Life Care Center of Burlington

Inspectors wroteThe facility had a census of 74 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for 73 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interviews the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide sanitary catheter (a tube inserted into the bladder to drain urine) care and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)40. The facility failed to implement an adequate water management program to prevent and /or mitigate risks from waterborne pathogens. This placed the residents at risk of contracting an infection or communicable diseases.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure all residents remained free from abuse when Resident (R)17 stomped on R8's foot after R8, who was cognitively impaired, went into R17's room. This placed the residents at risk for injury and ongoing abuse.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to identify a resident-to-resident incident as abuse and report immediately to the administrator when Resident (R)17 stomped on R8's foot after R8, who was cognitively impaired, went into R17's room. This placed the residents at risk for unidentified and ongoing abuse.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide protective measures and investigate an incident of resident-to-resident abuse by Resident (R)17, who stomped on R8's foot after R8, who was cognitively impaired, went into R17's room. This placed the residents at risk for unidentified and ongoing abuse.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents with three reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide written notification for the facility-initiated transfers and further failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) when Residents (R) 42, R32, and R217 discharged to a hospital. This placed the resident at risk for uninformed care decisions and impaired resident rights.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 47 received assistance eating her breakfast meal. This placed the resident at risk for choking, impaired nutrition, and further decline in ADL ability.

Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents with one reviewed for hospice services. Based on observation, record review, and interview the facility failed to ensure collaboration between the hospice provider and the facility for Resident (R)45, regarding the plan of care and the services provided including visit frequency, medications, and medical equipment. This placed the resident at risk of impaired end-of-life care.

Inspectors wroteThe facility reported a census of 64 residents with 11 selected for review including two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure the staff transferred the two residents reviewed, Resident (R)1 and R2 in a safe manner. Both residents required a full body mechanical (Hoyer) lift for transfers, and both had a fall when the staff transferred them with assistance of one staff member when the resident's required assistance of two staff.

Inspectors wrote- The Electronic Medical Record (EMR) documented R53 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 2 (when the body cannot respond to the insulin), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic diastolic heart failure (a condition in which the hearts main pumping chamber becomes still and unable to fill properly), and pulmonary hypertension (high blood pressure). R53's Medicare 5 Day Minimum Data Set (MDS), dated [DATE], documented R53 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. [...]

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for four sampled residents, Resident (R) 5, R17, R23, and R54. This placed the residents at risk for complications related to poor hygiene.

Inspectors wroteThe facility identified a census of 60 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 60 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure that food items stored in the refrigerator were properly labeled and dated. This deficient practice had the potential for food borne illnesses for the residents.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 49's plan of care with resident centered interventions to prevent and/or promote healing for a facility acquired pressure injury, which placed the resident at risk for continued unhealed wound.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents, with one reviewed for indwelling (tube placed in the bladder to drain urine into a collection bag) urinary catheterand urinary tract infection. The facility failed to provide Resident (R) 35 with appropriate catheter care which placed R35 for risk of infection.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to report blood sugars (the concentration of glucose [sugar] in the blood) outside of physician ordered parameters for two sampled residents, Resident (R) 5, and R9. This placed the residents at risk for physical decline and complications related to hyperglycemia (high blood sugar).

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 48's as needed (PRN) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication and failed to ensure an appropriate diagnosis for use of an antipsychotic (class of medications that treat psychosis (any major mental disorder characterized by a gross impairment in reality testing)) medication, which placed R48 at risk of receiving unnecessary psychotropic (medication that affects a person's mental status) medication.

Inspectors wroteThe facility reported a census of 56 residents. Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for residents and staff in the laundry.

Inspectors wroteThe facility reported a census of 56 residents. Based on observation, interview, and record review, the facility failed to ensure accurate labeling of seven insulin pens for five diabetic residents, Resident (R)45, R43, R207, R47, and R3 reviewed for medication label accuracy. Findings Included: -Resident 45's signed physician orders, dated 05/18/21, included diagnosis for diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The resident's order included Lispro Kwikpen (injectable medication [insulin pens] used to lower the level of blood glucose), five units, three times a day. In addition, the physician ordered Levemir (injectable medication used for diabetes), 20 units, at bedtime. Observation, on 07/07/21 at 02:45 PM, revealed four Lispro pens and one Levemir pen without accurate labeling. [...]

Inspectors wroteThe facility reported a census of 56 residents. The sample included 15 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a bed-hold policy for one of one resident, Resident (R) 59.

Inspectors wroteThe facility reported a census of 56 residents. The included 15 residents, with one resident reviewed for discharge. Based on interview and record review, the facility failed to complete a discharge summary consisting of a recapitulation of stay and a reconciliation of medications, as required, for one of one resident, Resident (R) 59 who transferred to another facility.

Inspectors wroteThe facility reported a census of 56. Based on record review, the facility failed to provide required prevention of abuse, neglect, exploitation and misappropriation of resident property for the staff of the facility.