Burbank Healthcare & Rehab: Medication Errors Put Resident at Risk - CA
The medication was valsartan, prescribed to control a resident's blood pressure. The physician's order was straightforward — administer it at 9 a.m. It wasn't administered on November 3, 2025. It wasn't administered on November 6, 2025.
The first nurse, identified in inspection records as LVN 1, told inspectors she simply did not give the medication on November 3. She acknowledged during an interview on November 20 that valsartan should have been administered that morning, and that the resident's blood pressure could increase because it wasn't.
The second missed dose three days later came from a different nurse, LVN 2. Her explanation was more specific, and in some ways more troubling. She told inspectors she was accustomed to following a physician order that instructed nurses to hold valsartan when a patient's systolic blood pressure dropped below 110 mmHg. On the morning of November 6, the resident's blood pressure was 106/58. She held the medication.
The problem was that no such order existed for this resident.
"She should have read the physician order and administer valsartan to Resident 1," LVN 2 told inspectors, referring to herself. She acknowledged the resident could experience hypertension because the dose was not given.
That kind of error, applying a standing rule from a different patient to someone whose order said something else entirely, is the kind of mistake that goes unnoticed until something goes wrong. On November 6, nothing catastrophic happened. But the resident went without a prescribed blood pressure medication because a nurse assumed she already knew what the order said.
The Director of Nursing confirmed both failures when inspectors interviewed her the same morning. She said LVN 1 and LVN 2 should have read the physician order, compared it against the blood pressure reading, and administered the medication. The facility's own written policy, last reviewed in March 2025, states that medications are to be given in a safe and timely manner, as prescribed, and in accordance with physician orders, with vital signs checked beforehand when necessary.
The DON did not dispute any of it.
Federal inspectors cited the facility under F0755, which covers safe and accurate medication practices. The violation was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents. It was identified through a complaint inspection conducted November 20, 2025.
That designation, minimal harm, reflects that no documented injury resulted from the two missed doses. Valsartan is used to treat high blood pressure and heart failure. Going without it for a single morning may not produce immediate symptoms. But for a resident whose physician specifically ordered the drug, the risk is real, and both nurses who skipped the dose said so themselves.
What the inspection record does not explain is how the same medication, for the same resident, went ungiving on two separate mornings four days apart, by two different nurses, without anyone catching it in between.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Burbank Healthcare & Rehab from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 30, 2026 · Our methodology
BURBANK HEALTHCARE & REHAB in BURBANK, CA was cited for violations during a health inspection on November 20, 2025.
The medication was valsartan, prescribed to control a resident's blood pressure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.