Aperion Care Burbank

In the surveyor’s words

From the most serious findings on record at Aperion Care Burbank, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 9, 2026

  Based 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.Findings include:R9 is 97 years and has resided at the facility since 2023. […]

• Actual harm, isolatedF689May 30, 2025

  Based 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: admitted [DATE]. 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. […]

• Actual harm, isolatedF689Nov 21, 2024

  Based 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. The findings include: R1 has diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic). Progress Note, dated 2/15/24, documents R1 is a 2 person assist with bed mobility. […]

• Actual harm, isolatedF689Sep 20, 2024

  Based 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. Findings include: Facility final report to the department, dated 9/19/24, denotes thorough investigation completed, including staff and resident interviews. On 9/13/2024 resident was observed on the floor in his room. Head to toe assessment completed. Minimal bleeding noted to right forehead. First aid rendered, and pressure applied to area. Neuro checks initiated and completed. NO change in LOC (level of consciousness). […]

• Actual harm, isolatedF686Aug 15, 2024

  Based 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. Findings include: R19 is an [AGE] year old, female, initially admitted in the facility on 06/14/22, with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side; Parkinson's Disease without Dyskinesia, Without Mention of Fluctuations; and Neurocognitive Disorder with Lewy Bodies. […]