Aperion Care Burbank

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 143 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 56 beds and averages 49.6 residents a day — about 89% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.453 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.65 hrs/resident/day on weekends vs 3.97 on weekdays — 8% thinner on weekends. RN hours go from 1.03 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 17 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2025-05-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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: 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: R1 have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day. Interventions: Chair/bed to chair transfer: R1 usual performance is dependent x 2, revision date 11/15/2024. R1 use a mechanical lift for transfer assist,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R1's MDS (Minimum Data Set), dated 8/7/24, notes a BIMS (Brief Interview for Mental Status) score of 3, impaired. R1 is noted to have no physical or verbal behavioral symptoms. R1 is noted to have Functional Limitation in Range of Motion to her lower extremity on both sides. Section GG notes R1 is dependent on staff for toileting hygiene, sit to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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). ROM (range of motion) at baseline. Resident denied pain. MD (Medical Doctor) gave orders to send resident to ER (Emergency Room). Staff Interviews revealed staff was present at the time of the fall. Based on the investigation, the root cause of the fall was resident stated he was attempting to reposition himself in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R19's MDS (Minimum Data Set), dated 07/02/24, recorded: Section C, BIMS (Brief Interview for Mental Status) score of 99, which means R19 was unable to complete the interview; and Section M0150 Risk of Pressure Ulcers/Injuries - R19 is at risk of developing pressure ulcers/injuries. R19's Care plan on potential for alteration in nutrition,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-03-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: 1. R5's Fall-Initial Occurrence Note, dated 12/29/23, shows R5 had a fall in the dining room at 1:46 PM and landed on the floor and her left side. R5's Progress Notes, dated 12/29/23 at 8:44 PM, shows, Left leg new onset of pain .MD (Medical Doctor) notified of new pain onset, new orders received. x-ray of left leg. R5's X-ray report shows a reported dated and time of 12/30/23 at 12:10 AM. The report…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. R18 is a [AGE] year-old, male, admitted in the facility on 07/24/23. with diagnosis of Multiple Sclerosis. According to Skin Wound Report. dated 07/24/23, he was admitted with Stage 2 pressure injury on the sacrum, measuring 1cm (centimeter) x 1cm x 0.1cm. R18's Care plan on pressure ulcer to sacrum related to immobility, dated 08/23/23, documented: Interventions: Avoid positioning the resident on sacrum; Encourage and assist with turning and repositioning at regular intervals as allowed and tolerated every shift and when requested for comfort; Facility follow…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R6 had no changes in mental status observed. There were no other changes of condition documented besides a skin tear to the right knee. The Hospital Records, dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-04-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. V3 said she took canned goods from her personal pantry to the facility's kitchen because she was running low of the food items and did not want to go to the store to buy them. V3 said she had taken maybe two or three cases containing twenty-four little green bean cans to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings include: On 11/19/24 at 11:45AM, V4, Licensed Practical Nurse (LPN), note was with V4. V4 said, The CNA (Certified Nursing Assistant) called me to the room. Whatever I wrote is what happened. V4 said she didn't remember more than what was written. On 11/19/24 at 1:57PM V8, CNA, said, I don't know who (R1) is. I don't remember someone falling and getting a goose egg or large bump on their head. I have had people fall, but I don't know their names. On 11/20/24 at 12:54PM, V13, CNA, said, On 10/24/24, there was only 2 CNAs that night. I was coming to east hall (opposite R1's hall) and the nurse called me and said they had a fall. I went in the room, and (R1) was on the floor next to the bed. She was trying to change her diaper and she fell. The surveyor who is she? V13 said V8 by name. V13 said, (V8) told me she was trying to change (R1's) diaper in bed. I did not help in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-15 · tag F0607 — failed to have anti-abuse policies — widespread
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Per census report, there are 55 residents currently residing in the facility. The following documentation were presented during review of residents' admission screening: R1 is a [AGE] year old, female, initially admitted in the facility on 07/11/24, with diagnoses of Systemic Lupus Erythematosus, Unspecified. Her name was checked under Department of Dorrections, local, and national sex offender websites on 08/09/24, which was 29 days post admission. R9 is a [AGE] year old, female, admitted in the facility on 07/24/24, with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-08-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: On 08/12/24 at 9:25 AM, a sign was on the door entering the kitchen stating hairnets must be worn when entering the kitchen. Observed multiple grilled cheese sandwiches with a use by date of 08/11/2024, and a fat free milk carton with best buy date of 08/08/2024 stored in the refrigerator. V17 (Cook) stated the grilled cheese sandwiches and milk carton should have been removed from the refrigerator. 16 fat free milk cartons, with a use by date of 08/11/2024, were stored in the freezer. On 08/12/24 at 11:02 AM, a personal phone was on the food prep table, where rolled up silverware were placed that were being used for lunch. V4 (Receptionist)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-15 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — the official record, unedited, may be distressing

  Based 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. Findings include: On 08/12/24 at 9:25 AM, surveyor observed gnats in the kitchen, and a large garbage bin next to the food prep area open without the lid when not in use. On 08/12/24 at 11:02 AM, surveyor observed a large garbage bin next to the food prep area, open without the lid when not in use. The facility's Garbage and Rubbish Disposal Policy received and reviewed 08/14/2024 states: Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents. All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R21 is an [AGE] year-old resident admitted to the facility on [DATE], with diagnoses including but not limited to generalized anxiety disorder, moderate intellectual disabilities, muscle wasting and atrophy, and history of falling. Minimum Data Set (MDS), dated [DATE], documents R21's Brief Interview for Mental Status (BIMS) score as 00, which indicates severe cognitive impairment. MDS, dated [DATE], also documents R21 is dependent on staff for wheelchair mobility and toileting hygiene; needs substantial/maximal assistance for oral hygiene,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R17 is an [AGE] year-old resident admitted to the facility on [DATE], with diagnoses that include but are not limited to: Dementia, major depressive disorder, schizophrenia, and Alzheimer's disease. Medication order, dated 05/27/2023, documents order as: Lexapro Oral Tablet 20 mg - Give 0.5 tablet by mouth in the morning related to Major Depressive Disorder. Medication consent, dated 05/28/2023, documents Lexapro 0.5 mg tablet. On 08/14/24 at 11:57 AM, V2, Director of Nursing (DON), stated, Every one of us is in charge of psychotropic medication. I am DON so I am in charge. For (R17), her order is for 10 mg Lexapro. Stock is 20 mg, but her order is for 0.5 tab so 10 mg. This consent is not correct. It should be for 0.5 tab of 20 mg, not 0.5 mg tablet. I believe this…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-15 · tag F0790 — failed to provide dental care — isolated
  Provide routine and 24-hour emergency dental care for each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. R41 is a [AGE] year-old, male, initially admitted in the facility on 12/22/22, with diagnoses not limited to Chronic Respiratory failure with hypoxia, Chronic Congestive Heart Failure, Severe Protein with Malnutrition, and Chronic Kidney Disease stage 3. On 08/12/24 at 10:41 AM, observed R41 with missing and discolored teeth. R41's current oral/dental care plan, initiated 09/13/2023, documents he exhibits dental/mouth problems as evidenced by: some missing/broken natural teeth and has the potential for further alteration and/or complications related to it; continue all interventions including Coordinate arrangements for Dental care. There was no documentation in R41's medical records of being seen by the Dental Hygienist from June 2023 to August 2024. R41's dental…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-10-25 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 10/22/23 at 10:15AM, surveyor asked V4 (Registered Nurse/RN) if she is still passing medication, and she said she is done with med pass. During observation of the residents on the floor, R208 stated at 10:18AM, she has not received her morning medication. At 10:34AM, R44 also told surveyor he has not received his medication; he does not know what the delay is. At 10:40 AM, surveyor asked V3 (Licensed Practical Nurse/LPN) the assigned nurse for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-10-25 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: On 10/22/2023 at 10:50AM, observed medication administration for R208 with V3 (Licensed Practical Nurse/LPN). V3 opened her electronic medication administration record (EMAR) for the resident to prepare her medications, and the surveyor noticed the resident's medications are green in color, indicating they have been administered. V3 stated she was not supposed to sign off the medications before they are given. V3 then prepared nine different pills in separate medicine cups for the resident, and confirmed she has nine pills when surveyor asked her to confirm her own records. V3 administered the nine pills to the resident. Review of physician order for the resident during medication reconciliation showed the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$90,114 in federal fines across 5 penalties. 2 Medicare payment denials on record.

• $12,438 — penalty dated 2025-05-30
• $14,050 — penalty dated 2024-11-21
• $42,900 — penalty dated 2024-08-15
• $10,839 — penalty dated 2024-03-08
• $9,887 — penalty dated 2023-09-08
• Medicare payment denial — starting 2024-09-12 for 9 days
• Medicare payment denial — starting 2023-10-04 for 44 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to APERION CARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 33 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL