Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burbank Parke Care Center during CMS and state inspections, most recent first.
Staff failed to provide ordered mealtime supervision for a resident with dementia, missing teeth, and aspiration risk; the resident was observed eating alone in her room, and staff were unaware she needed observation during meals. The facility also left a Skills Room unsecured with an unlocked refrigerator containing insulin pens that belonged to a staff member’s husband, while residents passed by the area throughout the day.
A resident with CHF, visual hallucinations, and impaired coordination developed redness, drooping, and crusting of the left eye, but staff did not promptly notify the physician. The resident reported occasional itching, and an LPN cleaned the eye and waited to see if it would resolve on its own. The physician confirmed he was not informed, and the DON stated staff should notify the physician when a change in condition is identified.
A resident with Parkinson's disease, dementia, severe cognitive impairment, and bowel and bladder incontinence was found with a urine- and stool-saturated brief and stool covering an open coccyx area. A CNA said the resident had not been changed since the start of the shift because two-person incontinence care was needed and there was not enough staff, and the CNA did not notify the nurse about the missing wound dressing.
A resident with Parkinson's disease, dementia, diabetes, anemia, and bowel/bladder incontinence had a coccyx pressure ulcer ordered for NS cleansing, Medihoney, and a dry dressing. During observation, the resident was found with a saturated brief, stool on the wound, and no dressing in place; the TAR showed the dressing was overdue, and staff confirmed the CNA did not notify the nurse when the dressing was missing.
Failure to Use PPE During EBP Care: Staff did not don gowns during high-contact care for two residents on EBP. One resident had a Foley catheter and was cognitively intact; the other had Parkinson's disease, dementia, incontinence care needs, and an open coccyx wound. CNAs and LPNs provided catheter care, incontinence care, and wound care without gowns, and one room lacked an EBP sign and readily available PPE.
A facility failed to implement skin integrity interventions for a resident with severe dementia and other conditions. The care plan required elbow protectors at all times, but during an observation, the resident was found without a protector on the right arm. An LPN confirmed the oversight, highlighting a lapse in care plan adherence.
A resident diagnosed with ESBL and COVID-19 was prematurely removed from isolation precautions by an LPN after a negative COVID-19 test, despite the need for continued contact precautions due to the ESBL diagnosis. The DON confirmed that the resident should have remained on contact precautions, as per CMS guidelines for MDROs.
A facility failed to follow professional standards for pressure ulcer care, affecting a resident with a Stage 4 ulcer. During a dressing change, an LPN did not maintain proper hand hygiene between glove changes, contrary to facility policy. The LPN acknowledged the oversight, confirming the need for hand washing or sanitizer use with each glove change.
Failure to Supervise Mealtime and Secure Medications
Penalty
Summary
Staff failed to provide the appropriate level of supervision during mealtimes for a resident at risk for choking. The resident had diagnoses including unspecified dementia, cerebral infarction, and acute and chronic respiratory failure, and the care plan identified a potential for altered nutritional status with interventions including monitoring eating ability, cutting up meats, and encouraging meals in the main dining room for choking risk. A speech therapy evaluation documented physical impairments and functional deficits that increased the resident’s risk for aspiration and recommended supervision for oral intake, including distant supervision, with staff having eyes on the resident during meals. Despite those findings, the resident was observed eating lunch alone in her room while staff were not present, and the resident stated that staff delivered the tray and left without returning. The resident also stated she had eaten breakfast in bed without supervision. The speech therapist confirmed the recommendation for distant supervision had been communicated to nursing staff and the CNA in the dining room, but the primary LPN and CNA stated they were not aware the resident required observation or monitoring during meals. The resident later stated she had multiple missing teeth and had trouble chewing food, and reported having choked on food because she could not chew hard food well. The facility also failed to ensure medications were stored in a safe and secure manner. Multiple observations showed the Skills Room was open and unsecured, and the room contained an unlocked refrigerator with four boxes of insulin pens. The Administrator confirmed the insulin pens belonged to a staff member’s husband who did not reside in the facility. The DON stated the Skills Room door was often unlocked and the refrigerator did not have a lock, and that residents passed by the room several times a day and had access to the unsecured medication stored there.
Failure to Notify Physician of Resident Eye Change
Penalty
Summary
The facility failed to ensure staff promptly notified the physician of a change in Resident #56’s condition. Resident #56 was admitted on 11/29/22 with diagnoses including congestive heart failure, visual hallucinations, and lack of coordination. The resident’s MDS dated 05/20/26 showed cognitive impairment and a need for substantial to maximal assistance with personal hygiene. Review of progress notes from 06/02/26 through 06/10/26 did not include documentation of drainage or redness to the resident’s left eye. Observation on 06/08/26 at 10:00 A.M. showed Resident #56’s left eye was red and droopy, and the resident stated the left eye itched occasionally. On 06/09/26 at 11:28 A.M., the left eye was again observed to be red with dried crust on the upper and lower lids. An LPN confirmed the resident received eye drops three times daily for dry eyes and that she would assess the left eye for redness and drainage. The physician later confirmed he had not been notified about the redness and drainage. The LPN stated she cleaned the eye with a wet washcloth to see if it would resolve on its own and verified she had not notified the provider, explaining she normally would wait a day before notifying the physician if a change in condition was noted. The DON confirmed staff should notify the physician when a change in condition is identified, and the facility policy required nurses to notify the resident, attending physician or provider, and resident representative of changes in condition or status.
Delayed Incontinence Care and Poor Skin Hygiene
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident with Parkinson's disease and dementia. The resident's care plan identified a risk for altered skin integrity related to immobility, diabetes mellitus, anemia, and bowel and bladder incontinence, with interventions including skin checks every two hours and as needed for incontinence. The Minimum Data Set showed the resident was severely cognitively impaired, always incontinent of bowel and bladder, and required assistance with toileting and personal hygiene. During observation, the resident's incontinence brief was saturated with urine and stool, and an open area on the coccyx was covered with stool. A CNA who identified herself as the resident's primary aide stated she had last laid the resident down to change the brief at the start of her shift and had not checked or changed the resident again before the observation because the resident required two people for incontinence care and there was not enough staff. She also confirmed there was an open area to the coccyx and that no dressing was present, and she had not notified the nurse about the missing dressing. The facility policy stated staff would provide skin hygiene daily and keep skin clean, dry, and free of urine, feces, perspiration, and wound drainage.
Missed wound dressing care and incontinence management
Penalty
Summary
Failure to provide appropriate care and treatment for a pressure ulcer was identified for a resident with Parkinson's disease, dementia, diabetes mellitus, anemia, and bowel and bladder incontinence. The resident's care plan identified a risk for altered skin integrity related to immobility and incontinence, and the MDS showed the resident was severely cognitively impaired, always incontinent, required assistance with ADLs, and was at risk for pressure ulcers. A wound care order was obtained for the coccyx area to be cleansed with normal saline, patted dry, treated with Medihoney, and covered with a dry dressing three times weekly and as needed after an open area was first identified on the buttocks. On the day of observation, the resident's incontinence brief was saturated with urine and stool, and there was no dressing present on the coccyx wound; the wound was covered with stool. The treatment record showed the dressing was due that day but had not been signed off, and the last documented dressing completion was several days earlier. The wound care nurse measured the wound after incontinence care and noted surrounding inflamed tissue. An LPN confirmed there was no dressing present, and a CNA stated she had seen no dressing at the start of her shift but did not notify the nurse and had not checked or changed the resident between the start of her shift and the observation.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to don appropriate PPE during care activities for residents with orders for enhanced barrier precautions (EBP). Resident #6 had diagnoses including chronic kidney disease and obstructive and reflux uropathy, a history of prostate cancer and recurrent urinary tract infections, an indwelling Foley catheter, and an EBP order. The resident was cognitively intact. The resident stated that staff did not wear PPE when emptying the catheter, and observation of catheter care showed a CNA entered the room without donning a gown even though a sign on the doorway indicated the resident was on EBP. The CNA confirmed the resident had a sign on the door indicating EBP and stated she did not wear a gown during catheter care. Resident #69 had diagnoses including Parkinson's disease and dementia and was severely cognitively impaired and dependent for activities of daily living. During observation of incontinence care, the resident did not have an EBP sign on the door and isolation gowns were not available outside the room. CNAs provided care without donning gowns, and the resident had an open wound to the coccyx. LPNs then entered the room to measure and complete wound care without donning gowns. The LPNs confirmed the resident had a pressure ulcer to the coccyx first identified on 05/26/26 and confirmed they had not donned gowns while providing wound care. The DON later observed there was no EBP sign on or near the doorway and no PPE readily available, and confirmed the resident should be on EBP and staff should don appropriate PPE when providing care.
Failure to Implement Skin Integrity Interventions
Penalty
Summary
The facility failed to implement interventions to maintain skin integrity as outlined in the care plan for a resident. Resident #50, who was admitted with diagnoses including Alzheimer's disease, severe dementia, and other mental health conditions, was receiving hospice services and was dependent on assistance for daily activities. The care plan specified the use of elbow protectors at all times, except during hygiene, to prevent skin integrity issues. However, during an observation, it was noted that the resident, who had a cast on the left arm, did not have an elbow protector on the right arm as required. An LPN confirmed that the resident should have had an elbow protector on the right arm, indicating a lapse in following the care plan. This deficiency was identified during a complaint investigation.
Failure to Maintain Isolation Precautions for Resident with ESBL
Penalty
Summary
The facility failed to implement appropriate isolation precautions for a resident diagnosed with extended spectrum beta-lactamase (ESBL) and COVID-19. The resident, who was severely cognitively impaired and required maximal assistance with activities of daily living, was initially placed on isolation due to a positive COVID-19 test. However, after a negative COVID-19 test, the resident was prematurely removed from isolation precautions by an LPN, despite the resident's recent diagnosis of ESBL, which required continued contact precautions. The Director of Nursing confirmed that the resident should have remained on contact precautions due to the ESBL diagnosis. The Centers for Medicare and Medicaid Services guidelines indicate that contact precautions should be implemented for residents infected or colonized with multidrug-resistant organisms (MDROs) when secretions or excretions cannot be contained. This oversight in maintaining appropriate isolation measures for the resident substantiates the complaint filed against the facility.
Failure in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were consistent with professional standards of practice, affecting one resident with a Stage 4 pressure ulcer. The resident, who was admitted with a diagnosis including diabetes type 2 and a Stage 4 pressure ulcer, had a physician's order for a specific dressing change procedure. This procedure involved cleansing the sacrum with normal saline, applying a collagen sheet to the wound bed, prepping the peri-wound skin, and covering it with a border gauze dressing. During an observation of the dressing change, it was noted that the LPN and STNA used hand sanitizer upon entering the room but failed to maintain proper hand hygiene between glove changes. The LPN did not wash her hands or use hand sanitizer between removing the old dressing, cleaning the wound, and applying the new dressing, which was against the facility's policy. The LPN acknowledged the oversight during an interview, confirming that she should have washed her hands or used hand sanitizer with each glove change. This incident substantiates a complaint filed against the facility.
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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) |
|---|---|---|---|---|
| Avenue At Wooster | 9.3 mi | ★★★★★ | 4 | 0 |
| Smithville Western Care Center | 10 mi | ★★★★★ | 0 | 0 |
| Champion Creek Health And Rehabilitation | 11.1 mi | — | 0 | 0 |
| West View Healthy Living | 11.4 mi | ★★★★★ | 0 | 0 |
| Apostolic Christian Home Inc | 11.6 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.