Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Burbank during CMS and state inspections, most recent first.
The facility failed to ensure that all food served to residents was obtained from approved or contracted sources. The Food Service Director, responsible for ordering food, reported that when running low on certain items such as canned green beans and fruit mix, she brought cases of canned goods from her personal pantry, which was not a contracted provider, and used them in resident meal preparation without creating delivery invoices or informing the Administrator. The Administrator confirmed that facility practice was to use only contracted food providers and that there was no formal policy for kitchen food procurement, while the facility’s menu showed green beans scheduled on multiple days corresponding to items brought from the personal pantry.
Two residents sustained serious injuries due to staff not following established care plans for transfers and supervision. One resident, requiring a two-person assist and mechanical lift, was transferred by a single CNA and suffered a leg laceration. Another resident, needing substantial assistance with bed mobility, was left briefly unattended and fell while reaching for personal items, resulting in an intraparenchymal hematoma. In both cases, staff did not adhere to required safety protocols, leading to these incidents.
A resident with multiple diagnoses, including paraplegia and dementia, fell from bed due to inadequate assistance during repositioning. Despite needing two-person assistance, the care plan ambiguously stated 1-2 staff as needed. The fall prevention program was not effectively implemented, leading to the resident's injuries.
A resident with multiple health conditions reported being pushed out of bed by a CNA during a diaper change, resulting in a head injury. The facility's records inaccurately documented the fall as unwitnessed and due to the resident's confusion. Staff interviews revealed inconsistencies, and external records supported the resident's account.
A resident in an LTC facility fell and sustained a head injury requiring nine sutures due to inadequate assistance during ADL care. The resident, who needed substantial assistance with bed mobility, was being cared for by a single CNA instead of the required two-person assist. The air mattress, set on static mode, contributed to the fall. The care plan did not reflect the need for a two-person assist, highlighting a lapse in safety measures.
A resident with a history of hemiplegia, Parkinson's disease, and neurocognitive disorder developed an unstageable pressure ulcer on the sacrum due to the facility's failure to identify, assess, and implement timely interventions. Despite being at risk for pressure ulcers, the resident's open area was not documented or addressed promptly, leading to the development of the ulcer. The wound care nurse was not present daily, and the facility's protocol for skin assessments and wound care was not adequately followed.
The facility failed to conduct timely background checks for eight residents and seven employees, contrary to its policies. Background checks for residents were delayed by 5 to 29 days post-admission, and there was no documentation of pre-employment screenings for employees. This deficiency potentially affects the safety of all 55 residents.
The facility did not comply with its food safety and sanitation policies, as staff failed to wear hair restraints in the kitchen, and expired food items were not discarded. Personal items were found on food prep tables, violating the facility's HACCP policy. These issues affected all 55 residents.
The facility did not follow its policy for sanitary food prep conditions, as observed by a surveyor who noted gnats and an uncovered garbage bin near the food prep area. This deficiency impacts all 55 residents.
A resident with severe cognitive impairment and a history of falls fell from a wheelchair while being transported by a CNA, resulting in a head injury. The resident, who is dependent on staff for mobility, became agitated and slid out of the wheelchair. Despite being identified as a high fall risk, the facility's interventions were insufficient to prevent the fall, highlighting a deficiency in ensuring safe transportation.
A resident with multiple diagnoses, including dementia and major depressive disorder, was administered Lexapro without proper informed consent. The consent form inaccurately documented the dosage, which was acknowledged as a clerical error by the DON. The facility's policy requires informed consent for psychotropic medications, which was not followed in this instance.
The facility failed to provide routine dental services to three residents, leading to a deficiency in care. A resident with chronic conditions was observed with missing and discolored teeth, with no dental services documented for over a year. Another resident with multiple health issues had heavy tartar buildup and abnormal teeth appearance, with no record of dental care since admission. A third resident with Alzheimer's and other conditions also showed signs of poor dental care. The DON and Social Services Director acknowledged the oversight.
Unapproved Food Sources Used in Resident Meal Preparation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all food served to residents was procured from approved or satisfactory sources in accordance with professional standards. The Food Service Director, who had been employed since August 2025 and was responsible for ordering food, reported that during times when she was running low on certain items, she would take canned goods such as green beans and fruit mix from her personal pantry, which she co-owned with her husband as part of a food pantry operation, and bring them to the facility kitchen for use in resident meal preparation. She stated she had done this on at least two occasions, bringing two or three cases of twenty-four small cans of green beans each time, and had prepared and served these items as part of resident meals, most recently about a week prior to the interview. She did not create any delivery invoices for these items and did not inform the Administrator that she was using food from her personal pantry. The Administrator confirmed that the facility’s practice was to use food from contracted food providers and that the Food Service Director’s personal pantry was not among the four contracted providers listed in facility documents. At the time of the survey, the Administrator acknowledged there was no policy and procedure in place for kitchen food procurement. The facility’s four-week cycle menu showed green beans scheduled on multiple days, aligning with the items the Food Service Director reported bringing from her personal pantry and serving to residents. This practice resulted in food being served to residents that was not obtained through the facility’s approved or contracted food sources.
Failure to Follow Care Plans for Transfers and Supervision Results in Resident Injuries
Penalty
Summary
The facility failed to implement safety measures as indicated in the care plans for two residents, resulting in significant injuries. One resident, with diagnoses including chronic obstructive pulmonary disease, lumbar radiculopathy, and a need for assistance with personal care, was care planned for dependent transfers requiring two staff members and the use of a mechanical lift. Despite this, the resident was transferred from wheelchair to bed by a single CNA using a stand-pivot method, during which the resident's left leg struck the lever of the bed's halo, causing a laceration that required hospital treatment and sutures. Documentation and staff interviews confirmed that the resident's care plan and transfer requirements were not followed at the time of the incident. Another resident, with a history of moderate intellectual disabilities, lack of coordination, and a history of falls, required substantial assistance with bed mobility and was care planned for assistance by one to two staff as needed. After being transferred into bed by a CNA, the resident was left momentarily unattended while the CNA turned away after providing incontinence care. During this brief period, the resident attempted to reach for personal comfort items and slid out of bed, resulting in a fall and subsequent diagnosis of an intraparenchymal hematoma. The care plan specified that essential and personal items should be kept within reach, but the resident's attempt to access these items led to the fall. In both cases, staff interviews and record reviews indicated that the established care plans and facility protocols for safe transfers and fall prevention were not consistently followed. The incidents were attributed to staff not adhering to the required level of assistance during transfers and not maintaining appropriate supervision during care activities, directly leading to the residents' injuries.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide the required two-person assistance while turning a dependent resident, resulting in the resident falling from the bed and sustaining injuries. The resident, who has multiple diagnoses including paraplegia, dementia, and immobility syndrome, was documented as needing two-person assistance for bed mobility. Despite this, the care plan ambiguously stated assistance of 1-2 staff as needed, which may have contributed to the incident. On the night of the incident, the resident was found on the floor by a CNA during rounds, with a frontal hematoma and laceration on the forehead. The resident was confused and had a history of not using the call light. The fall was unwitnessed, and the resident reported that she was being turned by a staff member when she fell. The facility's documentation and staff interviews revealed inconsistencies in the account of the incident, with some staff unaware of the resident's needs and others confirming the requirement for two-person assistance. The facility's fall prevention program was not effectively implemented, as evidenced by the lack of clear direction in the resident's care plan and the failure to adhere to the two-person assistance requirement. The resident's fall risk assessment indicated a high risk, yet the necessary precautions were not taken. The incident highlights a breakdown in communication and adherence to care protocols, leading to the resident's fall and subsequent injuries.
Inaccurate Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident's fall incident, affecting one of three residents reviewed for record accuracy. The incident involved a resident with multiple diagnoses, including paraplegia, dementia, and immobility syndrome, who was found on the floor with a head injury. The resident reported being pushed out of bed by a CNA during a diaper change, which was corroborated by the fire department and hospital records. However, the facility's records inaccurately documented the fall as unwitnessed and attributed it to the resident's confusion and incontinence. Interviews with staff revealed inconsistencies in the accounts of the fall. A CNA involved in the incident did not recall the resident or the fall, while another CNA reported being informed of the fall by a nurse. The resident, who was alert and oriented to place and self, described the incident as being pushed out of bed, which was not reflected in the facility's investigation records. The Director of Nursing and Regional Nurse Consultant acknowledged the need for further investigation into the discrepancies between the resident's account and the facility's documentation.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to prevent a fall by not providing the required two-person assist with bed mobility during ADL care for a resident. This deficiency resulted in the resident rolling off the bed and sustaining a head injury that required nine sutures. The incident occurred when a CNA was providing a bed bath, and the resident, who was lying on his left side, turned further and fell out of bed. The air mattress, which was on static mode, contributed to the resident being pushed out of bed. The resident involved in the incident had a history of requiring substantial to maximal assistance with bed mobility, as noted in the MDS. The resident was known to have gait imbalance and weakness on the left side, which were predisposing physiological factors. Despite these needs, the care plan did not address the use of a two-person assist with bed mobility or turning and repositioning while using an air mattress. Interviews with staff revealed that the CNA was aware of the need for a two-person assist but was alone during the incident. The Director of Nursing confirmed that the facility's plan was to use two people for turning and repositioning residents using an air mattress. However, this plan was not reflected in the resident's care plan, indicating a lapse in communication and implementation of safety measures.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
The facility failed to identify, assess, and implement interventions to prevent the development of a pressure ulcer for a resident, resulting in the resident developing an unstageable pressure ulcer on the sacral area. The resident, a female with a history of hemiplegia, hemiparesis, Parkinson's disease, and neurocognitive disorder, was at risk for pressure ulcers as indicated by her MDS and Braden score. Despite this, the facility did not document any skin issues until an open area was noted on the sacrum during a shower on August 6, 2024, but there was no corresponding documentation in the progress or wound notes. The wound was later assessed on August 9, 2024, as an unstageable pressure ulcer, and treatment orders were given. The wound care nurse, who was not present daily, was informed of the wound upon her return and notified the wound nurse practitioner. The facility's protocol required CNAs to assess skin during daily care and report issues to nurses, who would then assess and notify the physician. However, there was a lack of documentation and timely intervention following the initial identification of the open area on the sacrum. Interviews with staff revealed that the wound care nurse was not always present, and the responsibility for skin assessments and wound care fell to floor nurses and CNAs. The Director of Nursing was informed of the wound over the phone but was not present at the time of the incident. The facility's policy on pressure ulcer prevention emphasized regular skin inspections, but the lack of documentation and timely response contributed to the deficiency in care for the resident.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its policies regarding background checks for both residents and employees, leading to a deficiency in ensuring the safety and security of its residents. Specifically, the facility did not conduct timely background checks for eight residents, with delays ranging from 5 to 29 days post-admission. These residents had various medical conditions, including Systemic Lupus Erythematosus, heart failure, dementia, hemiplegia, and metabolic encephalopathy. The facility's policy mandates that criminal history and sex offender registry checks be conducted prior to or immediately upon admission, which was not followed. Additionally, the facility did not perform pre-employment screenings for seven employees, including CNAs and housekeeping staff. There was no documentation of checks on the state health agency registry, sex offender websites, or the Department of Corrections prior to their employment. The facility's policy requires these checks to be completed on the day of the interview, which was not done, as confirmed by interviews with the Admissions Director, Administrator, and Receptionist. The facility's policies, including the 'Admission of Identified Offender' and 'Abuse Prevention and Reporting,' clearly outline the procedures for conducting background checks to prevent abuse, neglect, and exploitation. However, the facility failed to implement these procedures effectively, as evidenced by the lack of documentation and delayed checks. This deficiency has the potential to affect all 55 residents currently residing in the facility, compromising their safety and well-being.
Non-compliance with Food Safety and Sanitation Policies
Penalty
Summary
The facility failed to adhere to its policies and procedures for maintaining sanitary conditions in food preparation and storage areas. Observations revealed that staff entering the kitchen did not consistently wear hair restraints, as required by the facility's Hair Restraint Policy. Specifically, a receptionist was seen walking through the kitchen without a hair net on two occasions. Additionally, personal items such as a phone and car keys were found on the food prep table, which is against the facility's HACCP and Foodborne Illness Policy that aims to prevent physical hazards like hair and dirt from contaminating food. Further inspection of the kitchen's food storage practices showed that the facility did not discard food items past their use-by and best-by dates, contrary to their Food Storage Policy. Grilled cheese sandwiches and a milk carton with expired dates were found in the refrigerator, and multiple milk cartons with expired use-by dates were stored in the freezer. These lapses in following established food safety protocols potentially compromised the safety and quality of food served to all 55 residents in the facility.
Failure to Maintain Sanitary Conditions in Food Prep Area
Penalty
Summary
The facility failed to adhere to its policy and procedures for maintaining sanitary conditions in food preparation areas, specifically regarding garbage and waste disposal. During an observation on August 12, 2024, at 9:25 AM, a surveyor noted the presence of gnats in the kitchen and observed a large garbage bin next to the food prep area that was open without a lid when not in use. A subsequent observation at 11:02 AM on the same day confirmed the same issue with the garbage bin being uncovered. The facility's Garbage and Rubbish Disposal Policy, reviewed on August 14, 2024, mandates that all garbage and rubbish containing food waste must be covered when not in immediate use to prevent access by vermin. This deficiency affects all 55 residents in the facility.
Resident Falls from Wheelchair Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safe transportation of a dependent resident, identified as R21, in a wheelchair, which resulted in the resident falling forward and sustaining a head injury. R21, who has severe cognitive impairment and is dependent on staff for mobility, was being wheeled back to his room by a CNA when he became agitated and slid out of the wheelchair, hitting his head on the floor. This incident led to a contusion on R21's forehead, requiring emergent care at a local hospital. R21 has a history of falls and is considered at high risk for falls, as documented in multiple fall risk assessments. The care plan for R21 acknowledges the risk of falls and includes interventions such as placing essential items within reach, assisting with ADLs, and providing supervision. However, during the incident, the CNA was unable to prevent the fall due to the resident's sudden agitated behavior, and it is unclear if leg rests were used during transportation. Interviews with staff, including the DON and CNAs, revealed that R21 is known to be a high fall risk and sometimes exhibits restless or aggressive behavior. Despite this knowledge, the facility's interventions at the time of the incident were insufficient to prevent the fall. The facility's fall prevention program outlines the need for safety interventions for residents at risk, but the incident indicates a lapse in ensuring these measures were effectively implemented during R21's transport.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a psychotropic medication to a resident, identified as R17, who was part of a sample of thirty-seven residents reviewed for unnecessary medications. R17, an elderly resident with diagnoses including dementia, major depressive disorder, schizophrenia, and Alzheimer's disease, was prescribed Lexapro for major depressive disorder. The medication order, dated 05/27/2023, specified a dosage of 0.5 tablet of a 20 mg Lexapro tablet, equating to 10 mg. However, the consent form, dated 05/28/2023, incorrectly documented the dosage as 0.5 mg, which was acknowledged as a clerical error by the Director of Nursing (DON). The DON admitted that the consent form was incorrect and confusing for the nursing staff, as it did not match the actual medication order. Despite recognizing the error, the DON confirmed that no other consents were available for R17 regarding Lexapro. The facility's policy on psychotropic medication and gradual dosage reduction, dated 11/28/12, mandates that informed consent must be obtained before administering such medications. This policy was not adhered to in R17's case, leading to the deficiency noted in the report.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to meet the needs of three residents, leading to a deficiency in dental care. Resident R41, a male with chronic respiratory failure, congestive heart failure, severe protein malnutrition, and chronic kidney disease, was observed with missing and discolored teeth. Despite having a care plan initiated in September 2023 that included coordinating dental care, there was no documentation of dental services from June 2023 to August 2024. A dental consult in June 2024 noted that R41 was not seen by the dentist due to hospitalization. Resident R51, a female with dysphasia, type 2 diabetes, Parkinson's disease, and systemic lupus erythematosus, was observed with heavy tartar buildup and abnormal teeth appearance. Her care plan, initiated upon admission in April 2024, included coordinating dental care, yet there was no record of her being seen by a dental hygienist from April to August 2024. Similarly, R30, a female with chronic respiratory failure, vitamin D deficiency, cerebral ischemia, and early-onset Alzheimer's disease, was observed with missing, discolored teeth and tartar buildup. Her care plan from October 2023 also indicated a need for dental care, but there was no documentation of dental services from June 2023 to August 2024. The Director of Nursing and Social Services Director acknowledged the oversight, noting that residents should be seen by the dental hygienist every three months.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thryve Of Burbank | 1.1 mi | ★★★★★ | 18 | 0 |
| Pavilion Of Bridgeview, The | 1.9 mi | ★★★★★ | 11 | 0 |
| Midway Neurological / Rehab Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Aperion Care Oak Lawn | 2.1 mi | ★★★★★ | 17 | 0 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 2.1 mi | ★★★★★ | 2 | 0 |
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