Inspection Reports for
Life Care Center of Burlington

The complaint investigation focused on resident-to-resident abuse, failure to report and investigate abuse, failure to notify residents and the Long-Term Care Ombudsman of transfers and discharges, inadequate assistance with activities of daily living, lack of certified dietary management, failure to coordinate hospice care, and infection prevention and control deficiencies.

The facility failed to prevent and report resident-to-resident abuse, failed to provide written notification for hospital transfers and notify the Long-Term Care Ombudsman, failed to assist a resident with eating, lacked a certified dietary manager, failed to ensure collaboration with hospice providers, and failed to implement adequate infection control measures including sanitary catheter care and water management.

The plan outlines corrective actions, staff education, monitoring, and auditing measures to address issues related to abuse, neglect, reporting violations, bed hold policy, activities of daily living, dietary staff qualifications, hospice services, and infection prevention and control.

The report represents findings from complaint investigations #KS00182892, #KS00182556, #KS00182433, and #KS00182824. The complaints involved unsafe transfer practices leading to resident falls.

The facility failed to ensure that two staff members assisted residents requiring mechanical lifts during transfers, resulting in falls for two residents. Both residents required full body mechanical lifts and two staff for safe transfers, but were transferred by only one staff member, leading to accidents and risk of injury.

The facility developed and implemented a system to assure correction and continued compliance related to safe mechanical lift transfers following resident falls. Nursing and therapy staff will be educated and audited to ensure safe transfer practices and equipment safety.

The facility had deficiencies related to infection control, including PPE use, hand hygiene, respiratory infection isolation, and environmental services such as linen handling. The Plan of Correction outlines education, auditing, and systemic changes to ensure compliance and prevent infection transmission.

The complaint survey was conducted for complaint #180749. The allegations were reviewed with no noncompliance found related to the complaint itself, but infection control deficiencies were identified during the targeted survey.

The facility was found to be in compliance with all regulations related to the complaint. However, the facility failed to utilize appropriate infection control practices to prevent COVID-19 transmission, failed to monitor residents who tested positive, and failed to ensure proper PPE use and signage. These failures increased the risk of spreading COVID-19.

The facility identified multiple deficiencies related to comprehensive care plans, ADL care, pressure ulcer treatment, urinary drainage system care, medication management, dietary staff qualifications, and food safety. The Plan of Correction outlines corrective actions, staff education, audits, and monitoring to achieve substantial compliance by 02.28.23.

The facility was found deficient in multiple areas including care plan revisions, ADL care, pressure ulcer prevention and treatment, catheter care, medication management, dietary staffing qualifications, and food safety practices.

The facility had multiple deficiencies including failure to prevent and properly treat pressure ulcers, inconsistent bathing services for several residents, inadequate catheter care, failure to report abnormal blood sugars, improper psychotropic medication management, lack of certified dietary manager, and improper food labeling and storage practices.

The complaint investigation #174535 was substantiated by findings that meals were not served timely according to the facility's scheduled meal times.

The facility failed to ensure meals were served to residents at the scheduled meal times, with observations and resident reports indicating meals were served up to one and one-half hours late.

The facility developed and implemented a system to assure correction and continued compliance with regulations related to meal time delivery. Actions include monitoring meal delivery, staff education, and ongoing audits to ensure timely and satisfactory food service.

The inspection was triggered by multiple complaint investigations (#171542, #171941, #172161, #172153, #172286, #172410, #171944, #171907, and #172129).

The facility failed to ensure Resident 2, assessed as a fall risk, remained free from accident hazards when staff did not use a gait belt during toileting assistance, resulting in a shoulder fracture. The facility also failed to follow the five rights of medication administration, resulting in a medication error for Resident 7.

The facility identified issues related to resident safety during ambulation and medication administration. Corrective actions include staff education, audits, and ongoing monitoring to ensure compliance and resident safety.

The visit was complaint-related, investigating three complaint numbers: KS00169161, KS00170883, and KS171413.

The facility failed to monitor and maintain an infection control program to prevent the spread of infection to 42 residents by not ensuring tuberculosis (TB) screening for newly hired employees who worked with those residents.

The report represents findings from complaint investigations # KS 00167367, KS 00168770, KS 0016049, and KS 0016001. The complaint was substantiated as the facility failed to provide timely follow-up care after a resident's fall and fracture.

The facility failed to ensure timely follow-up and communication with the physician after a resident sustained a fractured right clavicle following a fall. The staff delayed contacting the physician for further orders for 11 days after the x-ray report was faxed.

The facility identified a deficiency involving delayed physician notification and follow-up after a resident fall resulting in a change of condition. The Plan of Correction outlines systemic changes including staff education, audits, and monitoring to ensure compliance.

The visit was triggered by complaint investigations KS 00164293, KS 00164443, and KS 00165024. The complaint was substantiated as the facility failed to prevent elopement of residents during a fire drill.

The facility failed to provide adequate supervision to prevent residents, including Resident 4 who was an elopement and fall risk, from leaving the facility through an exit door during a fire drill without staff knowledge. The doors automatically unlocked during the fire alarm, and staff were insufficient to monitor the residents, resulting in Resident 4 exiting the building unnoticed.

The facility identified multiple deficiencies including failure to obtain signed bed hold agreements for residents transferred to hospital, incomplete discharge summaries and medication reconciliations, improper labeling of insulin pens, maintenance issues in the laundry area, and lack of required Abuse, Neglect, and Exploitation training for some staff. Corrective actions and monitoring plans were implemented to ensure compliance.

The facility had deficiencies related to resident supervision, elopement risk assessments, and staff response to fire alarms. Corrective actions include updated assessments, staff education, and implementation of monitoring procedures during fire drills.

Complaint investigation #163900. The findings represent the results of this complaint investigation.

The facility failed to ensure one dependent resident received proper personal hygiene care, specifically toenail care, despite the resident requiring extensive assistance. Staff did not trim the resident's toenails for a prolonged period, and documentation and physician orders for toenail care were lacking.

The facility was found deficient in providing routine nail care to residents, specifically Resident R1 who was dependent on staff for physical needs including nail care. The facility developed and implemented a system to assure correction and continued compliance with the regulation.

The visit was triggered by a complaint investigation #KS00163832. The facility was found noncompliant in several areas including bed-hold policy notification, discharge summary completion, medication labeling, environmental safety, and staff training.

The facility failed to provide a bed-hold policy notice for a resident transferred to the hospital, did not complete a required discharge summary for a discharged resident, failed to ensure accurate labeling of insulin pens for diabetic residents, did not maintain a safe and sanitary laundry environment, and failed to provide required abuse, neglect, and exploitation training to some staff.

The facility failed to provide appropriate bed hold notification for a hospitalized resident, did not complete a required discharge summary for a discharged resident, failed to ensure accurate labeling of insulin pens for diabetic residents, did not maintain a safe and sanitary laundry environment, and failed to provide required abuse prevention training to some staff.

The investigation was based on complaint investigation numbers 160499, 160500, and 160569. Immediate jeopardy was identified due to failures in care related to Resident 1's urinary output and infection management. The immediate jeopardy was abated on 03/04/2021 after the facility implemented corrective actions including staff education and audits.

The facility failed to identify lack of urinary output and notify the physician timely for Resident 1, failed to collect a urine sample as ordered, and delayed antibiotic administration, placing the resident in immediate jeopardy. The facility also failed to perform neurochecks and monitor healing for injuries following falls for Residents 1 and 3. Additionally, the facility failed to complete wound assessments, provide ordered treatment, and maintain appropriate linens and mattress settings for Resident 2's pressure ulcer.

The facility identified issues related to urinary catheter management, fall follow-up, and pressure ulcer care. Corrective actions include staff education, audits, and system improvements to ensure compliance and resident safety.

The facility developed and implemented corrective actions to address deficiencies related to accuracy of assessments, comprehensive care plans, and restorative services. Audits and education plans were established to ensure ongoing compliance.

The inspection was triggered by complaint investigation #155647. The complaint involved concerns about inaccurate resident assessments, inadequate care plans, and failure to provide restorative services to maintain residents' mobility. The findings substantiated these issues.

The facility failed to complete accurate comprehensive assessments and develop appropriate care plans for residents who frequently refused care. Additionally, the facility did not provide adequate restorative services to maintain or improve residents' range of motion, resulting in potential decline in mobility for two residents.

The investigation was triggered by complaints KS00151120, KS00151166, KS00151366, and KS00150409 related to abuse allegations and supervision failures to prevent accidents.

The facility failed to thoroughly investigate allegations of abuse including rape and resident-to-resident altercations, failed to implement adequate fall prevention interventions for a high-risk resident resulting in a fatal fall, and did not maintain an effective infection control program to track and manage COVID-19 cases among residents and staff.

The plan addresses deficiencies related to investigation and prevention of alleged violations, fall hazard supervision, and infection prevention and control. The facility implemented systemic changes including staff education, audits, and care plan updates to ensure compliance and resident safety.

The Plan of Correction outlines corrective actions for multiple deficiencies including baseline care plans, pharmacy services, drug regimen reviews, food service and safety, infection prevention and control, and antibiotic stewardship. The facility has implemented audits, education, and monitoring to ensure compliance and correction of cited issues.

The visit was complaint-related, triggered by multiple complaint investigations as noted in the initial comments section.

The facility was found deficient in multiple areas including failure to provide baseline care plan summaries to residents, failure to ensure availability and administration of medications as ordered, failure to timely act on pharmacist recommendations, failure to follow dietary recipes and serve food at proper temperatures, failure to maintain sanitary food preparation areas, and failure to maintain infection control and antibiotic stewardship programs.

The Plan of Correction addresses deficient practices related to incident reporting and fall management involving specific residents. The facility outlines corrective actions including incident investigations, staff education, care plan revisions, and ongoing compliance monitoring.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective April 13, 2019.

Complaint investigation #138098 regarding failure to report an incident of neglect involving a resident fall resulting in a fractured wrist. The incident was not reported because the facility staff did not believe abuse or neglect was substantiated.

The facility failed to report an incident of neglect to the state agency when a resident attempted to remove another resident from his/her bed, resulting in a fall and fractured wrist. The facility also failed to revise the care plan with appropriate interventions following the fall and did not ensure adequate supervision to prevent further falls.

The Plan of Correction addresses multiple deficiencies related to environmental maintenance, baseline care plans, respiratory care, pain management, dialysis, nurse aide performance, drug regimen, psychotropic medication use, medication error rates, medication storage, food procurement, and dietary services. The facility has implemented education, audits, and monitoring systems to ensure compliance and prevent recurrence.

The visit was triggered by complaints identified as #134987, #135133, and #135272.

The facility failed to retain the services of a full-time certified dietary manager to oversee the dietary department. Dietary staff reported not being certified or scheduled for the dietary manager exam.

The Plan of Correction addresses deficiencies related to incident investigations, door alarm response procedures, and elopement prevention education. The facility outlines corrective actions including staff education, audits, and ongoing monitoring to ensure compliance.

The facility was found not in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety related to F689; "J", CFR 483.25(d)(1)(2). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

The investigation was triggered by complaint #KS00130106 regarding an elopement incident involving Resident #1.

The facility failed to thoroughly investigate an elopement incident where Resident #1 exited the building unnoticed for 30 to 45 minutes and was found by a bystander. The facility also failed to ensure adequate supervision and training of staff, including agency personnel, regarding elopement risks and alarm procedures.

The survey found a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective February 15, 2018.

This Plan of Correction relates to a complaint investigation identified as LCC Burlington complaint 01172018.

The facility failed to transcribe and administer respiratory medication as ordered. A medication transcription audit was conducted on new admissions to ensure no other residents were affected.

The findings represent the results of complaint investigations #124968 and #125314.

The facility failed to transcribe and administer respiratory medication as ordered to one resident out of three sampled for respiratory needs. The error involved omission of scheduled and PRN doses of Albuterol Sulfate/Ipratropium.

The plan addresses multiple deficiencies including housekeeping and maintenance, care plan updates, medication administration, infection control, call light system functionality, food sanitation, specialized rehab services, and record accuracy. The facility has implemented education, audits, and monitoring to prevent recurrence and ensure substantial compliance.

The survey found a widespread 'F' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 09/26/2017.

The inspection was triggered by multiple complaint investigations #113193, #115877, and #116365.

The facility was found deficient in multiple areas including housekeeping and maintenance services, care plan revisions, medication administration and monitoring, infection control, call light system functionality, sanitary environment in laundry and medication rooms, RN coverage, nurse aide performance reviews, and medical record completeness.

Complaint investigation #108065 focused on the facility's failure to notify the physician timely and provide appropriate assessments for a resident with a fall and respiratory infection.

The facility failed to promptly notify the physician and provide timely assessments for a resident who experienced a fall with a hip fracture and pain, as well as a respiratory infection accompanied by fever. The resident remained in the facility for approximately 19 hours before being sent to the emergency room, and the facility also failed to adequately assess and notify the physician about the resident's ongoing fever and respiratory status.

The survey found the most serious deficiencies to be a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 27, 2016.

The facility addressed medication availability and administration issues for residents 1, 2, 3, and 4. Licensed nurses received education on medication procurement and notification procedures to ensure compliance.

The survey found the most serious deficiency to be an "E" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

The complaint investigation #103916 found the facility failed to ensure timely medication delivery and administration for four residents, including missed doses on admission days and ongoing delays due to pharmacy delivery issues and lack of policy guidance.

The facility failed to ensure the timely delivery and administration of medications for four residents reviewed, resulting in multiple missed doses due to medication unavailability and delayed pharmacy deliveries. The facility's policy lacked guidance on timely delivery of routine and stat medications.

The plan addresses multiple deficiencies related to fall prevention, resident wandering and fear, wound care orders, and care plan updates. The facility outlines corrective actions including staff education, audits, and monitoring to ensure compliance and resident safety.

The facility failed to revise care plans timely for a resident with multiple falls, manage inappropriate wandering behavior of another resident, provide preventative interventions for a resident with pressure ulcers, and implement effective fall prevention interventions for a resident with repeated falls.

The survey found isolated 'D' level deficiencies that constitute no actual harm but have the potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy.

The plan details corrective actions for multiple deficiencies including restorative services, resident safety regarding hazardous equipment and chemicals, medication administration and monitoring, nurse staffing documentation, and glucose monitoring practices.

The survey found the most serious deficiencies to be 'E' level deficiencies, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 17, 2014.

The visit was triggered by complaint investigations #79442 and #79454.

The facility failed to provide appropriate range of motion treatment for a resident, maintain adequate supervision to prevent elopement of a confused resident, ensure safe use of enabler bars, monitor medications properly including bowel management, maintain posted nurse staffing data, act on pharmacist recommendations, and adequately sanitize glucometers.

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the previously cited deficiency under regulation 483.25(c) was corrected as of 07/19/2013. No other deficiencies are listed as outstanding.

The plan outlines corrective actions including ongoing treatment for a resident with pressure sores, staff education on prevention and treatment, competency checks, and regular observations to ensure care plan interventions are followed.

The facility failed to provide adequate treatment and services to promote healing and prevent infection for a resident who developed an avoidable stage 3 pressure ulcer. Staff did not follow the care plan regarding pressure relieving boots and aseptic technique during wound care.

The report confirms that the deficiency identified under regulation 483.25(k) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.

The complaint investigation #58745 found the facility did not follow up on a physician's recommendation for respiratory equipment for one resident. The resident did not have the BIPAP machine ordered, and staff failed to clarify the physician's orders or document the resident's refusal.

The facility failed to follow up with the physician to clarify orders for a BIPAP machine for a resident with respiratory impairment. The resident did not have the recommended BIPAP machine nearly one month after the order, and staff failed to document the resident's refusal or clarify the physician's intentions.

The facility addressed a deficiency related to treatment and care for special needs, specifically regarding a resident's refusal of Bipap therapy despite physician recommendation. The facility provided education to nursing staff and planned routine audits to ensure compliance with physician orders.

The plan outlines corrective actions for multiple deficiencies including resident rights, abuse investigation, individualized activities, housekeeping and maintenance, comprehensive assessments, urinary incontinence care, nutrition status, drug regimen monitoring, infection control, food sanitation, ventilation, and safety handrails.

The facility was found deficient in multiple areas including residents' rights to access the state ombudsman, failure to thoroughly investigate and report abuse and neglect allegations, inadequate activity programs for cognitively impaired residents, maintenance issues with windows and screens, incomplete comprehensive assessments, failure to monitor medications with black box warnings, improper handling of discontinued medications, unsanitary food service practices, inadequate infection control related to linen handling, and insufficient ventilation in the beauty shop.

The plan addresses deficiencies related to timely notification of changes in resident condition and provision of care to ensure the highest well-being of residents. The facility outlines corrective actions including staff education, monitoring, and audits to ensure compliance.