Thryve of Burbank

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure unused isolation gowns were not hanging inside the sorting area of the soiled linen room and failed to ensure contaminated material did not cross over the clean area in the laundry room in an effort to prevent spread of infection. These failures affected 2 (R6 and R7) residents reviewed for infection control and have the potential to affect all the 123 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily staffing posting was completed appropriately. This failure has the potential to affect all the 123 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Fall Guideline Policy when the admitting nurse failed to complete the Fall Risk Evaluation upon a resident's admission into the facility. This affected 1 (R1) resident of 3 reviewed for accidents. R1 is a [AGE] year-old female admitted to the facility on facility 6/5/2025 at 12:30PM and discharged date on 6/6/2025 at 3:36PM. R1's medical diagnosis are, but are not limited to, Chronic Obstructive Pulmonary Disease with acute exacerbation, acute respiratory failure with hypercapnia, type 2 diabetes mellitus, unspecified asthma with acute exacerbation, epilepsy with status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal electroencephalogram, other supraventricular tachycardia, hypertension. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision and assistance during care in accordance with their assessed needs and care plans. This failure applied to two (R1 and R2) of three residents reviewed for accidents. These failures resulted in falls while being provided care that required emergent hospital transfer. R2 required three staples for the laceration to the left scalp and R2 also had a left shoulder contusion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their employee handbook on cell phone usage by having a staff member take a personal phone call while providing care to a resident. This failure affected 1 (R1) of 3 residents reviewed for resident rights in a total sample of 6.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to maintain the chiller (air conditioner), failed to clean intake vents, failed to document equipment maintenance, and failed to ensure that the chiller was functioning properly. These failures affected 108 residents residing in the facility.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to monitor daily atmospheric temperatures, failed to maintain the atmospheric temperaturerange of 71 to 81F (Fahrenheit), and failed to ensure that the temperature was comfortable for one of eight residents (R6) reviewed for safe/comfortable environment. These failures have the potential to affect 108 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement effective safety interventions, including frequent monitoring, for two dependent, immobile, ventilator-dependent residents at high risk for falls to prevent them from falling out of bed. This failure affected two of three residents (R1 and R3) reviewed for accidents and safety. As a result, R1 fell from the bed and sustained a C2 fracture.

Inspectors wroteBased on interview and record review the facility failed to implement fall prevention interventions for a resident identified at risk for falls for one (R1) out of three residents reviewed for accidents in a total sample of three residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the written policy and procedure that prohibit and prevent abuse. This deficiency affects all four (R46, R66, R106 and R107) residents in the sample of 23 reviewed for Abuse prevention Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its fall preventive interventions for a resident who is at high risk for falls. The facility failed to implement its policy on investigating and reporting resident's incident. The facility failed to assess accurately a resident who smokes in the facility. This deficiency affects all four (R6, R7, R103 and R106) residents in the sample of 23 reviewed for Resident safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their appropriate extreme high temperature policy and procedures in the facility. This deficiency affects two (R103 and R69) of three residents in the sample of 23 reviewed for Safe and comfortable resident environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility's policy for using Low Air loss mattress regarding bed linens for a resident with skin impairment. This deficiency affects one (R7) of three residents in the sample of 23 reviewed for Prevention of Pressure wounds protocol.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident not having any urine output from the urinary catheter for an entire eight-hour shift. This affected one of three residents (R2) reviewed for physician notification in a total sample of six. This failure resulted in R2 retaining 1,450 mL (milliliters) of urine in the bladder (maximum capacity is [PHONE NUMBER] mL) and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. Findings Include: R2 is a [AGE] year-old with the following diagnosis: quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy. A Nursing note dated 5/18/24 documents R2 refused breakfast and lunch. R2 reported not feeling well vital signs were stable. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess, change, or flush a resident's urinary catheter after the resident did not have any urine output from the catheter for an entire eight-hour shift. This affected one of three residents (R2) reviewed for catheter care in a total sample of six. This failure resulted in R2 retaining 1,450 mL (milliliters) of urine in the bladder (maximum capacity is [PHONE NUMBER] mL) and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. Findings Include: R2 is a [AGE] year-old with the following diagnosis: quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy. A Nursing note dated 5/18/24 documents R2 refused breakfast and lunch. R2 reported not feeling well vital signs were stable. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and treat a post-surgical wound site for 1 of 3 residents (R1) reviewed for wounds in the sample of 9. This failure resulted in R1's wound site becoming infected, requiring a 10-day course of antibiotics, and at least four weeks of wound care treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was seen by the eye doctor as requested by the resident's Power of Attorney (POA) for 1 of 3 residents (R1) reviewed for vision in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was seen by the dentist as requested by the resident's Power of Attorney (POA) for 1 of 3 residents (R1) reviewed for dental in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to implement interventions to monitor a resident with cognitive deficits and impulsive behaviors and failed to utilize assist of two people for bed mobility and repositioning. This affected 3 of 6 (R9, R10, and R16) residents reviewed for safety and fall prevention. This failure resulted in R16 falling, sustaining a laceration requiring 6 staples and having an acute fracture of left proximal humeral with displacement. R10 slid out of bed and developed an open and raised area on her forehead.

Inspectors wroteBased on interviews, observations, and records reviewed the facility failed to follow manufactures recommendation and meet the professional standards of care by failing to secure the air mattress to the bed frame and operate the air mattress according to the patient's weight for 5 of 5 (R9, R10, R12, R14, and R15) residents reviewed with the use of an air mattress.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their catheter care policy to document and maintain an accurate record of urine output for residents with a diagnosis of neurogenic bladder. This affected two of three (R8, R12) residents reviewed for urinary catheter care.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy to assess and clean the gastric tube stoma site for 1 of 3 residents (R11).

Inspectors wroteBased on interview and record review the facility failed to ensure staff was available to meet the turning and repositioning needs for a resident. This affected one of one resident (R10) reviewed adequate staff.

Inspectors wroteA. Based on interview and record review, the facility failed to acknowledge and transcribe hospice orders that were provided for one resident (R299) at the start of hospice care. This failure affected one out of four residents reviewed for receiving hospice care in the facility and led to R299 receiving a hemodialysis treatment after the order for hemodialysis was discontinued; placing R299 at increased risk of hemodynamic instability. This failure led to R299 expiring during hemodialysis treatment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures to prevent falls by not ensuring fall risk assessments were performed quarterly to reassess residents fall intervention needs, failed to not ensure a resident was adequately supervised; failed to not ensure a quadriplegic resident with a history of falling out of bed with two staff providing care received two person assistance when receiving incontinence care; and failed to ensure safety practices were applied for this resident when beginning to fall out of bed. These failures resulted in R28 experiencing a fall and sustaining a head injury and resulted in R58 falling out of bed and sustaining a right leg fracture. The facility failed to provide a resident with needed assistance and the resident subsequently had two falls within an hour time period. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for sanitary food preparation by not ensuring staff wore hairnets properly, not ensuring sanitizer solution in buckets were at the required levels, not ensuring the kitchen ceilings were cleaned properly and free of dust and debris, and not ensuring dishes were cleaned thoroughly, and sanitized after washing. This failure applies to all 95 residents in the facility.

Inspectors wroteBased on observations and record reviews the facility failed to follow their policy and procedures for garbage disposal by not ensuring garbage cans in kitchen area were covered when not in use. This failure applies to all 95 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner. This failure affected seven (R76, R45, R69, R91, R48, R7, and R55) of seven residents reviewed for assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the shower rooms were adequately clean and in proper working order. This failure affected three of three (R71, R56, R72) residents reviewed for environment and has the potential to affect all residents that utilize the shower room in the rehab and cardiac units.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that inhalers are dated when opened in accordance with pharmacy guidelines; and controlled medications are signed and reconciled upon administration. This deficiency affects four (R1, R11, R33 and R91) of five residents reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection prevention policy by failing to adequately wear personal protective equipment for residents who are on transmission-based precautions. The facility also failed to follow their hand washing policy by not ensuring staff practice adequate hand hygiene and disinfect medical equipment when dealing with residents who are on isolation. This failure applied to four (R4, R44, R53, and R350) of four residents reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to administer resident monthly trust fund payments on the same day monthly as previously requested. This failure affects two residents (R72 and R107) out of seven residents reviewed for resident funds.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy regarding discharge planning, failed to initiate a discharge care plan, and failed to conduct a care plan meeting with the resident and their representative. This failure affected one (R76) of two residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff follow their policy and procedure when administering medications through the G-tube. This failure affected one resident (R93) of three residents reviewed for G-tube management.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for psychosocial services by not consistently providing psychosocial services for a resident with a diagnosis of Major Depressive Disorder and exhibiting signs of depression. This failure applies to one resident (R55) reviewed for Behavioral Health Services.

Inspectors wroteBased on observation, interview and record review, the facility failed to adhere to documented food choices during mealtimes and failed to have any menus available to the residents. These failures affected one resident (R76) who was reviewed for choices and effects all 79 residents who receive meals from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure results of previous State inspections were made available to read. This failure affects all 95 residents that reside in the facility and their representatives.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain separate storage for dented cans, failed to test concentration of sanitizer in the dishwashing sink, sanitation buckets, and dish machine, failed to maintain frozen foods in freezer and safe conditions in the freezer, failed to cover and date foods in the cooler, and failed to maintain clean fans in cooler and clean dish area. These failures have the potential 78 residents receiving foods from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy to four of five residents (R16, R17, R80, R83) reviewed for privacy in a sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene in between resident contact, medication preparation and gloving technique affecting seven of eight residents (R3, R40, R43, R49, R86, R89, R291) and failed to clean and disinfect medical equipment (blood pressure and glucometer machines) after use affecting two of eight residents (R3, R40) reviewed for Infection control in sample of 26. On 08/09/2022 at 11:08AM, during medication administration observation, V37 (Licensed Practical Nurse/LPN) was observed checking blood pressure of R86. She went back to medication cart and started preparing medications for another resident without performing hand hygiene. On 08/10/2022 at 8:49AM during medication administration observation, V25 (Licensed Practical Nurse/LPN) was observed coming out of R43's room after giving medication to R43. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat the residents with dignity affecting two of five residents (R16, R80) reviewed for resident rights in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep call lights within reach for three of ten residents (R80, R83, R8) reviewed for accommodation of needs in a sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean and sanitized room after an isolation patient was discharged for 1 of 1 resident (R14) reviewed for providing a safe and homelike environment in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply hand splints on 3 residents (R16, R40, and R80) out of 10 residents observed for hand splints in the sample of 26. Findings Include: 1. On 8/09/2022 at 11:25 AM, R40 was observed by this writer in her room with no hand splint applied to her left hand. R40 said no one came in to apply the hand split. On 8/09/2022 at 11:30 AM, V35 (Licensed Practical Nurse/LPN) observed with surveyor that R40's hand splint was not on and said that R40's splint for her left hand should have been applied either by the restorative aide or the physical therapist. On 08/09/2022 at 1:37 PM, V2 (Director of Nursing/DON) said that the splint should have been applied by either the restorative aide or the physical therapist. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label feeding bag for one of three residents (R80) reviewed for tube feeding in a sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an additional trach tube, one size smaller, was at the bedside for 1 of 1 resident's (R291) reviewed for respiratory care in a sample of 26. Findings Include: On 8/9/2022 at 11:00am, R291 was observed in bed with a mechanical ventilator and no additional trach tubes smaller in size at bedside. On 8/9/2022 at 11:10am, V19 (Licensed Practical Nurse/LPN) said I don't know if it should be an extra trach tube, I'll ask the respiratory therapist to come and check. On 8/9/2022 at 11:20am, V8 (Respiratory Therapist/RT) observed with surveyor, no additional trach tube at bedside. V8 said it should be a smaller trach tube at her bedside for emergency use, I'll put one there now. On 8/9/2022 at 2:00pm, V2 (Director of Nursing/DON) said there should always be a trach tube at the bedside if that's the physician order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to reconcile the controlled drug receipt/record/disposition form for 3 residents (R6, R55, and R74) out of 26 residents observed for controlled drug receipt/record/disposition form.