Inspection Reports for Addington Place of Burlington
5175 West Avenue, Burlington, IA, 52601
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 28, 2025, found no deficiencies during complaint investigations. Earlier inspections showed a mixed pattern, with some reports citing deficiencies related mainly to tenant care documentation and assistance, particularly involving incontinence and respite care services. Prior investigations also noted issues with service plans, staff training, medication administration, and emergency procedures, but enforcement actions such as fines were limited to isolated structural and training deficiencies in earlier years. Complaint investigations were mostly unsubstantiated, with substantiated cases focusing on care documentation and notification of involuntary transfers. The facility’s recent clean inspections suggest improvement in addressing prior concerns.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
46 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
The inspection was conducted to investigate Incident #129056-I and Complaint #129767-C at the assisted living facility.
Complaint Details
Investigations of Incident #129056-I and Complaint #129767-C were conducted and found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigations of the incident and complaint.
Report Facts
Number of tenants without cognitive impairment: 37
Number of tenants with cognitive impairment: 9
Total census: 46
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The document is a plan of correction related to investigations of specific complaint or incident numbers at an assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigations of complaint or incident numbers #125242-I, #125810-C, #124869-I, or #126903-M.
Report Facts
Number of tenants without cognitive impairment: 43
Number of tenants with cognitive impairment: 17
Total census: 60
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as an investigation into complaints #122113-C and #124337-C regarding regulatory insufficiencies at Addington Place of Burlington.
Complaint Details
The investigation was triggered by complaints #122113-C and #124337-C. Findings were substantiated as the program failed to meet tenant rights and respite care service requirements.
Findings
The program failed to provide appropriate services to tenants, including inadequate documentation and assistance with incontinence care and respite care services. Specific deficiencies included failure to document care provided to tenants and failure to provide written directions for respite care needs.
Deficiencies (2)
Failure to provide appropriate services to 2 of 3 tenants reviewed, including inadequate assistance with toileting and incontinence care.
Failure to provide written directions to staff regarding care needs for 1 former respite care individual.
Report Facts
Number of tenants without cognitive impairment: 33
Number of tenants with cognitive impairment: 14
Total census: 47
Dates missing documentation for Tenant #1: 18
Dates missing documentation for Tenant #2: 22
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
Investigation of Complaint #118616-C at Addington Place of Burlington.
Complaint Details
Investigation of Complaint #118616-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive impairment: 41
Number of tenants with cognitive impairment: 12
Total census: 53
Inspection Report
Renewal
Census: 48
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
The visit was conducted as a recertification to determine compliance with certification for an Assisted Living Program for People with Dementia, including investigation of related complaints and incidents.
Complaint Details
The investigation into Complaint #116720-C, Incident #114007-I, and Incident #114660-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation into Complaint #116720-C and related incidents.
Report Facts
Number of tenants without cognitive disorder in general population: 31
Number of tenants with cognitive disorder in general population: 2
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 15
Total census of Assisted Living Program for People with Dementia: 48
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
Investigation into Complaint #100395-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #100395-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in General Population: 15
Number of tenants with cognitive disorder in General Population: 10
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Total Census of Assisted Living Program for People with Dementia: 34
Inspection Report
Renewal
Census: 37
Deficiencies: 0
Date: Aug 12, 2021
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program for People with Dementia and to conduct an onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the recertification visit or the onsite infection control survey.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 4
Date: Oct 29, 2020
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (93137-C, 93138-C, and 91278-C) and an onsite infection control survey. The visit aimed to investigate alleged regulatory insufficiencies related to tenant rights, tenant documents, service plans, and nurse reviews.
Complaint Details
The complaint investigation was triggered by complaints #93137-C, 93138-C, and 91278-C. No regulatory insufficiencies were cited during the investigation of Complaint #93742-C or the onsite infection control survey. The findings related to tenant rights, documentation, service plans, and nurse reviews were substantiated during the investigation.
Findings
The investigation found regulatory insufficiencies including failure to ensure tenants were free from restraints, incomplete tenant documentation such as missing powers of attorney, failure to update service plans after significant changes, and failure to conduct nurse reviews after significant changes in tenant conditions. Multiple tenants had incidents involving falls, injuries, and unmet care needs.
Deficiencies (4)
Failure to ensure restraints were not utilized for 1 of 5 tenants reviewed (Tenant #4).
Failure to maintain required tenant documents including power of attorney paperwork for Tenant #3.
Failure to update service plans within 30 days of significant change for 4 of 5 tenants reviewed.
Failure to ensure nurse reviews were completed with significant changes for 4 of 5 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder in general population: 37
Number of tenants with cognitive disorder in general population: 4
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 8
Total Census: 49
Tenants reviewed for deficiencies: 5
Tenants reviewed for documentation: 4
Tenants reviewed for nurse reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported involvement in restraint use and COVID-19 testing process for Tenant #4 | |
| Health Services Director | Health Services Director (HSD) | Involved in restraint use, care plan updates, nurse reviews, and confirming findings |
| Executive Director | Executive Director | Confirmed findings and involved in corrective actions |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Date: Nov 25, 2019
Visit Reason
The inspection was conducted as an investigation into Complaint #87013-C regarding regulatory insufficiencies at the assisted living program for people with dementia.
Complaint Details
The visit was triggered by Complaint #87013-C. The complaint was substantiated as deficiencies were found related to incident reporting, staff training, and service plan accuracy.
Findings
The investigation found multiple deficiencies including failure to complete an incident report for an unusual occurrence involving a tenant, inadequate staff training and competency related to service plan tasks, and failure to ensure individualized service plans reflected tenants' identified needs and preferences.
Deficiencies (3)
Failure to complete an incident report for an unusual occurrence affecting Tenant #4 involving insertion of a hanger into the anus to alleviate constipation.
Failure to ensure staff were competent and trained to meet the needs of tenants, specifically regarding toileting assistance for Tenant #1.
Failure to ensure service plans were individualized and reflected tenants' identified needs and preferences, including lack of wheelchair use documentation for Tenant #3 and failure to update service plan to reflect removal of hangers from Tenant #4's room.
Report Facts
Total census: 50
Number of tenants without cognitive disorder: 41
Number of tenants with cognitive disorder: 3
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported concerns about Tenant #1's incontinence briefs and toileting assistance | |
| Staff B | Reported concerns about Tenant #1 being wet in the morning and marking incontinence briefs | |
| Staff C | Reported marking incontinence briefs for Tenant #1 and observations of wet briefs | |
| Staff D | Overnight shift staff who reported never changing Tenant #1's incontinence brief | |
| Staff E | Overnight shift staff who had never met or checked on Tenant #1 | |
| Health Services Director | Interviewed regarding incident report, staff training, and service plan issues | |
| Executive Director | Confirmed incident report should have been completed and findings |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Date: Nov 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation into regulatory insufficiencies cited during Complaint #87013-C related to the Assisted Living Program for People with Dementia at Sunnybrook of Burlington.
Complaint Details
Complaint #87013-C investigation revealed regulatory insufficiencies related to incident reporting, staffing competency, and service plan adequacy.
Findings
The investigation found failures in completing incident reports for unusual occurrences affecting tenants, inadequate staff training and competency in meeting tenant needs, and deficiencies in service plans for tenants. Specific incidents included failure to report a hanger incident and inadequate toileting assistance for a tenant, as well as incomplete service plans for multiple tenants.
Deficiencies (3)
Program failed to complete an incident report for an unusual occurrence affecting 1 of 4 tenants (Tenant #4) involving a hanger incident.
Staffing deficiencies: failure to ensure staff were competent and trained to meet tenant needs and provide training regarding service plan tasks for 1 of 3 tenants reviewed (Tenant #1).
Service plans were not individualized or did not reflect identified needs for 2 of 4 tenants reviewed (Tenants #3 and #4).
Report Facts
Number of tenants with cognitive disorder: 9
Total census of Assisted Living Program for People with Dementia: 50
Number of tenants without cognitive disorder in General Population: 41
Number of tenants without cognitive disorder in Memory Care Unit: 0
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Oct 17, 2019
Visit Reason
The inspection was conducted as part of an investigation of Complaint #86023-C regarding regulatory insufficiency related to involuntary transfer from the program.
Complaint Details
Complaint #86023-C was investigated and found that the program did not meet requirements for notifying Tenant #1 and her POA about the involuntary transfer and discharge process.
Findings
The program failed to provide written notice of an involuntary transfer to Tenant #1, who was discharged due to higher health needs than the program could provide. The Executive Director and Health Services Director assessed the tenant and determined she was not appropriate to return. The tenant's Power of Attorney (POA) was not informed properly, and no discharge paperwork was provided.
Deficiencies (1)
Failure to provide written notice of an involuntary transfer from the program to Tenant #1.
Report Facts
Number of tenants without cognitive disorder in general population: 42
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 5
Total census of Assisted Living Program for People with Dementia: 48
Date tenant admitted to program: Jul 12, 2019
Date tenant hospitalized: Jul 15, 2019
Date tenant discharged: Sep 30, 2019
Date POA signed occupancy agreement: Jul 12, 2019
Notice period days: 30
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Date: Jul 29, 2019
Visit Reason
Investigation of Complaint #84137-C at Sunnybrook of Burlington.
Complaint Details
Complaint #84137-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in general population: 54
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 2
Number of tenants with cognitive disorder in memory care unit: 6
Total Census: 62
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Apr 3, 2019
Visit Reason
The inspection was conducted to investigate Complaint #81455-C at the assisted living facility.
Complaint Details
Complaint #81455-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder in general population: 39
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 2
Number of tenants with cognitive disorder in memory care unit: 10
Inspection Report
Renewal
Census: 50
Deficiencies: 4
Date: Jan 14, 2019
Visit Reason
The inspection was a recertification visit to determine compliance with certification rules for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection found multiple regulatory insufficiencies including failure to complete nurse delegated training within 30 days for some staff, failure to complete evaluations with significant change for some tenants, failure to develop and update service plans based on evaluations, and failure to complete required dementia-specific education for staff within 30 days of employment.
Deficiencies (4)
Program failed to complete nurse delegated training within 30 days of hire for 2 of 7 staff reviewed.
Program failed to ensure evaluations were completed as needed with significant change for 3 of 5 tenants reviewed.
Program failed to develop and update service plans based on evaluations for 5 of 5 tenants reviewed.
Program failed to complete eight hours of dementia-specific education within 30 days of employment for 5 of 7 staff reviewed.
Report Facts
Number of tenants without cognitive disorder in general population: 37
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 3
Number of tenants with cognitive disorder in memory care unit: 9
Total Census of Assisted Living Program for People with Dementia: 50
Staff reviewed for nurse delegated training: 7
Staff failed nurse delegated training within 30 days: 2
Tenants reviewed for evaluations: 5
Tenants failed evaluation completion as needed: 3
Tenants reviewed for service plans: 5
Staff reviewed for dementia-specific education: 7
Staff failed dementia-specific education within 30 days: 5
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Oct 8, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during investigations of complaint 78501-C.
Complaint Details
The complaint investigation found the program failed to ensure staff awareness and access to the backup system for medication documentation during electronic system malfunction. The finding potentially affected 50 tenants. The program corrected the issue by retraining staff and implementing measures to monitor compliance.
Findings
The program failed to consistently ensure staff were aware of the backup system to document medications when the electronic medication administration record system malfunctioned, potentially affecting 50 tenants. No regulatory insufficiencies were cited regarding investigation 78755-C.
Deficiencies (1)
Program failed to maintain a list of each tenant's medications and document medications administered when the electronic medication administration record system malfunctioned.
Report Facts
Number of tenants without cognitive disorder in general population: 40
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 11
Total census: 52
Tenants potentially affected: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas O Nelson | Executive Director | Signed the report |
| Staff A | Documented medication incident and confirmed electronic MAR malfunction | |
| Staff B | Interviewed confirming electronic MAR malfunction | |
| Staff C | Interviewed confirming electronic MAR malfunction | |
| Resident Care Coordinator | RCC | Explained use of electronic MAR and backup system |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Jul 9, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #76681-C regarding regulatory insufficiencies in service plans for tenants at the assisted living program.
Complaint Details
The complaint investigation cited regulatory insufficiency related to service plans. The program failed to ensure service plans were individualized and updated to reflect treatments and medications for tenants, including ointment applications, band-aid changes, and antibiotic treatments.
Findings
The investigation revealed that the program failed to ensure tenant service plans included needed services and care for 6 of 6 tenants reviewed. Specific deficiencies included lack of updated service plans reflecting medication and treatment orders for tenants with various medical needs.
Deficiencies (1)
Failure to ensure tenant service plans included needed services and care for 6 of 6 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder (General Population): 37
Number of tenants with cognitive disorder (General Population): 1
Number of tenants without cognitive disorder (Memory Care Unit): 0
Number of tenants with cognitive disorder (Memory Care Unit): 9
Total Census of Assisted Living Program for People with Dementia: 47
Number of tenants with deficient service plans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marketing and Operations Specialist | Interviewed on 7/9/18 and revealed unawareness of needed treatments to be addressed on service plans |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: May 17, 2018
Visit Reason
The visit was conducted to investigate Complaint #75150-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Investigation into Complaint #75150-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation into Complaint #75150-C.
Report Facts
Number of tenants without cognitive disorder: 40
Number of tenants with cognitive disorder: 41
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 11
Total Census: 52
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 9
Date: Apr 9, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during the investigation of complaints 74857-M, 74963-A, and 74932-C at Sunnybrook of Burlington.
Complaint Details
The investigation was triggered by complaints 74857-M, 74963-A, and 74932-C. The Executive Director and Health Services Director confirmed multiple findings during interviews on 4/2/18, 4/3/18, and 4/4/18. The findings included incomplete incident reports, inadequate staff training on emergency procedures, incomplete tenant evaluations, and deficient service plans.
Findings
The program failed to ensure incident reports were properly signed by the person in charge, staff were not adequately trained on emergency procedures, evaluations prior to occupancy were incomplete, service plans were not developed or updated timely, and the program lacked a policy for natural disaster evacuation. Multiple deficiencies were confirmed through interviews and record reviews.
Deficiencies (9)
Program failed to ensure incident reports were signed by the person in charge for 4 of 5 tenants reviewed.
Program failed to ensure all program staff were able to implement emergency procedures.
Program failed to ensure thorough evaluations were completed prior to occupancy for 2 of 2 tenants reviewed.
Program failed to ensure preliminary service plans were developed and signed prior to signing the occupancy agreement for 2 of 2 tenants reviewed.
Program failed to update service plans as needed with significant changes for 4 of 5 tenants reviewed.
Program failed to identify tenant needs and preferences for assistance in service plans for 3 of 5 tenants reviewed.
Program failed to identify service providers in service plans for 3 of 5 tenants reviewed.
Program failed to complete nurse reviews for 4 of 5 tenants reviewed regarding significant changes in condition.
Program failed to follow the policy regarding evacuation of the building and failed to develop a policy for natural disasters.
Report Facts
Number of tenants without cognitive disorder: 43
Number of tenants with cognitive disorder: 14
Total census: 57
Number of tenants reviewed for incident reports: 5
Number of tenants reviewed for evaluations: 2
Number of tenants reviewed for service plans: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Interviewed regarding emergency evacuation procedures and tenant care | |
| Staff G | Interviewed regarding emergency evacuation procedures and tenant care | |
| Staff F | Reported on tenant care and service plan issues | |
| Staff H | Reported on tenant care and service plan issues | |
| Executive Director | Confirmed findings and participated in interviews | |
| Health Services Director | Confirmed findings and participated in interviews | |
| Director of Nursing | Interviewed regarding tenant care and assessments |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: Oct 18, 2017
Visit Reason
The inspection was conducted as part of an investigation of Complaint #69288-C regarding medication administration errors and other deficiencies at the assisted living program.
Complaint Details
The complaint investigation was related to medication administration errors. It was substantiated that a staff member accidentally gave a tenant another tenant's medications on 7/8/17, resulting in the tenant being sent to the emergency room. Staff training and delegation documentation were found lacking.
Findings
The investigation found that one of four tenants reviewed did not receive appropriate medication care, including a medication administration error where a staff member gave a tenant another tenant's medications. Additionally, the program failed to ensure staff received timely medication administration delegation training and failed to ensure service plans were signed by all parties for some tenants.
Deficiencies (3)
Failure to ensure 1 of 4 tenants reviewed received appropriate care regarding medication administration, including a medication error where a staff member gave a tenant another tenant's medications.
Program could not confirm 3 of 3 staff reviewed received medication administration delegation training within 30 days of hire by the registered nurse.
Service plans were not signed by all parties involved in the creation and/or approval for 2 of 4 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 0
Total Population of General Population Program: 38
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 15
Total Population of Dementia-Specific Program: 15
Total census: 53
Date of medication error incident: Jul 8, 2017
Date of incident report: Jul 8, 2017
Date of staff training on medication administration: Jul 10, 2017
Date new RN started: Sep 5, 2017
Date all caregiving staff re-delegated and re-educated: Oct 31, 2017
Number of staff reviewed for delegation training: 3
Hire date of Staff A: Mar 3, 2016
Hire date of Staff B: Apr 4, 2016
Hire date of Staff C: Jul 22, 2015
Number of service plans reviewed for Tenant #1: 10
Number of unsigned service plans for Tenant #1: 3
Number of service plans reviewed for Tenant #2: 10
Number of unsigned service plans for Tenant #2: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Gave another tenant's medications to Tenant #2 on 7/8/17 | |
| Staff A | Reviewed for medication administration delegation training | |
| Staff C | Reviewed for medication administration delegation training |
Inspection Report
Renewal
Census: 61
Deficiencies: 11
Date: Jan 10, 2017
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, including investigation of Complaint #64181-C and Complaint #64938-C.
Complaint Details
Complaint #64181-C and Complaint #64938-C were investigated during the recertification visit.
Findings
The program failed to meet several requirements including policies and procedures for narcotics and dependent adult abuse reporting, adequate care and treatment for tenants, sufficient staffing, nurse delegation training, medication administration, dependent adult abuse training, tenant evaluations, service plans, nurse reviews, food service training, and dementia-specific education for personnel.
Deficiencies (11)
Program failed to follow policies and procedures regarding narcotics for 3 of 8 tenant files reviewed and failed to report suspected dependent adult abuse as required.
Program failed to provide adequate care, treatment, and services for 3 of 8 tenants reviewed.
Program failed to provide sufficient number of trained staff to meet the needs of 3 of 5 tenants reviewed.
Program failed to provide Registered Nurse delegation training for activities of daily living for 3 of 3 non-certified staff.
Program failed to administer medications as ordered for 2 of 8 tenants reviewed.
Program failed to provide dependent adult abuse training to ensure identification and reporting within required timeframes.
Program failed to evaluate tenants' functional, cognitive, and health status as required for 8 of 8 tenants reviewed.
Program failed to develop and update service plans based on evaluations for 8 of 8 tenants reviewed.
Program failed to conduct nurse reviews as required for 3 of 8 tenants reviewed.
Program failed to provide food safety and sanitation training for 2 of 4 staff reviewed.
Program failed to provide dementia-specific education including hands-on training for 6 of 6 staff reviewed.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 44
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program: 46
Number of tenants without cognitive disorder in Dementia-Specific Program: 5
Number of tenants with cognitive disorder in Dementia-Specific Program: 10
Total Population of Dementia-Specific Program: 15
Total census of Assisted Living Program: 61
Number of tenants reviewed for narcotics policies: 8
Number of tenants reviewed for care and treatment adequacy: 8
Number of tenants reviewed for staffing needs: 5
Number of staff reviewed for dementia-specific training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Terminated pending investigation due to discovery of discontinued controlled narcotic in her office | |
| Staff A | Non-certified staff lacking RN delegation training for activities of daily living | |
| Staff B | Non-certified staff lacking RN delegation training for activities of daily living | |
| Staff F | Non-certified staff lacking RN delegation training for activities of daily living | |
| Interim Executive Director | Confirmed staff were non-certified and interviewed regarding training and documentation | |
| Regional Nurse | Interviewed regarding medication destruction, narcotics, and pendant response policy |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Date: Aug 17, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to nurse review and level of care at Sunnybrook of Burlington, Iowa, during August 17-20, 2015.
Complaint Details
Complaint allegations regarding nurse review and level of care were investigated and found to be not substantiated.
Findings
The complaints regarding nurse review and level of care were found to be not substantiated. However, regulatory insufficiencies were identified in the areas of Evaluation of Tenant, Service Plans, and Structural Requirements, resulting in a $500 civil penalty and conditional operation status.
Deficiencies (3)
Evaluation of tenant functional, cognitive, and health status evaluations were not completed as needed with significant change.
Service plans were not individualized to tenant needs and preferences for assistance.
Mold and mildew were found in multiple locations within the facility, including tenant apartments and common areas.
Report Facts
Civil penalty amount: 500
Census: 59
Number of tenants without cognitive disorder: 45
Number of tenants with cognitive disorder: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact person for the Plan of Correction and appeal process |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Valerie Adams | Executive Director | Named in Plan of Correction response |
| Todd Earnest | Provided mold remediation and inspection reports | |
| Michael J. Buelow | Senior Environmental Consultant | Provided environmental consulting and mold clearance reports |
| Andrea Brooke | Microbiology Lab Manager | Signed fungal spore analysis reports |
Inspection Report
Monitoring
Census: 71
Deficiencies: 7
Date: Dec 5, 2014
Visit Reason
The report is a Final Recertification Monitoring Evaluation Report for Sunnybrook of Burlington, conducted to evaluate regulatory compliance in areas including staffing, service plans, food service, and dementia-specific education following a survey from December 3-5, 2014.
Findings
The report identifies multiple regulatory insufficiencies related to staffing training, evaluation of tenants, service plan updates, food service compliance, and dementia-specific education for personnel. The facility failed to provide adequate training and documentation for non-certified staff and did not complete timely evaluations or service plan updates for several tenants.
Deficiencies (7)
Failed to provide training on activities of daily living (ADLs) for four non-certified staff.
Failed to provide training of supervision of self-administration of insulin to seven staff.
Failed to evaluate cognitive, functional, and health status for three out of five tenant files within 30 days of occupancy or significant change.
Failed to update service plans within 30 days of tenant occupancy or significant change and obtain signatures for five tenant files.
Failed to provide service plans reflecting identified needs and preferences for three tenant files reviewed.
Failed to meet standards of state and local health laws for food service in the dementia unit, including lack of Type I hood and improper food preparation.
Failed to provide minimum of eight hours of dementia-specific education and training for staff within 30 days of hire.
Report Facts
Census: 71
Tenant count: 51
Tenant count: 20
Staff without documented training: 7
Tenants with incomplete evaluations: 3
Tenants with incomplete service plans: 5
Staff without dementia training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Adams | Executive Director | Named in letter as facility manager and signatory of Plan of Correction response |
| Rose Boccella | Program Coordinator | Author of the Final Recertification Monitoring Evaluation Report |
Inspection Report
Monitoring
Census: 62
Deficiencies: 0
Date: Jul 11, 2012
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to assess compliance with Iowa Administrative Code chapters 481—67 and 481—69 and to evaluate the assisted living program at Sunnybrook of Burlington.
Findings
No regulatory insufficiencies were found during this onsite recertification monitoring evaluation. The program was found to be in compliance with applicable regulations, and the State Fire Marshal's inspection and evacuation plans were approved.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 42
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program: 44
Number of tenants without cognitive disorder in Dementia-Specific Program: 3
Number of tenants with cognitive disorder in Dementia-Specific Program: 15
Total Population of Dementia-Specific Program: 18
Total census of Assisted Living Program: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the Final Recertification Monitoring Evaluation |
| Margaret Kaltefleiter | RN MS | Monitor for the Final Recertification Monitoring Evaluation |
| Angela Beardsley | Manager | Manager of Sunnybrook of Burlington, named in report |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Nov 30, 2010
Visit Reason
The visit was an on-site incident investigation at SunnyBrook of Burlington triggered by an incident intake (31511-I) to review a tenant's care following a stay at a Hospice House and concerns about oxygen use and tenant condition.
Complaint Details
The complaint involved a tenant who returned from a Hospice House with increased weakness and oxygen issues. The investigation found no regulatory insufficiencies. Staff provided care and monitored the tenant's oxygen use and condition. The tenant declined and died the next day.
Findings
No regulatory insufficiencies were identified during the investigation. The tenant was found to have declined and died the following day after being assisted with oxygen and nighttime care. Staff interviews and records showed appropriate care and monitoring were provided.
Report Facts
Current number of tenants without cognitive disorder: 49
Current number of tenants with cognitive disorder: 4
Total Population of General Population Program: 53
Total Population of Dementia Specific Program: 8
Total Census of Assisted Living Program: 61
Incident Intake Number: 31511
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Lunsford | RN Manager | Named as recipient and manager of SunnyBrook of Burlington |
| Stephanie Cummins | MA | Monitor conducting the incident investigation |
| Rose Boccella | Program Coordinator | Author of cover letter for the report |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Aug 9, 2010
Visit Reason
The inspection was conducted as a Final Recertification, Incident & Complaint Investigation at Sunnybrook Assisted Living of Burlington following complaints and incidents reported.
Complaint Details
Complaint Allegation #28623-C alleged the program was using an electric griddle to cook bacon and sausage in the dementia unit unattended. The complaint was investigated and regulatory insufficiency was found related to structural requirements.
Findings
The report found a regulatory insufficiency related to structural requirements involving the use of an electric griddle in the dementia unit. An incident involving a tenant who fell and later passed away was investigated with no regulatory insufficiency noted related to the incident. A $500 civil penalty was assessed.
Deficiencies (1)
The buildings and grounds shall be well-maintained, clean, safe and sanitary. The program used an electric griddle in the dementia unit without proper ventilation and fire suppression system, violating structural requirements.
Report Facts
Civil penalty amount: 500
Penalty reduced amount: 325
Census - tenants without cognitive disorder: 53
Census - tenants with cognitive disorder: 1
Total Population of General Population Program: 54
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the investigation |
| Tamara Halvorson | Certification Coordinator | Contact person for penalty and appeals |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Sep 8, 2009
Visit Reason
The visit was conducted as a final complaint investigation regarding an incident involving a tenant who fell and was injured at SunnyBrook Assisted Living.
Complaint Details
The complaint involved a tenant who activated an emergency pendant after falling and experiencing right hip pain. The tenant was admitted to the hospital with a pelvic fracture. Staff and family interviews indicated appropriate response and care. No regulatory insufficiencies were substantiated.
Findings
The investigation found that the tenant fell multiple times, resulting in a fracture of the right pelvic area. Staff responded appropriately, and the tenant was transported to the hospital. No regulatory insufficiencies were identified during the investigation.
Report Facts
Current number of tenants without cognitive disorder: 45
Current number of tenants with cognitive disorder: 4
Total Population of General Population Program: 49
Total Population of Dementia Specific Program: 4
Total Census of Assisted Living Program: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Lunsford | RN Manager | Named as manager of SunnyBrook Assisted Living |
| Stephanie Cummins | MA | Monitor of the incident investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed cover letter for the complaint investigation report |
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