Burgess Square Healthcare CTR

In the surveyor’s words

From the most serious findings on record at Burgess Square Healthcare CTR, in the surveyor’s own words.

• Actual harm, isolatedF686May 21, 2026

  Based on observation, interview, and record review, the facility failed to monitor for and report changes in existing pressure ulcers, prevent the development of new pressure areas, and failed to ensure pressure ulcer treatments were in place.This failure resulted in delayed identification of a resident's stage two coccyx pressure ulcer deteriorating to a necrotic and unstageable pressure ulcer, with a subsequent delay in treatment changes.This applies to 2 out of 4 (R1and R4) reviewed for pressure ulcers. The findings include:1. […]

• Actual harm, isolatedF760Nov 20, 2025

  Based on interview and record review, the facility failed to administer blood thinner medication as ordered by the physician. This failure resulted in R1 experiencing an elevated INR (International Normalized Ratio) blood test and requiring the administration of Vitamin K and hospitalization. This applies to 2 of 3 residents (R1, R4) reviewed for medication administration in the sample of 5.The findings include: 1. On November 17, 2025, R1 was sitting quietly. She was unable to answer questions due to her cognitive status.The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on November 4, 2025 and returned to the facility on November 5, 2025. […]

• Actual harm, isolatedF686Mar 8, 2024

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure sores. This failure resulted in R1 developing a Stage 3 pressure sore to her sacrum. This applies to three of four residents (R1, R3 and R4) reviewed for wounds. Findings include: 1. R1 was admitted to the facility on [DATE] for rehabilitation following a bilateral hip replacement. R1 has diagnoses that includes anemia, morbid obesity, diabetes, urine retention, constipation, anxiety, congestive heart failure, muscle weakness and a history of falling. R1 was discharged from the facility on 11/05/2023. The admission assessment, dated 9/29/2023, identified bruises on R1's left hand and right lower leg. […]

• Actual harm, isolatedF693Aug 27, 2021

  Based on observation, interview, and record review, the facility failed to ensure a resident received the prescribed amount of tube feeding. This failure caused the resident to receive too much tube feeding, resulting in an eight-day hospitalization for acute congestive heart failure. This applies to 1 of 2 residents (R1) reviewed for tube feedings. The findings include: R1's Face Sheet showed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's August 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's 8/14/21 Initial Facility Report showed, Nurse administered incorrect amount of tube feeding. Resident sent to hospital for eval (evaluation) and treat. […]

• Actual harm, isolatedF689Jul 8, 2021

  Based on interview and record review, the facility failed to ensure safe practices or follow their policy when turning a resident in bed for a confused resident with a high fall risk. This failure resulted in the resident falling out of bed sustaining a subacute subdural hemorrhage and was admitted to the Intensive Care Unit. This applies to 1 of 3 residents (R1) reviewed for falls. The findings include: According to the Electronic Health Record (EHR), R1 had diagnoses including nontraumatic chronic subdural hemorrhage, urinary tract infection, [CONDITION(S)], [CONDITION(S)], skin cancer, asthma, anxiety disorder, colon cancer, prostate cancer, and [CONDITION(S)]. […]