Aperion Care Burbank

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and interventions for a resident assessed as being at risk for falls. This failure affected one (R9) of three residents reviewed for falls. This failure resulted in harm with injury when R9 was found on the floor in his room and sustained an impacted distal radius fracture to right wrist and reverse obliquity IT fracture of right hip. R9 underwent a surgical procedure of insertion of intermedullary rod to proximal femur.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at temperatures that were palatable and attractive. This failure affected all 48 residents that consume food/beverages from the facility's kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all food served to residents was procured from approved or satisfactory sources. This has the potential to affect all residents receiving meals from the facility kitchen. On 04/02/2026 at 11:17 AM, V3 (Food Service Director) said she had been working at the facility since August 2025 and was in charge of ordering the facility's food. V3 said if a food shortage ever happened, she would go to the store and buy what was needed with the Administrator's card, then provide the Administrator with a receipt of the purchased items. V3 said she co-owned a food pantry with her husband and, occasionally, would take canned goods, like green beans or fruit mix from her personal pantry to the facility's kitchen for use in the resident's meal preparation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety measures with Activities of Daily Living (ADL) as indicated in resident plan of care. This failure resulted in R1 sustaining a laceration on the left leg during transfer from wheelchair to bed with 6x4x2 measurements and being transferred to the local hospital for sutures. This failure also resulted in R2 sustaining intraparenchymal hematoma and transferred to local hospital. Findings Include: 1. R1's medical record documents: admission date 3/17/2025. Diagnosis Information include Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Radiculopathy, Lumbar Region, Need for Assistance with Personal Care, Subsequent Encounter for Fracture Without Routine Healing. R1's Care Plan Report read Focus: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the 2 persons assistance while turning one dependent resident (R1) in bed. This failure affected one resident of three reviewed for accidents. This failure resulted in R1 falling to the floor and sustaining a frontal hematoma and laceration requiring glue to close.

Inspectors wroteBased on interviews and records reviewed the facility failed to have accurate record of one resident's fall (R1). This failure affected one of three residents reviewed for accuracy of resident records.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall by providing a two person assist with bed mobility during ADL (Activity of Daily Living) care. This affected one of three (R2) residents reviewed for safety during direct care. This resulted in rolling of the bed during direct care and sustaining a head injury requiring 9 sutures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and implement interventions in preventing the development of pressure ulcer for one (R19) of three residents in the sample of 37 reviewed for pressure ulcer. This failure resulted in R19 developing an unstageable pressure ulcer on the sacral area.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy in conducting background checks for eight (R1, R9, R13, R32, R34, R39, R46 and R55) of ten residents in a sample of 37 reviewed for admission screening; and failed to implement pre-employment screening on seven (V11, V12, V13, V14, V15, V16 and V17) of 10 employees reviewed for background checks. This deficiency has the potential to affect all 55 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing and storing food under sanitary conditions by not ensuring all staff entering the kitchen wore hair restraints, not discarding food past their used and best by dates, and not keeping the food prep area free of potentially contaminated objects. This failure applies to all 55 residents in the facility.

Inspectors wroteBased on observation and record review, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not ensuring garbage and waste disposal in the food prep was covered when not in use. This failure applies to all 55 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one dependent resident (R21) was safely transported in a wheelchair. This failure affected one (R21) of two residents reviewed for falls in a sample of 37. This failure resulted in R21 falling forward out of a wheelchair while being pushed by staff, hitting R21's head, and sustaining a contusion to right forehead, requiring transfer to a local hospital for emergent care.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent prior to administering a psychotropic medication for one (R17) of five residents reviewed for unnecessary medications in a sample of thirty-seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services to meet resident's needs. This failure applies to three of six residents (R41, R51, and R30) reviewed for dental services.

Inspectors wroteBased on interview and record review, the facility failed to immediately transfer a resident to the emergency room after a fall that resulted in left hip pain and a fracture. This failure resulted in a surgical delay in treatment (more than 7 hour) for R5 who was experiencing left leg pain and had a fracture. The facility also failed to ensure a resident (R6) was not transferred from the floor after a fall and complaints of right upper leg pain prior to emergency medical services arriving. These failures apply to 2 of 4 residents (R5 and R6) reviewed for quality of care in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions in preventing the reopening of a healed pressure ulcer and worsening of an existing pressure ulcer for two (R18 and R29) of four residents in the sample of 27 reviewed for skin breakdown. This deficiency resulted in R18's healed pressure ulcer on the sacrum reopening and being identified as a facility acquired, Stage 3 wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice by not administering medications within the scheduled times ordered, failed to have a physician order before administering a medication, and failed to ensure that staff do not document medications as given in the electronic medication administration record (EMAR) without administering the medications to residents. This failure affected three residents (R18, R44 and R208) of five residents reviewed for medication administration and have the potential to affect all 51 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were ten medication errors out of 25 medication opportunities resulting in a 40% medication error rate. This failure applied to four (R18, R44, R51 and R208) residents observed during the medication administration task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for ensuring residents at risk for nutrition problems received adequate feeding supervision and assistance ,and failed to ensure consistent monitoring of meal intake. This failure applied to two of three residents (R51 and R157) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to follow their policy and procedure for providing dental services by not following up on the status of the dentist's recommendation for a tooth extraction for a dependent resident with a loose tooth. This failure applied to one of one residents (R26) reviewed for dental care.

Inspectors wroteBased on interview and record review, the facility failed to ensure incontinence care was provided for a resident who required extensive staff assistance with mobility and toileting. This failure applied to one of five residents (R157) reviewed for activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to prevent or determine how an injury of unknown origin occurred. This affected one of three residents (R6) reviewed injury of unknown origin. This failure resulted in R6 sustaining an injury to the right knee receiving seven sutures at the local hospital. Findings Include: R6 is a [AGE] year old with the following diagnosis: chronic venous hypertension with ulcer of the left lower extremity, venous, insufficiency, chronic obstructive pulmonary disease, congestive heart failure, and Alzheimer's disease. R6's Care Plan, dated 8/23/23, documents R6 has a potential for impairment of skin integrity related to fragile skin, impaired mobility, and incontinence. The Change of Condition Evaluation, dated 8/27/23, documents R6 had a change in condition of a skin wound and this occurred in the afternoon. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not reporting an injury of unknown origin to the regulatory agency. This affected one of three (R6) residents reviewed for abuse policy reporting. Findings Include: R6 is a [AGE] year old with the following diagnosis: chronic venous hypertension with ulcer of the left lower extremity, venous, insufficiency, chronic obstructive pulmonary disease, congestive heart failure, and Alzheimer's disease. The Change of Condition Evaluation, dated 8/27/23, documents R6 had a change in condition of a skin wound and this occurred in the afternoon. There were no other changes of condition documented besides a skin tear to the right knee. The Hospital Records, dated 8/27/23, documents R6 was sent to the hospital when staff noted a linear laceration to the right knee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing food under sanitary conditions and safe food storage by not discarding opened and unused foods past their expiration date, not using hand hygiene after contact with surfaces and upon re-entry into the kitchen, not thoroughly washing hands, and not ensuring cleaning linens contained appropriate levels of cleaning and sanitation solutions before use. This failure has the potential to affect all 55 residents currently in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to promote care for residents in a manner and in an environment that maintains or enhances each residents dignity by not assisting residents with toileting, feeding, and not containing urinary catheter collection bags in privacy bags. These failures applied to four (R4, R12, R28, and R43) of 27 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders by not giving medications as ordered and not following their medication administration policy for four (R4, R8, R26, and R42) of 27 residents reviewed during the medication administration survey task.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy for monitoring and assessing signs of involuntary movement disorder by not observing and reporting tongue thrusting for a resident who is taking psychotropic medications. This failure applied to one (R22) of six residents in a total sample of 26 residents reviewed for unnecessary medications.