Burke Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Burke Health & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jun 29, 2023

  Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a clean homelike environment for 1 Resident (Resident #38) in a survey sample of 38 Residents. The findings included: For Resident #38, the facility staff failed to provide a clean and homelike environment by ensuring cobwebs were removed. On 6/27/23 at approximately 2:00 PM, Surveyor C visited Resident #38 in his room. Surveyor C noticed 2 cobwebs in the ceiling corner of the room over the Resident's bedside table. On 6/27/23 at 2:50 PM, LPN C accompanied Surveyor C to Resident #38's room. LPN C was shown the cobwebs and confirmed them. On 6/27/23 at approximately 3 PM, the Director of Nursing came to the room and confirmed the above findings. […]

• No harm, potential for more than minimal, patternF658Jun 29, 2023

  Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure nursing standards of practice were followed for 2 Residents (Resident #15 and #217) in a survey sample of 38 Residents. The findings included: 1) For Resident #15, LPN D failed to verify the right resident during medication pass. On 6/29/23 at 9:58 AM, LPN D was observed during the medication administration. LPN D pulled and prepared the medication for Resident #217, which was a total of 8 pills (tablets and capsules). […]

• No harm, potential for more than minimal, patternF755Jun 29, 2023

  Based on observation, staff interview, and facility documentation review, the facility staff failed to implement a system to account for and reconcile controlled drugs on 1 of 2 nursing units. The findings included: 1. The facility staff failed to implement their system of reconciliation to ensure the appropriate quantity of controlled medications was accurate on 2 of 4 medication carts inspected. 1a. On 06/28/23 at 05:19 PM, a medication storage inspection was conducted of the second floor, medication cart 1 with LPN E. During the verification of the controlled medications, it was determined that the controlled count was not correct. […]

• No harm, potential for more than minimal, patternF759Jun 29, 2023

  Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 9 medication errors in 31 opportunities, resulting in an 29.03% error rate. The findings included: On 6/29/23 at 9:58 AM, LPN D was observed during medication administration. LPN D pulled and prepared the medication for Resident #217, which was a total of 8 pills (tablets and capsules). The medications were: Amlodipine Besylate 10 MG tablet for hypertension/blood pressure, Oxycodone 5 mg immediate release tablet for pain, Budesonide extended release 3 mg capsule for Crohn's disease, Carvedilol 6.25 mg tablet for hypertension, Venlafaxine HCl extended release 150 mg capsule for depression, Prevacid delayed… […]

• No harm, potential for more than minimal, patternF761Jun 29, 2023

  Based on observation, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications on 2 of 4 medication carts inspected. The findings included: For 2 of 4 medication carts inspected, the facility staff failed to label insulin with the open date to ensure it is not used beyond the expiration date. On [DATE] at 05:19 PM, an inspection was conducted of the second-floor cart 1, in the presence of LPN E. The following was noted: A Lantus Solostar pen was open, had been used, and had no open date. A Humalog 100-unit multi-dose vial was dated [DATE]. LPN E stated, today is last day, indicating it was good for 31 days. On [DATE] at 05:34 PM, an inspection of the 2nd floor, cart 2, was conducted. […]