Below 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 Thryve Of Burbank during CMS and state inspections, most recent first.
Surveyors found that isolation gowns were being hung in the soiled linen sorting area and that contaminated identification papers from residents’ soiled clothing were carried into the clean laundry area and placed between dryer drums and doors. A laundry aide reported routinely pre-hanging clean gowns in the soiled area for use while sorting dirty linens, and laundry staff described using the same papers taken from soiled clothing bags to track clothing through washing and drying. These practices occurred despite facility policies requiring separation of clean and dirty areas, proper PPE use, and elimination of crossing soiled and clean linen. Two cognitively intact residents on Enhanced Barrier Precautions for ostomy-related conditions were directly involved through the contaminated papers bearing their names and room numbers.
The facility failed to complete daily nurse staffing postings in accordance with its policy and regulatory requirements by not including the current resident census on the postings over a multi-day period. The Staffing Director reported that reception staff are responsible for filling out the daily staffing sheet based on schedules she provides each morning, but review of the forms showed the census section was left blank. The facility’s written policy requires that the daily posting include the facility name, current date, current resident census, and total number and hours worked by RNs, LPNs/LVNs, and CNAs per shift, yet the census information was consistently omitted, potentially affecting all residents in the building.
The facility did not maintain required indoor temperatures of 71–81°F on one wing and in the dialysis room, resulting in multiple areas measuring around 60–63°F over several days. Staff, including the ADON, CNA, and an LPN, reported that the wing was cold and that some rooms lacked proper heat. Temperature logs and on-site readings by the Maintenance Director confirmed substandard temperatures in several rooms and hallways, as well as in the dialysis room where residents were observed wrapped in multiple blankets. Several residents receiving dialysis reported that the room was very cold, causing discomfort and body pain, and one resident stated they had to use two blankets to cover their body and head due to the lack of heat.
A resident with multiple comorbidities, including COPD, DM2, epilepsy, history of falls, lack of coordination, and altered mental status, was admitted and experienced two falls during a brief stay. The facility’s Fall Guideline Policy requires a fall risk evaluation on admission, but the admitting LPN did not complete this assessment, and the DON and Restorative Director confirmed no admission fall risk score was present. Incident reports documented one fall when the resident attempted to go to the bathroom without using the call light and another unwitnessed fall from a wheelchair while reaching for a phone, after which a later fall risk observation classified the resident as high risk for falls.
Two residents with significant cognitive and functional impairments, both care-planned and assessed via MDS as requiring two-person assistance for bed mobility and personal care, experienced falls during care when CNAs provided assistance alone instead of using the required two-person assist. In one case, a resident with morbid obesity, COPD, dementia, and dependence for ADLs slid from the bed to the floor during evening care provided by a single CNA, later becoming unresponsive and requiring EMS and CPR. In the other case, a ventilator-dependent resident with hypoxic ischemic encephalopathy and severe decision-making impairment slid from the edge of the bed to the floor during peri-care performed by one CNA, sustaining a scalp laceration that required staples and a shoulder contusion, and was transferred to the hospital. Nursing staff and leadership acknowledged that both residents should have had two-person assistance during care, but this was not followed at the time of the incidents.
A staff member failed to follow facility policy by taking a personal phone call while providing care to a resident dependent on staff for lower body care due to paraplegia and other medical conditions. The incident was observed by an LPN, who instructed the CNA to stop using her phone and reported the event to nursing leadership. The CNA admitted to using her phone and air pods during care, and documentation confirmed a formal warning was issued for unauthorized device use.
The facility did not follow its preventive maintenance policy for the chiller system, resulting in repeated equipment shutdowns due to debris and low water flow. Intake vents were found dirty, and no documentation of maintenance activities was available, despite staff claims of regular filter changes and chemical treatments. These failures led to the use of portable AC units and building temperatures exceeding 80°F, affecting all residents.
The facility did not consistently monitor or document daily temperatures, resulting in multiple days without records and prolonged periods where temperatures exceeded the required 71–81°F range. Malfunctions in the cooling system led to hot and humid conditions throughout the building, with staff and a resident reporting discomfort and the use of portable AC units and fans to address the issue. These failures affected the comfort and safety of all residents.
Two ventilator-dependent residents with severe cognitive impairments fell out of bed due to inadequate safety interventions in a facility. Despite being high fall risks, the facility lacked measures like floor mats and low beds. Both residents were on air mattresses, which contributed to movement during coughing episodes, leading to falls. The facility's failure to provide a hazard-free environment and adequate supervision resulted in these incidents.
A resident with multiple diagnoses and a high fall risk score was found on the floor after an unwitnessed fall in the facility. The care plan lacked fall prevention interventions, and the resident's call light was not activated. Staff did not observe any behaviors indicating a fall risk, but the resident's bedside table was not within reach, potentially contributing to the fall. The facility's fall prevention guidelines were not adequately followed.
The facility failed to implement its abuse prevention policies, affecting four residents identified as offenders. Care plans were not developed for these residents, and abuse/neglect screenings were incomplete upon admission. The Social Service Director was unaware of the requirement to create care plans for identified offenders, despite facility policy. The Director of Nursing and Administrator were informed of these deficiencies.
The facility failed to implement fall prevention measures for two high-risk residents, did not investigate or report a resident's injury, and inaccurately assessed a resident's smoking habits. Observations showed non-compliance with care plans for fall precautions, lack of documentation for an injury, and incorrect smoking assessments, indicating a breach of facility policies.
A facility failed to follow its policy for using Low Air Loss (LAL) mattresses, leading to a deficiency in pressure ulcer care for a resident with skin impairment. The resident, who had multiple diagnoses and a history of pressure ulcers, was observed with multiple layers of linen on the LAL mattress, contrary to the policy that allows only a flat sheet. The DON confirmed the policy breach and instructed the LPN to correct the issue.
The facility failed to implement its extreme high temperature policy, affecting residents' safety and comfort. A resident with multiple health conditions experienced discomfort due to a malfunctioning air conditioner, with room temperatures recorded at 84°F. The facility did not document temperature and humidity readings as required, nor did it monitor residents' fluid intake or signs of heat-related symptoms. Another resident reported feeling unwell due to a non-functioning air conditioner, with ongoing air conditioning issues since May.
A facility failed to notify a physician about a resident's lack of urine output from a urinary catheter, leading to the resident retaining 1,450 mL of urine and requiring hospital treatment for a urinary tract infection and acute kidney injury. Despite staff noticing the issue, the catheter was not changed before the resident was sent to the hospital.
A facility failed to assess, change, or flush a resident's urinary catheter after no urine output for an entire shift, leading to the resident retaining 1,450 mL of urine and requiring hospitalization for a urinary tract infection and acute kidney injury. The catheter was not changed or flushed despite orders, and staff interviews confirmed the catheter should have been addressed.
A facility failed to identify, assess, and treat a post-surgical wound site for a resident with a tracheostomy, leading to an infection that required a 10-day course of antibiotics and four weeks of wound care treatment. The embedded suture was not initially identified during daily trachea care, resulting in delayed treatment.
A facility failed to ensure a resident was seen by an eye doctor as requested by the POA. Despite multiple requests during care plan meetings, the resident's eye doctor visit was delayed. The resident was eventually diagnosed with presbyopia and given a prescription for glasses. The facility lacks a policy on vision services but expects residents to be seen upon physician's order or request.
A facility failed to ensure a resident was seen by the dentist as requested by the POA. Despite requests during two care plan meetings, the resident was only seen by the dentist after the second meeting. The resident's dental consult revealed moderate plaque and staining, mildly dry mouth, puffy tissue, and mild thrush. The facility's policy indicates that oral health services should be available to meet residents' needs, but the resident only had one dental exam since admission.
Improper Laundry Practices and PPE Handling Breach Infection Control Standards
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices within the laundry and soiled linen areas. Surveyors observed two yellow disposable isolation gowns hanging in the sorting area of the soiled linen room on multiple days. A laundry aide reported that she routinely prepared unused isolation gowns by hanging them in the sorting area so she could don one while sorting dirty linens, discard it, and then use the second gown later if she needed to sort soiled linens again. She stated this had been her practice for 38 years. The DON stated that the expectation was not to prepare and hang clean isolation gowns in the soiled linen sorting area, as this could contaminate the gowns and the aide’s uniform and potentially cross-contaminate the clean area of the laundry room. Surveyors also observed contaminated materials crossing from the dirty area to the clean area of the laundry room. Papers containing residents’ names and room numbers, originally taken from soiled clothing bags, were found stuck between the drum and door of dryers in the clean area. Laundry staff, including a laundry aide and the housekeeping/laundry supervisor, acknowledged that they had been using this practice to identify residents’ clothing after washing and drying. One aide described removing the paper from the resident’s soiled clothing bag, placing it on top of the washer while the clothes were washed, and then placing the same paper between the drum and door of the dryer to keep track of the clothing. Staff acknowledged that they did not know what contaminants might be present on residents’ clothing and that bringing these papers into the clean area could cause cross-contamination. These practices occurred despite existing facility policies and job descriptions that addressed infection control and laundry handling. The Linen/Laundry Handling guideline required use of appropriate PPE when handling contaminated linen and promoted infection control through standard precautions. The PPE policy defined gowns as protective barriers to prevent contamination of clothing and skin from potentially infectious materials. The laundry aide job description required labeling laundry per facility procedures, eliminating crossing of soiled and clean linen, maintaining a clean work area, and following proper infection control practices. Two cognitively intact residents on Enhanced Barrier Precautions due to colostomy or ileostomy status were specifically identified through the contaminated papers used for laundry identification, and the DON and administrator both stated that contaminated materials from the dirty area should not cross into the clean area to prevent cross-contamination, with the potential to affect all residents in the facility.
Failure to Include Resident Census on Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the required daily nurse staffing information postings were completed appropriately, specifically by omitting the daily resident census. Review of the midnight census report for 04/13/2026 showed there were 123 residents in the facility, but the Daily Staffing postings from 04/01/2026 through 04/13/2026 did not include the daily resident census. During an interview on 04/13/2026 at 2:41 p.m., the Staffing Director stated that reception staff are responsible for filling out the Daily Staffing Posting and that she provides the daily schedule to the receptionist each morning between 6:30 a.m. and 8:00 a.m. When presented with the Daily Staffing Posting forms for 04/01/2026–04/13/2026, the Staffing Director acknowledged that the resident census section was not completed and confirmed that regulations require inclusion of the resident census and that the posting should be fully completed daily. The facility’s written Nurse Staffing Posting Information policy dated 1/2/2026 requires that the daily posting include the facility’s current resident census along with other staffing details, which was not followed during the reviewed period. This deficiency had the potential to affect all 123 residents in the facility, as the incomplete postings did not reflect the required census information as outlined in the facility’s own policy and regulatory expectations.
Failure to Maintain Required Indoor Temperatures on One Wing and in Dialysis Room
Penalty
Summary
The facility failed to maintain indoor temperatures within its policy range of 71–81°F, resulting in prolonged cold conditions on the XXX complex wing and in the dialysis room. During unit rounds, surveyors observed residents in the XXX complex hallway wearing multiple layers of clothing, hoodies, and zipped jackets, and staff, including the ADON, also wearing zipped sweaters and commenting that the hallway was cold. The Maintenance Director reported that the heating system on the XXX wing had been worked on in late November, which restored heat only to rooms on one side of the wing (odd-numbered rooms), while rooms on the opposite side (even-numbered rooms) continued to have heating issues. A CNA and an LPN both stated that the XXX wing was cold and that some resident rooms did not have proper heating. Temperature logs reviewed by surveyors showed multiple documented readings well below the facility’s required range, including temperatures of 63.9°F near one resident’s room, 62.1°F near another’s room, 63.2°F near a third resident’s room, and 60.1°F near two other residents’ rooms on various early-morning dates. On-site temperature checks by the Maintenance Director and surveyor in the XXX hallway and in specific resident rooms showed readings between 61.9°F and 62.2°F, which the Maintenance Director acknowledged were unacceptable and below the policy standard. In the dialysis room on the XXX complex wing, residents receiving dialysis were observed wrapped in multiple blankets, and the room temperature measured 62.2°F. Residents who received dialysis reported that the dialysis room was cold; one resident stated the cold made her body hurt and was very uncomfortable, another said it was so cold it made them angry, and another reported taking two blankets and covering their body and head because there was no heat in the dialysis room.
Failure to Complete Admission Fall Risk Evaluation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Guideline Policy by not completing a Fall Risk Evaluation upon admission for a newly admitted resident. The resident, an older female with multiple diagnoses including COPD with acute exacerbation, acute respiratory failure with hypercapnia, type 2 diabetes mellitus, asthma with acute exacerbation, epilepsy with status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal EEG, supraventricular tachycardia, and hypertension, was admitted on 6/5/2025 and discharged on 6/6/2025. The facility’s policy, revised 8/2024, requires that a fall risk evaluation be completed upon admission, quarterly, annually, and with significant change in condition, and that if the evaluation finds the resident at risk, resident-specific interventions and precautions are implemented. The Restorative Director, the admitting LPN, and the DON all confirmed through interview that the admitting nurse is responsible for completing the initial fall risk assessment on the day of admission and that no such assessment was found for this resident on the admission date. During the resident’s short stay, two falls were documented. On 6/5/2025 at 3:15 PM, an incident report completed by the admitting LPN documented that the resident was found sitting on the floor in her room after stating she needed to go to the bathroom and had not used the call light because she forgot and urgently needed to use the bathroom. On 6/6/2025 at 1:00 PM, another incident report documented that the resident was observed on the floor after an unwitnessed fall, with a knot noted on the left side of the head and no active bleeding; the resident reported she had been sitting in her wheelchair, reached down to grab her phone, and lost her balance. A Fall Risk Observation completed later on 6/6/2025 at 2:56 PM categorized the resident as high risk for falls with a score of 13. Staff interviews confirmed that the initial fall risk evaluation, which should have been completed upon admission, was not done, and that failure to complete this assessment places a resident at risk of falling.
Failure to Follow Two-Person Assist Requirements During Care Resulting in Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care in accordance with residents’ assessed needs and care plans, resulting in falls for two residents. The first resident (R1), an older adult with morbid obesity, lack of coordination, COPD, dementia, and hypertension, had an MDS dated 09/15/2025 indicating moderate cognitive impairment (BIMS 10/15) and dependence on staff for toileting hygiene, rolling, showering, dressing, and bed mobility, requiring the assistance of two or more helpers. On the evening of the incident, a CNA (V8) provided routine evening care to R1 alone, positioning the resident on her side. During this care, V8 observed R1’s leg moving downward and R1 sliding toward the edge of the bed, ultimately sliding to the floor into a seated position while holding the side rail. Following the fall, an LPN (V4) responded to the room after being called and found R1 on the floor, not very responsive. V4 instructed one nursing assistant to call 911 and another to call the supervisor, assessed R1 on the floor and again after R1 was assisted back to bed with a mechanical lift, and noted that R1’s vital signs were lower than initially but that R1 was still breathing. EMS arrived, and when V4 returned to the room after printing paperwork, paramedics had initiated CPR, which V4 estimated lasted about 20 minutes before R1 was pronounced deceased. R1’s roommate recalled that staff helped R1 right away after the fall, and a family member reported having spoken with R1 earlier that evening while staff were in the room assisting, later being called to the facility after the event. The family member stated that R1 fell because only one CNA provided care when two were required and expressed questions about how R1 was assessed and when CPR was initiated. The facility was awaiting the coroner’s report, and the relationship between the fall and R1’s death could not be determined at the time of review. The second resident (R2), an older adult with hypoxic ischemic encephalopathy, respiratory failure on a ventilator/tracheostomy, acute embolism and thrombosis of the femoral vein, thoracic aortic aneurysm, bowel and bladder incontinence, and receiving enteral nutrition, had an MDS indicating severely impaired decision-making and dependence on staff for toileting hygiene, rolling, showering, oral care, dressing, and bed mobility, requiring the assistance of two or more helpers. During rounds, a CNA (V13) provided peri-care to R2 alone, with R2 positioned at the edge of the bed. V13 reported that when turning R2, the resident slid out of bed toward the door, despite the care plan requiring two-person assistance; V13 stated that R2 required two-person assist but that she believed she could handle the care by herself and had been doing so. Nursing notes by an RN (V12) documented that R2 was found lying on his back on the floor next to the bed with a laceration to the left scalp with active bleeding and a scratch on the left side of the neck. R2 was treated at the facility for bleeding control and then transferred via 911 to a local hospital, where records showed a scalp laceration requiring three staples and a left shoulder contusion. The Restorative Director and the DON acknowledged that both R1 and R2 required two-person assistance during care based on MDS assessments, but each was being cared for by a single CNA at the time of their falls, contrary to their care plans and the facility’s fall prevention policy.
Staff Cell Phone Use During Resident Care
Penalty
Summary
A staff member failed to follow the facility's employee handbook regarding cell phone usage by taking a personal phone call while providing care to a resident. The incident occurred during a shower provided to a male resident with paraplegia, diabetes mellitus type 2, convulsions, hypertension, cervical spinal cord injury, and colostomy status. The resident, who is cognitively intact and dependent on staff for lower body care, reported that the Certified Nursing Assistant (CNA) used her cell phone, including FaceTime, during his shower. The resident did not report the incident to management due to anxiety and fear of triggering seizures, but did inform a family member. A Licensed Practical Nurse (LPN) working that day confirmed observing the CNA using her personal phone and air pods while providing care to the resident. The LPN instructed the CNA to stop using her phone during patient care and reported the incident to the assistant director of nursing the following day. The CNA admitted to receiving an emergency personal phone call during the resident's shower, apologized to the resident, and acknowledged that she should not have been using her phone or air pods during patient care. The CNA denied being on FaceTime but confirmed the phone call was answered through her air pods. The Director of Nursing (DON) and the facility administrator both stated that staff are regularly informed not to use personal phones in resident areas and that staff are expected to step out of resident areas to answer personal calls. The facility's employee handbook prohibits the use of devices that obstruct or restrict hearing during working time, except for management-authorized use. Documentation confirmed that the CNA received a formal warning for unauthorized use of electronic devices on the unit during working hours.
Failure to Maintain and Document Chiller Maintenance Leads to Unsafe Temperatures
Penalty
Summary
The facility failed to maintain essential equipment, specifically the chiller (air conditioning system), in accordance with its own policies and procedures. Surveyors observed that the chiller, which was installed the previous year, repeatedly shut down due to low water flow caused by dirt and debris accumulation. Maintenance staff reported that the water filter and strainer were frequently clogged with rust-colored debris and other materials, resulting in the chiller shutting off multiple times during the inspection. Intake vents throughout the facility were also found to be completely covered in dust, debris, and cottonwood remnants. Despite the maintenance staff's efforts to clean and restart the chiller, the system continued to experience operational issues, and portable AC units were in use while building temperatures remained above 80°F. Additionally, the facility failed to document any maintenance activities related to the chiller, despite staff stating that filters were changed weekly and chemicals were added monthly as part of regular maintenance. When asked, the Maintenance Director admitted to not having any records of chiller maintenance. The facility's preventive maintenance policy requires the maintenance department to maintain a preventive maintenance program and document equipment work orders and repairs, but this was not followed. These failures affected all 108 residents in the facility at the time of the survey.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not following its own policies and procedures regarding atmospheric temperature monitoring and control. Observations and interviews revealed that the facility did not consistently monitor and document daily temperatures, particularly on weekends when maintenance staff were not present, resulting in multiple undocumented days. On several occasions, the building's temperature exceeded the required range of 71 to 81°F, with readings as high as 84.3°F in various areas, and staff and residents reported the environment as warm, humid, and uncomfortable. The facility's chiller, which is responsible for cooling, experienced repeated malfunctions, including being shut down for cleaning and tripping due to low water flow and heat sensor issues. During these periods, the temperature in resident rooms and common areas rose above the acceptable threshold, and portable AC units and fans were used in an attempt to mitigate the heat. Despite these efforts, temperatures remained elevated, and the environment was described as hot and humid by both staff and residents. One resident specifically reported opening a window for ventilation due to the heat, and others in activity rooms and halls were exposed to temperatures above 80°F. Facility guidelines required daily temperature and humidity monitoring and immediate implementation of high temperature procedures if the temperature index exceeded 80°F. However, the lack of consistent monitoring, incomplete documentation, and delayed response to equipment failures led to prolonged periods where the environment was not maintained within the required comfort and safety parameters. These failures had the potential to affect all 108 residents in the facility.
Failure to Implement Effective Fall Prevention for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to implement effective safety interventions for two dependent, immobile, ventilator-dependent residents at high risk for falls, leading to incidents where both residents fell out of bed. Resident 1, who has severe cognitive impairment and is dependent on staff for all activities of daily living, fell from her bed and sustained a C2 fracture. Despite being identified as a high fall risk, the facility did not have adequate interventions in place to prevent the fall, such as floor mats or low beds, and the resident was found on the floor after a forceful cough and involuntary movements. Resident 3, who also has severe cognitive impairment and is dependent on staff for care, experienced a similar incident where she was found on the floor after a coughing episode. The facility's incident report noted that coughing can trigger involuntary movements, especially in residents who are physically compromised. Despite this, the facility had not implemented sufficient fall prevention measures until after the incident occurred, such as adding bed bolsters. Both residents were on air mattresses, which staff noted could contribute to movement during coughing episodes. The facility's failure to provide an environment free from hazards and adequate supervision, as outlined in their fall prevention guidelines, contributed to these incidents. Staff interviews revealed a lack of awareness and communication regarding the residents' fall risks and the potential for coughing to cause significant movement, leading to the falls.
Failure to Implement Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident identified at risk for falls. The resident, an older individual with multiple diagnoses including respiratory failure and reduced mobility, was admitted to the facility and later found on the floor after an unwitnessed fall. The resident's care plan did not include any fall risk interventions, despite a high fall risk score of 16, indicating a significant oversight in the resident's care management. On the day of the incident, the resident was last seen in bed by a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) before being found on the floor by a respiratory therapist. The CNA reported that the resident was able to move her arms and use the side rails to turn, but could not move her legs. The resident's call light was not activated at the time of the fall, and her bedside table was not within reach, which may have contributed to the fall. The CNA and LPN both noted that the resident did not exhibit any behaviors indicating distress or a fall risk during their shifts. The facility's fall prevention coordinator confirmed that the resident's fall risk assessment lacked necessary interventions, such as ensuring personal items were within reach and regular checks by staff. The facility's fall guidelines emphasize the importance of an interdisciplinary team approach to managing fall risks, which was not adequately implemented in this case. The resident was sent to the hospital following the fall, where she was diagnosed with hyperkalemia and leukocytosis.
Failure to Implement Abuse Prevention Policies for Identified Offenders
Penalty
Summary
The facility failed to implement its written policy and procedure to prohibit and prevent abuse, affecting four residents identified as offenders. During the survey, it was observed that these residents did not have care plans developed as identified offenders, contrary to the facility's policy. The Social Service Director (SSD) admitted to not being aware of the requirement to develop care plans for identified offenders, despite the facility's policy stating that care plans should incorporate security measures for such residents. Additionally, the abuse/neglect screening upon admission was not completed for these residents, with the SSD acknowledging the incomplete documentation. The facility's policy on abuse prevention and identified offenders outlines the need for a resident-sensitive and secure environment, including comprehensive care plans and regular evaluations for identified offenders. However, the survey revealed that the facility did not adhere to these policies, as evidenced by the lack of care plans and incomplete abuse assessments for the residents in question. The Director of Nursing (DON) and the Administrator were informed of these deficiencies, highlighting a systemic failure in implementing the facility's abuse prevention program.
Deficiencies in Fall Prevention, Incident Reporting, and Smoking Assessment
Penalty
Summary
The facility failed to implement fall preventive interventions for residents at high risk for falls. Observations revealed that two residents, both with a history of falls and identified as high risk, did not have their beds in the lowest position as required by their care plans. Additionally, one resident did not have bilateral floor mats as specified. The staff, including an LPN, were unsure of the fall precautions for these residents, indicating a lack of adherence to the facility's fall prevention policy. The facility also failed to investigate and report an incident involving a resident who sustained a reddened and swollen thumb after catching it in a bathroom door. The incident was not documented, and the staff, including the RN and ADON, were unaware of the injury. This lack of documentation and awareness contravenes the facility's policy on reporting and investigating accidents or incidents, which requires immediate reporting and investigation of all incidents, regardless of severity. Furthermore, the facility did not accurately assess a resident who smokes, as the smoking assessment indicated that the resident does not smoke, despite the resident keeping cigarettes and a lighter at the bedside. This oversight suggests a failure to adhere to the facility's policy on smoking assessments, which mandates that all residents desiring to smoke be assessed for safety and that these assessments be reviewed by an interdisciplinary team.
Failure to Follow Low Air Loss Mattress Policy for Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its policy regarding the use of Low Air Loss (LAL) mattresses for a resident with skin impairment, leading to a deficiency in pressure ulcer care. During an observation, it was noted that a resident, who was on a LAL mattress due to pressure ulcers, had multiple layers of linen, including a folded linen used as a draw sheet and a cloth pad, contrary to the facility's policy. The Director of Nursing (DON) confirmed that the resident should only have a flat sheet over the LAL mattress, and instructed the Licensed Practical Nurse (LPN) to inform the Certified Nursing Assistant (CNA) to remove the excess linens. The resident in question was readmitted with several diagnoses, including peripheral arterial disease, bed confinement status, severe morbid obesity, and venous insufficiency, and had a history of pressure ulcers and decreased mobility. The facility's policy, effective since January 2017, specifies that a single non-fitted sheet should be used on LAL mattresses to manage the skin's microclimate. However, the observed practice did not align with these guidelines, as confirmed by the Wound Care Nurse, who stated that the resident should only have two layers, such as an adult brief and a flat sheet or cloth pad, but not both.
Failure to Implement Extreme High Temperature Policy
Penalty
Summary
The facility failed to implement its extreme high temperature policy and procedures, affecting the safety and comfort of residents. On the 2nd floor unit, a surveyor observed warm air and noted that a resident, identified as R103, was experiencing discomfort due to the heat. R103, who has a medical history including hypertension, diabetes mellitus type 2, vascular dementia, chronic pulmonary disease, and anxiety disorder, complained of being unable to sleep and feeling exhausted due to the hot room. The air conditioner in R103's room was malfunctioning, and the room temperature was recorded at 84 degrees Fahrenheit. The facility's Director of Nursing and Maintenance Director were unaware of the situation, and there was no documentation of monitoring R103's fluid intake or signs of heat-related symptoms. The facility's policy on extreme high temperatures requires monitoring of air temperatures and humidity, as well as resident conditions, but these procedures were not followed. The Maintenance Director admitted to not documenting temperature and humidity readings, which are supposed to be taken every two hours during extreme heat. Additionally, the facility's policy mandates that residents be relocated if temperatures exceed 80 degrees Fahrenheit, but this was not done. The surveyor also noted that the dining room temperature was 86.8 degrees Fahrenheit, with residents appearing sleepy and no staff offering water to them. Another resident, R69, also experienced issues with room temperature, which was recorded at 80.6 degrees Fahrenheit. R69 reported feeling unwell, with symptoms of nausea and loss of balance, due to a non-functioning air conditioner. A concerned party mentioned that air conditioning issues had been ongoing since May, and the Administrator confirmed that the Maintenance Director was responsible for documenting temperatures and humidity, which was not done on extreme heat days. The facility's failure to adhere to its own guidelines for managing high temperatures resulted in unsafe and uncomfortable conditions for the residents.
Failure to Notify Physician of Urinary Catheter Issues
Penalty
Summary
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 failure resulted in the resident retaining 1,450 mL of urine in the bladder and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. The resident, who has a history of quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy, reported not feeling well and refused meals, but the physician was not notified of the lack of urine output or the leaking catheter in a timely manner. On the day in question, the nursing staff documented that the urinary catheter was leaking and that the resident was exhibiting confusion. Despite this, the catheter was not changed before the resident was sent to the hospital. Hospital records indicated that the resident had a palpable bladder and elevated kidney levels, confirming a kidney injury. The catheter was found to be completely dry, and upon replacement, a significant amount of urine was drained, indicating that the catheter had not been functioning properly for some time. Interviews with the staff revealed that the CNA had notified the nurse about the leaking catheter, and the nurse had received orders to change it but did not complete the task before the resident was transferred to the hospital. The Director of Nursing and other medical staff confirmed that the expectation was to notify the physician and take immediate action if there was no urine output. The facility's policies on notification of resident change in condition and catheter care were not followed, leading to the resident's severe sepsis and acute kidney injury.
Failure to Assess and Change Urinary Catheter
Penalty
Summary
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 resulted in the resident retaining 1,450 mL of urine in the bladder and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. The resident, who has a history of quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy, reported not feeling well and had stable vital signs initially. However, the urinary catheter was noted to be leaking, and the resident exhibited confusion and low blood pressure, leading to hospitalization via 911 where severe sepsis and acute kidney injury were diagnosed. The catheter was found to be completely dry and was replaced at the hospital, resulting in a significant amount of urine being drained immediately after replacement. The Medication Administration Record (MAR) indicated that the catheter was not changed or flushed despite an order to monitor output every shift and change the catheter for blockage or leaking. Interviews with staff revealed that the catheter was leaking and the resident had no urine output, but the catheter was not changed before the resident was sent to the hospital. The Director of Nursing (DON) and other medical staff confirmed that the catheter should have been flushed or changed if there was no urine output, and failure to do so could lead to severe complications such as kidney issues, bladder rupture, or infection.
Failure to Identify and Treat Post-Surgical Wound
Penalty
Summary
The facility failed to identify, assess, and treat a post-surgical wound site for a resident who had undergone a tracheostomy and PEG tube placement. The resident was admitted to the facility with no documented wounds to the right clavicle/neck area. However, on a later date, redness and an embedded suture were noted by the respiratory therapist, which was not initially identified during daily trachea care. The wound care nurse was informed and subsequently removed the embedded suture, initiated a care plan, and started the resident on antibiotics for the infection. Despite these actions, the resident required a 10-day course of antibiotics and at least four weeks of wound care treatment due to the infection that developed from the untreated embedded suture. The resident's medical records show that the wound care nurse documented the presence of the embedded suture and the infection, and the wound care physician ordered treatments for the wound. The respiratory therapist acknowledged that the suture should have been identified during daily trachea care, and the wound care nurse confirmed that the sutures should have been removed before becoming embedded. The failure to identify and treat the embedded suture in a timely manner led to the resident developing an infection, necessitating extended medical treatment and wound care management.
Failure to Ensure Timely Vision Services
Penalty
Summary
The facility failed to ensure a resident was seen by the eye doctor as requested by the resident's Power of Attorney (POA). The resident, who was admitted to the facility, had two care plan meetings where the POA requested an eye doctor visit. Despite these requests, the Social Service Director was unsure if the resident had seen the eye doctor. The Director of Nursing confirmed that an eye doctor visits the facility monthly and that residents are seen routinely and upon request. However, the Director of Nursing was also unsure why it took so long for the resident to see the eye doctor. The resident eventually saw the eye doctor and was diagnosed with presbyopia, receiving a prescription for glasses. The facility does not have a policy on vision services but expects residents to be seen by the eye doctor upon physician's order or as requested by the resident or POA.
Failure to Ensure Timely Dental Care for Resident
Penalty
Summary
The facility failed to ensure a resident was seen by the dentist as requested by the resident's Power of Attorney (POA). The resident was admitted to the facility and had two care plan meetings where the POA requested dental services. Despite these requests, the resident was not seen by the dentist until the second care plan meeting. The Social Service Director confirmed that the POA had requested dental services at both meetings, but the resident was only seen by the dentist after the second meeting. The Director of Nursing stated that the facility has a dentist who visits monthly and that residents are seen routinely and as requested, but could not explain why the resident was not seen sooner. The resident's dental consult revealed moderate plaque and staining, mildly dry mouth, puffy tissue, and mild thrush. The facility's Dental Services Policy indicates that oral health services are available to meet residents' needs and that the Director of Nursing or their designee is responsible for notifying Social Services of a resident's need for dental services. Social Services is then responsible for assisting the resident or family in making dental appointments. Despite this policy, the resident only had one dental exam since admission, highlighting a failure in the facility's process to ensure timely dental care as requested by the POA.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,904 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Burbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Burbank | 1.1 mi | ★★★★★ | 1 | 0 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 1.3 mi | ★★★★★ | 2 | 0 |
| Warren Barr Oak Lawn | 1.5 mi | ★★★★★ | 3 | 0 |
| Aliya Of Oak Lawn | 1.5 mi | ★★★★★ | 11 | 2 |
| Aperion Care Oak Lawn | 1.6 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.