Burbank Healthcare & Rehab

In the surveyor’s words

From the most serious findings on record at Burbank Healthcare & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jul 2, 2021

  Based on interview and record review, the facility failed to provide the necessary care and services in accordance with its policy and procedure, and professional standards of care for one of seven sampled residents (Resident 1), by: 1.) Failing to ensure Licensed Vocational Nurse 1 (LVN 1) verified each medication order with Admitting Physician (AP) upon the resident's admission to the facility. 2.) Failing to ensure Licensed Vocational Nurse 1 (LVN 1) properly transcribed the Physician's admission medication orders correctly. […]

• Immediate jeopardy, patternF760Jul 2, 2021

  Based on interview and record review, the facility failed to administer [MEDICATION(S)] ([CONDITION(S)] [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements] medication) as ordered by the physician for one of seven sampled residents (Resident 1). Resident 1 was given [MEDICATION(S)] 25 milligram (mg, a unit of measure) rather than the intended dose of [MEDICATION(S)] 175 mg. This deficient practice resulted in Resident 1 receiving nine (9) doses of [MEDICATION(S)] that was seven (7) times less than the intended prescribed dose between the dates of 5/15/2021 to 5/19/2021. […]

• Immediate jeopardy, isolatedF880Jan 31, 2026

  Based on observation, interview, and record review, the facility failed to implement contact isolation precautions (infection control measures used in the healthcare settings to prevent the spread of infections transmitted by direct or indirect contact with a resident or their environment) for one of three sampled residents (Resident 1) when Resident 1 was suspected and exhibited signs and symptoms (indicators of an illness, injury, or condition) consistent with Clostridiodes (known before as Clostridium) Difficile infection (CDI or C. difficile - bacteria that causes severe, diarrhea [loose, watery stools], and inflammation [swelling] of the colon) on 1/18/2026 and subsequently tested positive for CDI on 1/20/2026, by failing to:1. […]

• Immediate jeopardy, isolatedF755Jan 31, 2025

  Based on observation, interview, and record review, the facility failed to have a system-wide (something that extends or exists throughout a system) method of accountability for controlled medications (drugs that are regulated by the government because it may be abused or cause addiction) and ensure safeguarding of controlled medications for two of nine sampled residents (Resident 1 and Resident 2) by: 1. Failing to ensure licensed nurses document the administration of controlled substances in Resident 1's electronic Medication Administration Record (eMAR- an electronic report detailing the drugs administered to a resident) 2. […]

• Immediate jeopardy, isolatedF711Jul 2, 2021

  Based on interview and record review, the facility failed to ensure the admitting physician for one of seven sampled residents (Resident 1) reviewed the transcribed order for [MEDICATION(S)] ([CONDITION(S)] [sudden, uncontrolled electrical disturbance in the brain] medication) to ensure accuracy prior to signing for validation. This deficient practice resulted in Resident 1 receiving nine (9) doses of [MEDICATION(S)] that was seven (7) times less than the intended prescribed dose between the dates of 5/15/2021 to 5/19/2021. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation due to uncontrolled body movement, potentially compromising the health and safety, and placing Resident 1 at risk for death. […]