Complete Care at Burlington Woods, LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Burlington Woods, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 13, 2023

  Based on observation, interview, and record review, it was determined that the facility failed to: a) ensure adequate supervision was provided to a resident to prevent falls, b) follow the facility accident policy to investigate falls, and consistently initiate new fall prevention interventions in response to falls, c) ensure current care plan interventions to prevent accidents were implemented. This deficient practice occurred for 1 of 1 resident reviewed (Resident #116) for fall with major injury who was identified as being at high risk for falls, sustained multiple falls including a fall on 02/14/22 that required transfer to the emergency room which resulted in a fracture of the left proximal humerus (arm bone) and the left olecranon (bony part of elbow), and required a surgical Open… […]

• Actual harm, isolatedF692Jul 29, 2021

  Based on observations, interviews, review of clinical records and facility policies and procedures, it was determined that the facility failed to a.) provide a timely and adequate nutritional assessment and/or intervention to impede an unplanned significant weight loss and improve the nutritional parameters for 1 of 6 residents reviewed for nutrition (Resident #132). Resident #132 had a unplanned significant weight as follows: Resident #132 experienced a 14.6 pound (lb.) 6 % weight loss in one week between 6/08/21 to 6/15/21, a 10.5% weight loss of 23.9 lbs. in one month from 6/08/2021 to 7/06/21, and a 31.6 lb. weight loss in seven weeks from 6/08/21 to 7/28/21. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2023

  Based on observation, interview and document review it was determined that the facility failed to ensure: a) potentially hazardous and perishable food items located in the refrigerator were labeled with a use by date and covered. b) staff restrained hair c) resident food storage areas were maintained in a clean and sanitary manner and food was appropriately labeled and dated with a use by date to prevent the potential for food borne illness. This deficient practice occurred in the main kitchen and 2 of 2 remote resident food pantries and was evidenced by the following: On [DATE] at 8:54 AM, the surveyor conducted a tour of the kitchen with Food Service Manager FSM and observed the following: 1) The walk-in refrigerator was observed with opened potentially hazardous food items that were… […]

• No harm, potential for more than minimal, widespreadF867Dec 13, 2023

  Based on observation, interview and document review, it was determined that the quality assessment and assurance committee (QAPI) facility failed to ensure: a) written policies and procedures were followed to ensure all adverse events were identified and investigated, b) written procedures were followed to ensure the QAPI was consistently data driven and measurable to ensure the effectiveness of the performance improvement initiative, and c) a mechanism was in place and consistently followed to obtain input from staff, residents/ resident representatives. […]

• No harm, potential for more than minimal, widespreadF812Jul 29, 2021

  Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 7/20/21 at 09:35 AM, the surveyor toured the kitchen in the presence of the Temporary Account Manager ([NAME]) and observed the following: 1. The surveyor washed hands at handwashing sink #1 and observed the paper towel dispenser was empty. […]