Premier Rehab and Healthcare at Burlington

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the call light was within reach and secured for 1 (Resident #2) of 3 sampled residents while in bed.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and the implementation of care planned interventions for 1 of 3 sampled residents (Resident #1). The facility did not ensure staff followed the resident's individualized transfer requirements, including the use of a Hoyer lift with two staff members as outlined in the care plan and facility policy. A Licensed Nursing Assistant (LNA) independently conducted a manual transfer of Resident #1 and as a result, Resident #1 experienced pain and subsequently sustained a fractured scapula (shoulder blade).

Inspectors wroteBased on record review and interview, the facility failed to provide care to a resident with a wound vac (wound vacuum; a negative pressure pump that helps a wound heal faster by removing fluid and infection-causing bacteria with suction) in accordance with their facility policy for 1 of 1 sampled residents (Resident #14). The facility did not have a care plan or physician orders and evidence of monitoring in accordance with facility policy for the wound vac until 11/27/25, 22 days later, did not maintain a wound vac or following wound treatment orders after wound vac was removed on 11/13/25, and did not provide necessary education and ensure staff were competent to provide care to a resident with a wound vac. As a result, Resident #14 developed an infection requiring hospitalization and two surgical interventions.

Inspectors wroteBased on record review and interview, the facility failed to provide necessary education and ensure staff were competent to provide care to a resident with a wound vac (wound vacuum; a negative pressure pump that helps a wound heal faster by removing fluid and infection-causing bacteria with suction) for 3 of 3 sampled licensed nurses providing care to Resident #14 . As a result, Resident #14 developed an infection requiring hospitalization and two surgical interventions.

Inspectors wrotePer interview and record review, the facility failed to have a qualified food service director or a full-time qualified dietician. This has the potential to impact all residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide substantial snacks at bedtime when there is more than14 hours between a substantial evening meal and breakfast the following day. This has the potential to impact all residents.

Inspectors wroteBased on observations and interviews, the facility failed to store food in a safe, sanitary condition. This has the potential to impact all residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement infection control practices designed to provide a safe and sanitary environment for 1 of 4 units (Second floor) and ensure infection control measures were followed to prevent the transmission of diseases and infections for one randomly sampled resident (Resident #14).

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment regarding construction debris and resident room equipment maintenance and repair on 1 of 4 units (Second Floor).

Inspectors wroteBased on record review and interview the facility failed to put effective measures in place to ensure that further potential abuse does not occur while investigating an allegation of abuse for one of three sampled residents (Resident #73).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who required dialysis received services consistent with professional standards of practice for one of two residents (Resident #106).

Inspectors wroteBased on interview, record review, and observation, the facility failed to safely store locked medications for 1 of 7 medication carts.

Inspectors wroteBased on interview and record review, the facility failed to create and implement a baseline care plan for 2 of 3 sampled residents related to communication (Residents #1 and #2).

Inspectors wroteBased on record review and interview, the facility failed to assure that 2 of 4 residents reviewed were free from physical abuse (Resident #1 and Resident #3). 1. Per record review, Resident #1 was the victim of a physical assault on 5/18/25 at 9:30 AM. A progress note dated 5/18/25 says, Resident noted to have verbal altercation with [Resident #2], resulting in [Resident #2] hitting resident on the side of the face. Per interview with Resident #1 on 5/20/25 at 11:43 AM, s/he reported that Resident #2 was touching his/her belongings and when s/he tried to get Resident #2 to stop, it resulted in him/her getting hit in the head by Resident #2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of abuse was reported to the licensing agency for 1 of 5 sampled residents (Resident #5). Per record review, the facility was unable to provide evidence that they submitted a report to the state licensing agency after Resident #5 reported an allegation of abuse; being hit with a wet towel by a staff member. Additionally, there is no evidence of an investigation in Resident #5's medical record. Per interview with Resident #5's nurse on 5/20/25 at 11:54 AM, she reported that she sent a message using the electronic health record (EHR) reporting this incident on 4/29/25 and that Resident #5's hospice nurse also communicated with the Assistant Director of Nursing and the former Director of Nursing about this allegation of abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.71 regarding 13 residents [Res.#44, #145, #88, #73, #8, #1, #70, #87, #90, #295, #89, #21 and #6] of 44 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to treat and care for each resident in a manner that maintains their dignity and respect for 8 out of 29 Residents in the sample (Residents #3, #88, #19, #1, #81, #17, #39, and #8)

Inspectors wrotePer interview and facility policy review, the facility failed to establish a grievance reporting system that supports the resident's right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal for 6 of 29 sampled residents (Residents # 1, #19, #1, #81, #17, #39, and #8).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) without assistance receives the proper level of assistance for 3 of 29 sampled residents (Residents #18, #145, and #73) related to transferring and toileting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities that support the physical, mental, and psychosocial well-being of each resident for 1 of 29 sampled residents (Resident #29).

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident environments were free of accident hazards related to smoking for one sampled resident (Resident # 86).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure residents receiving PRN (as needed) medications were appropriately evaluated for psychoactive drug use beyond 14 days for 1 resident in a standard survey sample of 7 (Resident #51).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide residents with food that accomodates preferences regarding drink options.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that there is sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services. This has the potential to affect all residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food served to residents is palatable, attractive, and at an appetizing temperature.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide all residents appealing options of similar nutritive value when the menu options did not meet his/her expressed preferences.

Inspectors wroteBased on interview and record review the facility failed to ensure the screening for abuse was completed according to their policy for 1 of 3 Licensed Nursing Assistants reviewed (LNA #1).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure each resident is free from significant medication errors for one of three residents (Resident #12).

Inspectors wroteBased on interview and record review, the facility failed to provide radiology services to meet the needs of its residents for one applicable resident (Resident #1) related to not obtaining an x-ray.

Inspectors wrotePer interview and record review, the facility failed to include the resident and their representative in developing a baseline care plan and failed to provide the resident and the representative a baseline care plan summary for 3 of 3 residents sampled (Residents #1, #2, and #3).

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one applicable resident (Resident #1) by neglecting to provide services that are necessary to avoid physical harm and emotional distress related to providing care to a port (port-a-cath; a device, typically implanted in the chest, used to access the central vein to deliver medications or obtain blood samples) for 1 applicable resident (Resident #1). As a result, Resident #1's port became infected and had to be removed which delayed Resident #1's chemotherapy.

Inspectors wroteBased on interview and record review, the facility failed to provide care to a port [A port protects your veins during cancer treatment. An implanted port is a type of central venous catheter .[that] lets the medication go into your bloodstream through your vein. It can be used to give you medication for several days in a row.1.] for 1 applicable resident (Resident #1) as evidenced by staff not conducting comprehensive skin assessments, obtaining and implementing orders for port care, and care planning for the care of a port. As a result, Resident #1's port became infected and had to be removed which delayed Resident #1's chemotherapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for three applicable residents (Resident #1, #3, and #5).

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 7 of 7 sampled alleged abuse allegations. Facility policy titled OPS300 Abuse Prohibition states: 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following . 7.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required. 11 All documentation related to allegations of abuse will be maintained at the Center for not less than three (3) years. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide activities that support the physical, mental, and psychosocial well-being of each resident for 1 of 20 sampled residents (Resident #63).