Burlington Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678Sep 14, 2023

  Based on record review and interview, the facility did not have an effective system to ensure residents' advanced directives for emergency end-of-life care/code status were accurate and carried out as the resident wished and did not follow facility policies to call a Code Blue when a resident was found pulseless and non-breathing. This affected 1 of 1 residents (R1) who expired while at the facility and 11 of 16 sampled residents (R11, R30, R27, R28, R29, R20, R7, R22, R23, R24, R25) whose code statuses identified delays in obtaining resident/responsible party signatures, witness signatures, signatures of the physician/nurse practitioner and at times issues with code status orders. […]

• Immediate jeopardy, patternF689Dec 15, 2022

  Based on observation, interview and record review, the facility did not ensure it provided an environment that was free of accident hazards and safe for 43 residents of 45 residents reviewed for safety concerns. The facility identified at the time of the survey, 40 residents smoked and utilized the smoking patio at the facility. Additional concerns exist regarding R7 and R4. On 12/6/22 Surveyor observed R20 being taken out to the smoking patio by Certified Nursing Assistant (CNA)-P and observed R20 actively had oxygen on. The CNA was heard speaking to R20 about not wearing oxygen and smoking prior to the CNA leaving R20 unsupervised. R20 was then observed interacting with other residents on the patio including R21 who told R20 to take off her oxygen as they walked to R20. […]

• Immediate jeopardy, isolatedF740Nov 2, 2023

  This is an uncorrected deficiency from Survey Event: VLJH11 Based on interview and record review the facility did not ensure 4 (R2, R4, R5, & R32) of 4 residents received necessary behavioral health care to attain their highest practicable mental health well-being. * R2 is a long-term resident with a history of substance abuse, behavioral and mental health concerns. R2 had an extensive history of taking Clonazepam multiple times daily to address an anxiety disorder. In May of 2023, the facility became aware of treatment concerns in the relationship between R2 and the psychiatric Nurse Practitioner who had been addressing his anxiety disorder and prescribing his Clonazepam. […]

• Immediate jeopardy, isolatedF841Nov 2, 2023

  Based on interview and record review, the Facility failed to utilize the services of the Facility's Medical Director to ensure 1 (R2) of 1 Residents received the appropriate behavioral health services, including ensuring R2 received medications and health services as assessed. R2 had been receiving Clonazepam since being admitted in 2020. In May of 2023, the facility became aware that the psychiatric nurse practitioner (psych NP) that was seeing R2 and actively prescribing R2's antianxiety medication would no longer see R2. The psych nurse practitioner did not help refer R2 to an alternate provider and the psychiatrist supervising the psych nurse practitioner did not step in to assess R2 or help refer R2 to an alternate provider. […]

• Immediate jeopardy, isolatedF600Sep 14, 2023

  Based on interview and record review the facility failed to protect 1 of 6 residents (R10) right to be free from sexual and mental abuse by Dietary Aide (DA)-O. (DA)-O failed to maintain caregiver boundaries by engaging in a personal/sexual relationship with R10. DA-O became overly involved with R10 which included spending inappropriate amounts of time while off duty with R10, directing staff that she was providing 1:1 supervision and cares of R10, such as doing dressing changes, allowing R10 to call her for support when R10 wanted to get high, allowing R10 to watch movies at her home, assisting R10 with detoxing by providing R10 with narcotics (such as Heroin and/or Fentanyl). The facility was aware of the relationship and dynamics that were developing between DA-O and R10. […]