Burbank Healthcare & Rehab

actions that can be measured.

care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care

quick, minor medical procedure where a doctor uses a dull blade to gently rub or scrape the top layer of skin to collect a small sample).This failure had the potential for delays in the delivery of necessary care and services and could place Resident 5 at risk for scabies (a contagious skin infestation caused by tiny, eight-legged mites called Sarcoptes scabiei).Findings:During a review of Resident 5?s admission Record, the admission Record indicated the facility admitted Resident 5 on 4/17/2026, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), unspecified (unconfirmed) pruritus (an uncomfortable, irritating sensation that makes you want to scratch your skin) and history of fall.During a review of Resident 5's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/20/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 4/22/2026, the COC indicated Resident 5 was placed on contact isolation (a safety measure used in hospitals to prevent the spread of germs that are transferred by touching a patient or items in their room) to rule out scabies.During a review of Resident 5's Order Summary Report, dated 4/23/2026, the Order Summary Report indicated skin scraping.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.

The MDS indicated Resident 5 required moderate assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a concurrent interview and record review on 4/24/2026, at 9:46 a.m., with the Infection Preventionist (IP), Resident 5's Care Plans, were reviewed.

The IP stated there was no care plan developed for Resident 5's skin scraping to test for the presence of scabies.

The IP stated care plan serves as a guide for nurses on what to do when the skin scraping for scabies resulted.

The IP stated without care plan it could potentially spread scabies to other residents.

During an interview on 4/24/2026, at 12:25 p.m. with the Director of Nursing (DON), the DON stated care plan for skin scraping for scabies should have been developed.

The DON stated without a care plan, the nurses will not have a guide on what to do for a suspected scabies resident.

The DON stated there is a potential spread of scabies to other residents, staff and visitors.During a review of facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plans, dated 3/2023, and last reviewed on 2/20/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (it describes how your mind and emotions affect your social life, and how your social situation affects your mental health) and functional needs is developed and implemented for each resident.7.

The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, .c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.10.

When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

056129 04/24/2026

Burbank Healthcare & Rehab 1041 S.

Main St.

Burbank, CA 91506

Summary Report indicated clobetasol propionate external cream 0.05 percent (%-amount in every hundred), apply to general body, topically (directly to a specific surface area of the body, such as the skin) every day and evening for unspecified dermatitis for four weeks.During a review of Resident 5's Treatment Administration Record (TAR- flowsheet that indicates treatment given to a resident), dated 4/2026, the TAR indicated on 4/23/2026, at evening shift, clobetasol was left blank.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.

The MDS indicated Resident 5 required moderate assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a concurrent interview and record review on 4/24/2026, at 9:46 a.m., with the Infection Preventionist (IP), Resident 5's Physician Order, dated 4/22/2026, and TAR, dated 4/23/2026, were reviewed.

The IP stated the physician ordered application of clobetasol twice a day for Resident 5's unspecified dermatitis.

The IP stated the TAR, dated 4/23/2026, evening was left blank.

The IP stated if TAR was blank, it means clobetasol was not given.

The IP stated the nurse did not follow the order.

The IP stated Resident 5's rashes can worsen because clobetasol was not administered.

During an interview on 4/24/2026, at 12:25 p.m., with the Director of Nursing (DON), the DON stated Resident 5's rashes can worsen because clobetasol was not administered.

The DON stated Treatment Nurses (TXN) should apply the clobetasol according to the physician order.During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated 3/2023, and last reviewed on 2/20/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4.

Medications are administered in accordance with prescriber orders, including any required time frame.

056129 04/24/2026

Burbank Healthcare & Rehab 1041 S.

Main St.

Burbank, CA 91506

in accordance with accepted professional standards.

record for one of three sampled residents (Resident 3) by failing to document contact isolation (a

patient or items in their room) monitoring on 4/22/2026, during night shift.This failure had the potential to cause confusion in Resident 3's care and the medical records containing inaccurate documentation.Findings:During a review of Resident 3?s admission Record, the admission Record indicated the facility admitted Resident 3 on 8/15/2024, with diagnoses that included unspecified (unconfirmed) emphysema (a long-term lung condition that causes shortness of breath), unspecified dermatitis (a common condition that causes swelling and irritation of the skin) and history of fall.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/5/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 3's Order Summary Report, dated 4/22/2026, the Order Summary Report indicated contact isolation precaution every shift due to unspecified dermatitis for four weeks until 5/20/2026.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medication given to a resident), dated 4/2026, the MAR indicated on 4/22/2026, at night shift, the contact isolation was left blank.During a concurrent interview and record review on 4/24/2026, at 9:46 a.m., with the Infection Preventionist (IP), Resident 3's Physician Order, and MAR, dated 4/22/2026, were reviewed.

The IP stated the MAR on 4/22/2026, for contact isolation was left blank.

The IP stated blank means the contact isolation was not documented as ongoing.

The IP stated the nurses did not complete their task of documentation.

The IP stated there was no documented evidence that Resident 3 was on contact isolation on 4/22/2026, during night shift and could cause confusion in care.During an interview on 4/24/2026, at 12:25 p.m., with the Director of Nursing (DON), the DON stated without documentation of contact isolation, it could cause spread of scabies to other residents and staff.During a review of facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, and last reviewed on 2/20/2026, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

056129 04/24/2026

Burbank Healthcare & Rehab 1041 S.

Main St.

Burbank, CA 91506

due to weakened immunity, and harbors thousands of mites): .1.

Maintain contact precautions until

free.5.

Bed linens, towels and clothing used by the affected persons during the four days prior to

and gowned laundry staff without sorting, and laundered in hot water for at least 10 minutes.During a review of ACDC- Scabies Prevention and Control Guidelines for Healthcare Settings, dated 2/2026, the ACDC indicated, Place bed linens, towels and clothing used by an affected person during the three days prior to initiation of treatment in plastic bags inside the patient's/resident's room, handled by gloved and gowned HCW without sorting, and washed in hot water.

The hot cycle of the dryer should be used.

Non-washable blankets and articles can be placed in a plastic bag for three to seven days, dry cleaned or tumbled in a hot dryer.