Health inspection·March 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to notify Medical Doctor (MD) 1 when two of three sampled residents (Resident 1 and Resident 2) had a change of skin condition and itchiness. This deficient practice had the potential to result in delayed medical intervention to Residents 1 and 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), angina pectoris (type of chest pain caused by reduced blood flow to the heart), and dysphagia (difficulty in swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation - a communication and assessment tool), dated 1/14/2025, the SBAR indicated Resident 1 had rashes unspecified but no indication of itching. The SBAR further indicated to keep Resident 1's skin clean and dry and to provide skin care maintenance per physician. During an observation on 3/3/2025, at 9 a.m., Resident 1 was observed lying and moaning in bed while itching her both arms and moving back and forth rubbing her skin against the sheet/mattress in bed. Resident 1's skin rashes were observed as raised, some are open, and red in color. During a review of Resident 1's Nursing-Daily Medicare Notes/Change of Condition, dated 3/3/2025 at 9:33 a.m., the notes documented by Licensed Vocational Nurse (LVN) 1 indicated Resident 1's vital signs were within normal range and was showing no sign and symptoms of distress or discomfort. The nursing note did not mention physician and family notification. During concurrent interview on 3/3/2025, 2025, at 10 a.m., the MDS coordinator (MDS 1) stated she could not find any documented evidence indicating Resident 1's physician was notified of the itchiness and redness of the skin. MDS 1 stated the licensed nurses should have notified Resident 1's physician. Page 1 of 4 555690 555690 03/03/2025 Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

F 0580 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/16/2023 with diagnoses that included Alzheimer's disease (is a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), metabolic encephalopathy (is a change in how your brain works due to an underlying condition), and unspecified dermatitis (skin inflammation or irritation of an unknown or unspecified origin). Residents Affected - Few During a review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was severely impaired. During an observation on 3/3/2025 at 9:45 a.m., Resident 2 was observed sitting at the edge of the bed scratching her neck, chest area, and back. Resident 2 was asked how long she had skin itchiness, she stated it has been weeks. Resident 2 stated the itchiness is so bad at night that it keeps her awake without sleep. Resident 2 stated the facility staff applied some cream, but it does not help. During and interview on 3/3/2025 at 10:45 a.m., LVN 1 stated she did not call the physician to report the changes of condition for both Resident 1 and Resident 2 During an interview on 3/3/2025 at 11 a.m., the Director of Nursing (DON) stated the policy is to report to the physician any change in a resident's condition. The DON was unable to explain as to why the licensed nurses did not call the physicians once they noticed the change of skin condition in Residents 1 and 2. During a telephone interview on 3/3/2025 at 4:03 p.m., MD 1 stated he has not been informed of any residents' changes of condition and that he is planing to stop by at the facility tomorrow to look at all residents with itching and will order skin scraping to rule out scabies (a contagious skin condition caused by tiny mites that burrow under the skin, leading to intense itching and rash). During a review of the facility-provided policy and procedure titled, Change of Condition, reviewed 1/29/2025, indicated, Content: A. ALL CHANGES OF CONDITION IN A RESIDENT SHALL BE HANDLED PROMPTLY C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions. Physician shall be called promptly. 555690 Page 2 of 4 555690 03/03/2025 Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services for two of three sampled residents (Resident 1 and Resident 2) when: Residents Affected - Few 1. Resident 1 had a skin rash and itchiness on bilateral (both) upper and lower extremities (refers to the hands and feet, or parts of the body farthest from the center, like the arms and legs). Medical Doctor (MD) 1 was not informed of the change of Resident 1's skin condition. This deficient practice placed Resident 1 at risk for more skin irritation and delay in provision of care. 2. The facility failed to effectively manage Resident 2's discomfort by not identifying the cause of Resident 2's skin itchiness. Resident 2 stated the itchiness keeps her awake at night because she cannot sleep at night. This deficient practice had the potential for Resident 2 to experience unnecessary discomfort. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), angina pectoris (type of chest pain caused by reduced blood flow to the heart), and dysphagia (difficulty in swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated the resident was severely impaired with his cognitive ((mental action or process of acquiring knowledge and understanding) skills for daily decision-making and required supervision from staff with activities of daily living (ADLs). During a review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation - a communication and assessment tool), dated 1/14/2025, the SBAR indicated Resident 1 had rashes unspecified but no indication of itching. The SBAR further indicated to keep Resident 1's skin clean and dry and to provide skin care maintenance per physician. During an observation on 3/3/2025, at 9:15 a.m., Resident 1 was observed lying and moaning in bed while itching her both arms and moving back and forth rubbing her skin against the sheet/mattress in bed. Resident 1's skin rashes were observed as raised, some are open, and red in color. During an interview at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, LVN 1 stated that she has been doing skin treatment for Resident 1 and that this was the first time she is noticing the raised rashes on Resident 1 skin. LVN 1 was asked if she had reported the change of condition to the Physician, she stated she had not but will be calling MD 1 to inform him of the change in resident's skin condition. During a review of Resident 1's Nursing-Daily Medicare Notes/Change of Condition, dated 3/3/2025 at 9:33 a.m., the notes documented by Licensed Vocational Nurse (LVN) 1 indicated Resident 1's vital signs were within normal range and was showing no sign and symptoms of distress or discomfort. The 555690 Page 3 of 4 555690 03/03/2025 Alameda Care Center 925 W. Alameda Ave. Burbank, CA 91506

F 0684 nursing note did not mention physician and family notification. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/16/2023 with diagnoses that included Alzheimer's disease (is a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), metabolic encephalopathy (is a change in how your brain works due to an underlying condition), and unspecified dermatitis (skin inflammation or irritation of an unknown or unspecified origin). Residents Affected - Few During a review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was severely impaired. During an observation on 3/3/2025 at 9:45 a.m., Resident 2 was observed sitting at the edge of the bed scratching her neck, chest area, and back. Resident 2 was asked how long she had skin itchiness, she stated it has been weeks. Resident 2 stated the itchiness is so bad at night that it keeps her awake without sleep. Resident 2 stated the facility staff applied some cream, but it does not help. During an interview on 3/3/2025, at 10:26 a.m., Registered Nurse (RN) 1 stated there was no documented evidence indicating Resident 1 and Resident 2's physician was notified due to change of skin condition. RN 1 stated the licensed nurses should have notified the physician immediately after they noticed the change of condition. During and interview on 3/3/2025 at 10:45 a.m., LVN 1 stated she did not call MD 1 to report the changes of condition for both Resident 1 and Resident 2 During an interview on 3/3/2025 at 11 a.m., the Director of Nursing (DON) stated the policy is to report to the physician any change in a resident's condition. The DON was unable to explain as to why the licensed nurses did not call the physician once they noticed the changes of skin condition in Residents 1 and 2. During a telephone interview on 3/3/2025 at 4:03 p.m., MD 1 stated he has not been informed of any resident's change of skin condition and that he is planing to stop by at the facility tomorrow to look at all residents with itching and will order skin scraping to rule out scabies (a contagious skin condition caused by tiny mites that burrow under the skin, leading to intense itching and rash). A review of the facility-provided policy and procedure titled, Changes in Resident Condition initiated on January 29,2025 indicated all upon changes in condition for any reason nursing staff members are to During a review of the facility-provided policy and procedure titled, Change of Condition, reviewed 1/29/2025, indicated, Content: A. ALL CHANGES OF CONDITION IN A RESIDENT SHALL BE HANDLED PROMPTLY C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions. Physician shall be called promptly. 555690 Page 4 of 4