Burlington House Rehab & Alzheimer's Care Center

In the surveyor’s words

From the most serious findings on record at Burlington House Rehab & Alzheimer's Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 8, 2023

  Based on medical record review, observations, staff interview, review of witness statements, review of the police report, review of information from Google Maps, review of a weather report, review of the facility investigative files, review of in-service education, and policy review, the facility failed to complete thorough investigations following resident elopements to prevent additional elopements from occurring. Additionally, the facility failed to update residents' elopement assessments and care plans following elopements. Lastly, the facility failed to identify like-residents at risk for elopement to ensure appropriate interventions were in place to potentially prevent the same actions, situations, and/or practices from occurring in the future. […]

• Immediate jeopardy, isolatedF684Sep 14, 2022

  Based on medical record review, review of the hospital records, staff interviews, and review of the facility policies, the facility failed to provide a resident with timely care and treatment to a wound which was found on 07/31/22. This resulted in Immediate Jeopardy when Resident #10 was placed at a potential risk for serious life-threatening harm and injury when Resident #10 went without a physician ordered wound treatment and no wound team follow up from 07/31/22 to 08/07/22. Resident #10 developed maggots and gangrene on his right second toe resulting in [CONDITION(S)] (bone infection) and required a partial amputation to the right foot on 08/15/22. This affected one (#10) of three residents reviewed for wound care at the facility. […]

• Actual harm, isolatedF686Jan 31, 2023

  Based on record review, staff interview, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement physician-recommended interventions for residents with pressure ulcers, failed to thoroughly assess resident's skin and failed to identify pressure ulcers until they had already reached an advanced stage. This resulted in Actual Harm to Resident #105 who was admitted to the facility without pressure ulcers and developed an avoidable unstageable pressure ulcer to his right heel. This affected one (#105) of three residents reviewed for pressure ulcers. The facility census was 99. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF761May 8, 2023

  Based on observation, interview, review of manufacturer recommendations, and policy review, the facility failed to ensure expired medications were removed from the medication carts. This affected two medication rooms out of two observed, and two medication carts out of three carts observed for expired medications. This had the potential to affect all residents who reside in the facility. The facility census was 101. Findings include: Observation on 04/24/23 at 1:22 P.M. of the west unit cart one with Licensed Practical Nurse (LPN) #315 revealed there was one bottle of stool softener that expired on 10/2022, a bottle of calcium carbonate (a supplement) expired on 11/2022, and a bottle of senna plus (a laxative) that expired on 03/2023. Observation on 04/24/23 at 1:23 P.M. […]

• No harm, potential for more than minimal, widespreadF801May 8, 2023

  Based on record review, observations, and staff interviews, the facility failed to ensure dietary staff were competent to fulfill their responsibilities. This had the potential to affect 100 residents who received food from the kitchen. The facility identified one resident (#24) who did not consume any food from the kitchen. The facility census was 101. Findings include: Interview on 04/19/23 at 5:49 P.M. with Culinary Aide #342 revealed he would put his hand in the water from the dishwasher and make an educated guess regarding the temperature. Review of a performance evaluation for Culinary Aide #346 completed on 11/07/22 indicated Culinary Aide #346 had an N for no on the evaluation for testing of parts per million (PPM) for the low temperature dishwasher. […]