Assessment Form, dated 11/6/2025, and the DON stated it indicated it was created on 11/13/2025 at 10:56 a.m. The DON stated Resident 1's COC should have been done on the same day or it can be an hour later but should be done

during the shift and care plan and the rest of the forms can be done the following day. The DON was not able to provide documented evidence the MD and the RR were notified on 11/6/2025. The DON stated not documenting the COC can result to not providing the appropriate interventions and/or not following the plan of care. The DON stated monitoring should be specific to the COC. The DON stated there was no 72 hours monitoring for the fall. The DON stated COC monitoring should be per shift for 72 hours after a new COC and since this was not documented it did not occur. The DON stated the care plans were also not done until today (11/13/2025). During a review of the facility's policy and procedure (P&P) titled, Incident and Accidents, last reviewed on 1/29/2025, the P&P indicated charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report. 11. Nursing assessment and documentation of incident onb. Nurses notes to include:i. complete body checkii. documentation of resident's activities prior to incidentiii. MD notifiediv. MD orders carried outv. Family notified12. Nursing assessment and documentation of incident on:c. care plan entryd. investigation of incident/falle. documentation of conclusion and steps taken to prevent recurrence completed within five (5) days f. in-service as related to incident g. Post Fall Assessment completed. During a review of the facility's P&P titled, The Resident Care Plan, last reviewed on 1/29/2025, the P&P indicated to provide an individualized nursing care plan and to promote continuity of resident care.

Event ID:

Facility ID:

If continuation sheet