Health inspection·November 20, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow Resident 1's physician order to administer valsartan (medication used to treat high blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) above 100 millimeters of mercury (mmHg-a standard unit of pressure).This failure had the potential to result in medication error and could cause Resident 1's uncontrolled hypertension (HTN-high blood pressure).Findings:During a review of Resident 1‘s admission Record, the admission Record indicated the facility admitted Resident 1 on 10/15/2025, with diagnoses that included paroxysmal atrial fibrillation (irregular heartbeat in the upper heart chambers that starts and stops on its own), generalized muscle weakness and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 10/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 10/20/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 11/2025, the MAR indicated Licensed Vocational Nurse 1 (LVN 1) and LVN 2 did not administer valsartan to Resident 1 on the following dates and times:1. 11/3/2025, at 9 a.m., blood pressure 108/63 mmHg and heart rate of 79 beats per minute (bpm).2. 11/6/2025, at 9 a.m., blood pressure was 106/58 mmHg and heart rate of 62 bpm.During a concurrent interview, and record review on 11/20/2025, at 9:57 a.m., with the Director of Staff Development (DSD), Resident 1's Physician Order, dated 10/15/2025, and MAR, dated 11/2025, were reviewed. The Physician Order dated 10/15/2025, indicated an order for valsartan oral tablet 320 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) give one tablet by mouth daily for HTN, hold for sbp less than 100 mmHg or heart rate less than 60 bpm. The DSD stated LVN 1 and LVN 2 held (did not administer) valsartan on 11/3/2025, and 11/6/2025, at 9 a.m. The DSD stated LVN 1 and LVN 2 should have administered the valsartan following the physician's order to only hold the valsartan if sbp is below 100 mmHg or if heart rate below 60 bpm. The DSD stated Resident 1's blood pressure could increase since valsartan was not administered.During an interview on 11/20/2025, at 10:15 a.m., with LVN 1, LVN 1 stated she (LVN 1) was used to following the physician order to hold the valsartan if blood pressure was less than 110 mmHg. LVN 1 stated she (LVN 1) did not see the order that valsartan should only be held if sbp was less than 100 mmHg and not 110 mmHg. LVN 1 stated she (LVN 1) should have reviewed the physician order before holding Page 1 of 2 056129 056129 11/20/2025 Burbank Healthcare & Rehab 1041 S. Main St. Burbank, CA 91506

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the medication. LVN 1 stated valsartan should have been administered on 11/3/2025, at 9 a.m. LVN 1 stated Resident 1's blood pressure could increase because valsartan was not administered.During an interview on 11/20/2025, at 10:30 a.m., with LVN 2, LVN 2 stated on 11/6/2025, at 9 a.m., Resident 1's blood pressure was 106/58 mmHg. LVN 2 stated she (LVN 2) should have administered valsartan as per physician order. LVN 2 stated she (LVN 2) was used to following a physician order to hold the valsartan for sbp less than 110 mmHg. LVN 2 stated she (LVN 2) should have read the physician order and administer valsartan to Resident 1. LVN 2 stated Resident 1 could experience HTN because valsartan was not administered.During an interview on 11/20/2025, at 10:23 a.m., with the Director of Nursing (DON), the DON stated valsartan should have been administered on 11/3/2025, and 11/6/2025, at 9 a.m. as per physician order. The DON stated LVN 1 and LVN 2 should have read the physician order, compare with the blood pressure result and follow the physician order to administer the medication.During a concurrent interview, and record review on 11/20/2025, at 10:26 a.m., facility's policy and procedure (P&P), titled, Administering Medications, dated 3/2023, and last reviewed on 3/21/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.10. The following information is checked/verified for each resident prior to administering medications:a. Allergies to medications; andb. Vital signs, if necessary. The DON stated the facility's P&P indicated that nurses should follow the physician order. 056129 Page 2 of 2