Burlington Convalescent Hospital

In the surveyor’s words

From the most serious findings on record at Burlington Convalescent Hospital, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 21, 2025

  Based on interview and record review, the facility failed to revise/update fall care plan to include updated interventions after the fall on 12/28/2024 to prevent a repeat fall for one of two residents (Resident 165) who was a high risk for fall. As a result, on 2/3/25, Resident 165 fell again and suffered severe pain of 7 (seven) out of 10 (7/10 - a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the buttocks and to the left and right thighs. On 2/5/2025, the facility transferred Resident 165 to General Acute Care Hospital (GACH) 1 via non-emergency medical transportation where Resident 165 was diagnosed with a left hip fracture (broken bone). […]

• Actual harm, isolatedF689Jan 5, 2022

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), who had dementia (loss of memory, thinking and reasoning), impaired vision, and was at risk for elopement (a resident who leaves the facility when doing so may present an imminent threat to the resident's health and safety because the resident is too impaired to make a decision to leave), was provided with a safe environment and supervision to prevent the resident from eloping as per the resident's comprehensive assessment, plan of care, and facility's policy. […]

• Actual harm, isolatedF689Nov 8, 2021

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with history of falls, and history of healed fracture (broken bone), was observed by staff frequently and provided a floor mat by the bed, per Resident 1's care plans on falls/injury and fracture. As a result, on 8/9/2021, at 1:02 PM, Resident 1 had a fall to the floor, requiring transfer to General Acute Care Hospital (GACH) where Resident 1 was diagnosed with a displaced and angulated oblique fracture (a break that is curved or at an angle to the bone) near the distal aspect of a medullary rod within the right femur (broken thigh bone). […]

• Actual harm, isolatedF600Apr 21, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse and prevent abuse (willful infliction of injury) for one of three sampled residents (Resident 3), when Resident 1, who was diagnosed with [CONDITION(S)] (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), identified with paranoia (thought process that causes an irrational suspicion or mistrust of others), and aggressive behavior leading to anger, and attempts to harm others, assaulted (a sudden, violent attack) Resident 3 on 11/1/2020. Resident 1 asked Resident 3 for a cigarette lighter. When Resident 3 stated he did not have a lighter, Resident 1 punched Resident 3 in the right eye. […]

• Actual harm, isolatedF689Apr 21, 2021

  Based on interview and record review, the facility failed to identify and evaluate accident risks and provide supervision to prevent accidents and injuries for one of three sampled residents (Resident 1). Resident 1, who was diagnosed with [CONDITION(S)] (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), and identified with paranoia (thought process that causes an irrational suspicion or mistrust of others) with aggressive behavior leading to anger and attempts to harm others, the facility failed to: 1.Provide one to one (1:1) monitoring for Resident 1, per the care plan interventions. […]