Health inspection·November 13, 2025

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: 555690 If continuation sheet Page 2 of 6 Printed: 05/15/2026 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 555690 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 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of an employee-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA), the ombudsman (advocates for residents of nursing homes), and local law enforcement for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, when on 11/6/2025 at 3 p.m. Activities Assistant (AA) 1 alleged Certified Nursing Assistant (CNA) 1 pushed Resident 1.This deficient practice increased Resident 1's risk for further abuse, which could have led to additional unreported incidents and failure to protect other residents from potential harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 9/12/2025, the Fall Risk Evaluation indicated Resident 1's fall risk score was 16 (a total score of 10 or greater, the resident should be considered at high risk for potential falls). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand a resident's health by combining medical history and physical examination), dated 9/13/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/17/2025, the MDS indicated Resident 1 sometimes understood and was sometimes understood. The MDS indicated Resident 1 was dependent (helper does all the effort) for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's condition) assessment dated [DATE] at 4:27 p.m., the COC Assessment indicated Resident 1 had a fall from the wheelchair at around 3 p.m., after CNA 1 brought Resident 1, in a wheelchair, to the big dining room and placed Resident 1 by the area near the TV. The COC Assessment indicated CNA 1 quickly went to clock out and when CNA 1 returned she saw Resident 1 on the floor. The COC Assessment indicated that within two to three seconds after CNA 1 placed Resident 1 in the dining room, Resident 1 quickly stood up from the wheelchair and landed on her (Resident 1) right side without hitting her (Resident 1) head. During an interview on 11/13/2025 at 12:08 p.m. with AA 1, AA 1 stated on 11/6/2025 at around 3 p.m. she (AA 1) was in the dining room and heard a commotion then observed Resident 1's wheelchair moving slowly without Resident 1 on it. AA 1 stated Resident 1's wheelchair was moving on its own and Resident 1 was found sitting on the floor in the entrance of the dining room closest to Resident 1's room. AA 1 stated she was not aware of how Resident 1 ended up on the floor.During an interview on 11/13/2025 at 3:03 p.m. with CNA 1, CNA 1 stated on 11/6/2025 at 3 p.m. she (CNA 1) was already leaving and saw Resident 1 going into a room that was not hers (Resident 1). CNA 1 stated she (CNA 1) took Resident 1 into the dining 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 on the floor. CNA 1 stated she (CNA 1) then went home. CNA 1 stated she heard from other staff that AA 1 was going around telling everyone that CNA 1 pushed Resident 1 and that was why Resident 1 fell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555690 If continuation sheet Page 3 of 6 Printed: 05/15/2026 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 555690 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: 555690 If continuation sheet Page 4 of 6 Printed: 05/15/2026 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 555690 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of four sampled residents (Resident 1) when Resident 1 had a fall on 11/6/2025, by failing to: 1. Ensure interventions were developed through a care plan after Resident 1's fall on 11/6/2025. 2. Update Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling).3. Ensure monitoring was provided after Resident 1's fall. These deficient practices had the potential to place Resident 1 at risk for more falls in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 9/12/2025, the Fall Risk Evaluation indicated Resident 1's fall risk score was 16 (a total score of 10 or greater, the resident should be considered at high risk for potential falls).During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand resident's health combining medical history and physical examination), dated 9/13/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 sometimes understood and was sometimes understood. The MDS indicated Resident 1 was dependent (helper does all the effort) for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 1's Electronic Medical Record (EMR- digital collection of medical information about a person that is stored on a computer) on 11/13/2025 at 10:27 a.m., the EMR indicated Resident 1 did not have a Fall Risk Evaluation dated 11/6/2025. During an interview on 11/13/2025 at 12:08 p.m. with Activity Assistant (AA 1), AA 1 stated on 11/6/2025 at 3 p.m. in the dining room she (AA 1) heard a commotion and saw Resident 1's wheelchair moving slowly without Resident 1 on it. AA 1 stated Resident 1's wheelchair was moving on its own and Resident 1 was sitting on the floor in the entrance of the dining room closest to Resident 1's room. AA 1 stated she was not aware of how Resident 1 ended up on the floor. During an interview on 11/13/2025 at 12:47 p.m. with AA 2, AA 2 stated on 11/6/2025 at 3 p.m. AA 2 was in the dining room by the entrance closest to Room A. AA 2 stated she (AA 2) was facing the opposite entrance near Resident 1's room (Room B) and Resident 1 was by the entrance near Resident 1's room. AA 2 stated she (AA 2) saw Certified Nursing Assistant (CNA) 1 brought Resident 1 into the dining room. AA 2 stated Resident 1 got up and turned quickly on her own and fell on Resident 1's left side. During an interview on 11/13/2025 at 3:03 p.m. with CNA 1, CNA 1 stated on 11/6/2025 at 3 p.m. she (CNA 1) was already about to leave the facility and saw Resident 1 going into a room that was not hers (Resident 1). CNA 1 stated she (CNA 1) took Resident 1 into the dining room. CNA 1 stated she (CNA 1) left Resident 1 at 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 in the dining room to join any activities. The DSD stated CNA 1 left Resident 1 in the dining room by doorway then CNA 1 clocked out and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555690 If continuation sheet Page 5 of 6 Printed: 05/15/2026 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 555690 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: 555690 If continuation sheet Page 6 of 6