Burlington Convalescent Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to make reasonable efforts to accommodate and timely respond to one of five sampled residents (Resident 1), request for a room change and failed to document Resident 1's request and the facility's actions in the medical record, in accordance with facility policy. This failure resulted in Resident 1 remaining in an environment that increased her anxiety due to disruptive behaviors exhibited by neighboring residents. During a review of Resident 1's admission Record, dated 7/28/2026, indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician regarding a significant change in condition for one of three sampled residents (Resident 1), who refused to continue dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) treatment and verbalized a desire to die. This failure resulted in delayed physician evaluation, psychiatric intervention, and implementation of medically necessary treatment and safety measures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) to address diagnosis of depression (a mood disorder that may cause persistent sadness or loss of interest in activities), refusal of treatment, and non-pharmacological interventions for mood and behavioral symptoms. This failure had the potential to place the resident at risk for worsening depression, psychosocial decline, nutritional compromise, and lack of appropriate mental health interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for one of three residents (Resident 1) by failing to obtain timely psychiatric evaluation and intervention for Resident 1 exhibiting depression (a mood disorder that may cause persistent sadness or loss of interest in activities), refusal of dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to), and verbalizations indicating a desire to die. This failure placed Resident 1 at risk for worsening mental health status, self-neglect, decline in medical condition, and avoidable harm. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen staff labeled all foods stored in the refrigerator and freezer with the correct food name, date of food delivery, date the food container was opened, and best by date. This deficient practice of not correctly labeling all foods stored in the refrigerator and freezer had the potential for residents who consume food from the kitchen to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages) and hospitalization

Inspectors wroteBased on interview and record review, the facility failed to ensure that two out of two residents (Resident 5 and Resident 45) did not sign Advanced Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Resident 5 and Resident 45 had severe cognitive (the mental ability to make decisions of daily living) impairment. This deficient practice violated Resident 5 and Resident 45's rights with the potential to cause conflict with the residents healthcare wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to securely store and dispose off personal health identifiable (PHI - any health-related data that can directly or indirectly trace back to a specific individual) information was stored securely and disposed after admission from a general acute care hospital (GACH) visit for one of one (Resident 129). The deficient practice had the potential to result in a breach protected PHI and medical identity theft, targeted financial fraud, and alterations to personal medical records for Resident 129's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for one out of one resident (Resident 110). This deficient practice had the potential for Resident 110 to experience low self esteem and not appreciated.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff provided an accurate medical concern description to an optometrist (OPT - a primary healthcare professional who specializes in eye and vision care) when Resident 101's eyeglasses were missing for of one of four residents' (Resident 101) . This deficient practice resulted in Resident 101 complaining that without his eyeglasses, his eyes would get wet, it was very hard to see or do anything, he could not read and loves to read.

Inspectors wroteBased on interview and record review, the facility failed to supervise and monitor and immediately attend to residents' meal carts to ensure that one of one sample resident (Resident 54) did not access meal carts that had left over foods and drinks. Resident 54 has a history of dysphagia (difficulty swallowing). This deficient practice placed Resident 54 at increased risk for aspiration (accidentally inhaling food or liquids which can lead to infection), hospitalization, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove expired medication prescribed for two out of eight sampled residents (Resident 6 and Resident 64) from the medication cart (is a mobile workstation used in healthcare facilities to store, transport, and dispense medicines, medical equipment, and supplies). This deficient practice had the potential to result in the administration of expired medications to residentsFindings: A review of Resident 6's admission record indicated Resident 6 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure), Acute Kidney Failure (a condition in which the kidneys suddenly can't filter waste from the blood), and Depression (a constant feeling of sadness and loss of interest). [...]

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Resident 4 and Resident 54) the facility failed to:1. Ensure staff provide Resident 4 with a clean urinal (a portable, reusable or disposable container into which a resident can urinate without getting out of bed) This deficient practice placed Resident 4 at increased risk for infections due to contamination (unintentional transfer of bacteria/germs or other contaminants from urinal to the resident).2. Ensure Resident 54 did not have access to meal carts with left over foods and drinks already consumed by residents. This deficient practice placed Resident 54 at increased risk to suffer from food borne illness/ infections due to contaminated (unintentional transfer of bacteria/germs or other contaminants from urinal to the resident) food and drinks

Inspectors wroteBased on observations and interview, the facility failed to maintain an insect free building according to its facility's policy and procedures (P&P) titled Pest Control with review date 3/17/2026, for one of one sampled resident room (Resident 14). This deficient practice had the potential to significantly compromise the resident's safety, health leading to infection and possibly hospitalization.

Inspectors wroteBased on interview and record review the facility failed to maintain record that is complete and accurate for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1. Provide assistance with activities of daily living (ADLs) on 11/11/22. 2. Document nursing services that were provided to Resident 1 on 11/11/22 from 7 p.m. to 12:30 a.m. These deficient practices resulted in incomplete and inaccurate medical record for Resident 1.

Inspectors wroteBased 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). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received meals with flavor, attractive, appetizing, nutritive value, proper temperature, safe, and adequate portions. This deficient practice had the potential for the residents to experience poor/reduced meal intake, weight loss, and a decline in their health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to ensure that: 1. Kitchen staff are trained and competent in food cooling down method 2. Cooked left over chicken and ground beef are not stored in the refrigerator 3. Kitchen staff recorded and retained documented evidence of the cooling down food/meat following the cooling down method. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation and record review, the facility failed to provide a refrigerator to store food brought in for the residents. This deficient practice had the potential to cause food borne illness due to the residents not having a refrigerator to store their food.

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that a resident would not be allowed to keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications for one of 12 sampled residents (Resident 58). This deficient practice had the potential for other residents to gain access/ingest the medication and or result in adverse reaction to the medication.

Inspectors wroteBased on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change in a Residents Condition or status revised 3/2023 for one of four sampled residents (Resident 39). This deficient practice had the potential to result in the delay of care for Resident 39.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan in accordance with the facility's policy and procedures (P&P) titled Care plans, Comprehensive Person-Centered revised 3/2023 for one of four sampled residents (Resident 39). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 39.

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for one of four residents (Residents 14) This failure had the potential to result in Resident 14 acquiring infection, and foul odor of the feet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff did not crush Ferrous Sulfate (supplement) Oral (by mouth) tablet 325 (65 Fe) mg 1 tablet by mouth and administered via gastrointestinal tube (G-tube -feeding tube surgically inserted into the stomach). for one of four sampled residents (Resident 315). This deficient practice: 1. Resulted in staff crushing and administering Ferrous Sulfate Oral tablet 325 mg 1 tablet via GT for six days. 2. Had the potential to result in increasing the risks of side effects, toxic effects and/or hospitalization.

Inspectors wroteBased on interview and record review, facility failed to accurately and completely document medication administration in the resident's chart for one of four sampled residents (Resident 39). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 39.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 39 of 45 resident room(rooms 3,5,6,7,8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45). Rooms 3,5 and 6 had two beds inside the room. Rooms 8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45 had three beds inside the room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the staff, which could affect the quality of life and safety for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call buttons were within reach for two of 26 sampled residents (Resident 1 and Resident 11). This deficient practice had the potential for the residents' needs not being met, placing the residents at risk for accidents including falls and injuries.

Inspectors wroteBased on interview and record review, facility failed to obtain and retain all resident assessment for hospice (care that is focused on the comfort and quality of life for a person with a serious illness who is approaching the end of life) care in residents active record for one of three sampled residents (Resident 44). This deficient practice had the potential for the resident not receiving needed care according to assessment and care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and food thawing practices in the kitchen when: a. Thawing pork at room temperature. b. One of five staff did not wear gloves during Trayline food preparation. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in medically compromised residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, facility failed to obtain and retain all resident assessment for hospice (care that is focused on the comfort and quality of life for a person with a serious illness who is approaching the end of life) care in residents active record for one of three sampled residents (Resident 44). This deficient practice had the potential for the resident not receiving needed care according to assessment and care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the handwashing sink for kitchen area in a safe operating condition. This deficient practice had the potential for kitchen staff not being able to perform hand washing which was required for staff before starting work in the kitchen and before and after handling foods.

Inspectors wroteBased interview, and record review, the facility failed to ensure that advanced healthcare directives (legal documents that outline an individual's preferences regarding major medical decision) information was provided to the resident representative (RP) for one of eight sampled residents (Resident 11). This deficient practice had a potential to violate the resident's rights related to the provision of health care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 39 of 45 resident room(rooms 3,5,6,7,8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45). Rooms 3,5 and 6 had two beds inside the room. Rooms 8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45 had three beds inside the room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the staff, which could affect the quality of life and safety for the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents ' environment remained free of accident hazards for one of three residents (Resident 1) by failing to ensure that a box of hand rubber gloves was not left within reach of a resident with a dementia (a decline in thinking skills). On 12/13/2023, Resident 1 developed acute (severe) sudden shortness of breath. This deficient practice resulted in Resident 1 was transferred to the General Acute Care Hospital (GACH 1) and during endotracheal intubation (a medical procedure in which a tube is placed into the windpipe through the mouth or nose) a rubber glove was found intraorally and was removed.