Burton Health Care Center

In the surveyor’s words

From the most serious findings on record at Burton Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF610Sep 1, 2022

  Based on record review, facility Self-Reported Incident review, facility policy and procedure review and interview the facility failed to ensure Temporary Nurse Aide (TNA) #369 was immediately removed from the facility once an allegation of resident abuse involving the TNA was made. This affected one resident (#222) and had the potential to affect 32 additional residents (#1, #7, #9, #10, #12, #13, #15, #18, #21, #30, #34, #30, #36, #40, #43, #44, #45, #47, #49, #51, #55, #56, #58, #59, #61, #62, #66, #67, #71, #231, #232 and #234) residing on the unit where TNA #369 worked. The facility census was 70. Findings include: Record review revealed Resident #222 was admitted to the facility on [DATE] for a respite stay and then transitioned to long term care placement on 08/24/22. […]

• No harm, potential for more than minimal, isolatedF580Sep 1, 2022

  Based on interview and record review the facility failed to ensure the physician was notified when Resident #224 missed five doses of her muscle relaxant and for Resident #56's elevated blood sugars. This affected two residents (Resident #56 and #224) out of two residents reviewed for physician notification of change in condition. The facility census was 70. Findings included: 1. Review of the medical record for Resident #56 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 02/07/22 revealed Resident #56 had diabetes. […]

• No harm, potential for more than minimal, isolatedF602Sep 1, 2022

  Based on record review, facility Self-Reported Incident (SRI) review and interview the facility failed to prevent the misappropriation of medications for Resident #58 and Resident #122. This affected two residents (#58 and #122) of two residents reviewed for misappropriation of medication. The facility census was 70. Findings Include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #58 had intact cognition. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the closed medical record for Resident #122 revealed an admitted [DATE]. Resident #122 expired on [DATE]. Resident #122 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF658Sep 1, 2022

  Based on record review, observation and interview, the facility failed to ensure medications were administered at the time they were prepared per professional standards. This affected two residents (Resident #16 and #17) of six Residents reviewed for medication administration. The facility census was 70. Finding included: Review of Licensed Practical Nurse (LPN) #320's personnel file revealed a date of hire of 06/28/13. There was no education and/ or disciplinary action revealed in her file regarding the concern of preparing medications in advance or leaving medications in rooms unattended. 1. Review of medical record for Resident #17 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]