Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Burlington during CMS and state inspections, most recent first.
The facility did not employ a full-time certified dietary manager, affecting the nutritional services for 73 residents. During a kitchen observation, a staff member identified as the Dietary Manager admitted to not having completed a state-approved certification course. The facility could not provide a policy for the Certified Dietary Manager, placing residents at risk for inadequate nutrition.
The facility failed to maintain a sanitary environment, as staff did not follow Enhanced Barrier Precautions (EBP) during catheter care for a resident, and the uncovered catheter bag was placed on the floor. Additionally, the facility lacked an adequate water management program to prevent Legionella, with no evidence of required testing or water flushing. These deficiencies increased the risk of infection for residents.
A resident with a history of aggressive behavior stomped on the foot of another cognitively impaired resident who entered their room. The facility failed to report and investigate the incident promptly, as required by their abuse prevention policy. This oversight placed residents at risk for injury and ongoing abuse.
A resident with a history of aggressive behavior stomped on another resident's foot after the latter entered their room. The incident was not reported to the administration or investigated as required by the facility's policy. Staff only educated the aggressive resident, failing to recognize the incident as abuse and take necessary protective measures.
A resident with a history of behavioral issues stomped on the foot of another cognitively impaired resident. Despite the incident being reported, the facility failed to investigate or implement protective measures, contrary to their policy. This oversight placed residents at risk for further abuse.
The facility failed to provide timely written notification to residents, their representatives, and the LTCO for facility-initiated transfers to hospitals. Three residents, each with serious health conditions, were transferred without receiving the required written notice, and the LTCO was not informed. This placed residents at risk for uninformed care decisions and impaired their rights.
A resident with dementia and dysphagia did not receive necessary assistance during breakfast, leading to a deficiency. Despite requiring supervision, the resident was assisted by another cognitively impaired resident, contrary to facility policy. Staff failed to intervene, leaving the resident to struggle with eating independently, risking choking and impaired nutrition.
A facility failed to ensure proper collaboration with a hospice provider for a resident receiving hospice services. The resident, with chronic conditions and moderately impaired cognition, had a care plan lacking essential information such as hospice contact details, supplies, and visit schedules. An administrative nurse confirmed these omissions, and the facility did not designate a coordinator as required by the hospice service agreement, risking impaired end-of-life care.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time certified dietary manager, which affected the nutritional services provided to 73 residents. During an observation in the facility's kitchen, staff were seen preparing and serving breakfast. Dietary Staff BB, who was assisting with meal service, confirmed that she was the Dietary Manager but had not completed a state-approved dietary manager certification course or test. The facility was unable to provide a policy regarding the Certified Dietary Manager. This deficiency placed the residents at risk for inadequate nutrition as there was no qualified individual to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to ensure a sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. This was evident when staff did not provide sanitary catheter care and failed to implement Enhanced Barrier Precautions (EBP) for a resident. During an observation, a Certified Nurse Aide (CNA) and a Licensed Nurse (LN) were seen providing perineal care to a resident without wearing gowns, which is a requirement under EBP. The staff acknowledged that they should have donned gowns before providing catheter care. Additionally, the resident's uncovered catheter bag was placed on the floor, which is against the facility's expectations for maintaining sanitary conditions. The facility also failed to implement an adequate water management program to prevent and mitigate risks from waterborne pathogens, such as Legionella. The TELS system, which is used for maintenance operations, indicated that monthly Legionella meetings and documentation were required, but there was no evidence of Legionella testing or water flushing throughout the facility. Maintenance staff admitted to not documenting water flushes, and there was no designated Water Management Plan in place. The facility's policies on Legionella and EBP were not effectively followed, placing residents at risk of contracting infectious diseases.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when a resident with a history of aggressive behavior stomped on the foot of another cognitively impaired resident who had entered their room. The aggressive resident, who had diagnoses of dementia, hypertension, and depression, was known to have potential for physical aggression due to anger, dementia, a history of harm to others, and poor impulse control. Despite these known risks, the facility did not effectively implement interventions to prevent the incident, as evidenced by the lack of an incident report and investigation following the event. The incident was not reported immediately, and no investigation was initiated until later, which indicates a failure in the facility's protocol for handling resident-to-resident altercations. Staff members were unaware of the altercation, and the facility's policy on abuse prevention was not followed, as the incident was not documented or addressed in a timely manner. This oversight placed residents at risk for injury and ongoing abuse, as the facility did not take the necessary steps to ensure the safety and protection of all residents involved.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify and report a resident-to-resident incident as abuse when a resident with a history of behaviors stomped on another resident's foot. The incident occurred after the cognitively impaired resident entered the room of the resident with dementia, who had a history of physical aggression and poor impulse control. The incident was documented in the electronic medical records, but staff only educated the aggressive resident not to repeat the behavior, without reporting the incident to the administration or initiating an investigation. The facility's policy required immediate reporting and investigation of any suspected abuse, neglect, or resident-to-resident altercations. However, the incident was not reported to the administrator, and no investigation was initiated until later, when a consultant became aware of the situation. Interviews with staff revealed a lack of awareness and adherence to the policy, as the incident was not recognized as abuse, and the necessary steps to protect the residents and investigate the incident were not taken.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide protective measures and investigate an incident of resident-to-resident abuse involving two residents. One resident, who had a history of behaviors and was documented to have intact cognition, stomped on the foot of another resident who was cognitively impaired. The incident occurred when the cognitively impaired resident entered the room of the resident with behavioral issues. Despite the incident being reported by the resident who committed the act, the staff only educated her not to repeat the behavior and did not initiate an investigation or protective measures. The facility's policy required that any allegation of abuse be promptly and thoroughly investigated, with measures taken to prevent further abuse while the investigation was ongoing. However, the staff failed to report the incident to the charge nurse, and no investigation was initiated at the time. The facility's failure to act placed the residents at risk for injury and ongoing abuse, as no interventions were put in place to prevent future occurrences.
Failure to Notify Residents and LTCO of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the Office of the Long-Term Care Ombudsman (LTCO) for facility-initiated transfers to hospitals. This deficiency was identified through the review of three residents' cases, where the facility did not adhere to its own policy of notifying the necessary parties about transfers or discharges. The lack of notification placed residents at risk for uninformed care decisions and impaired their rights. Resident 42, who had multiple fractures and severe pain, was transferred to the hospital twice without receiving written notice of the transfer. The facility also failed to notify the LTCO about these transfers. Social Services staff confirmed that the resident was not given written notice, and the facility's policy required such notification. The absence of documentation and notification was a clear violation of the resident's rights. Similarly, Resident 32, who had emphysema, COPD, and other serious health conditions, was transferred to the hospital on two occasions without receiving written notice. The facility did not notify the LTCO, and Social Services staff were unaware of the requirement to do so. Additionally, Resident 217, who had Alzheimer's disease and other mental health issues, was discharged to an acute behavioral unit without the LTCO being notified. The facility's failure to follow its policy for notifying the LTCO and providing written notice to residents and their representatives was consistent across these cases.
Failure to Assist Resident with Meal Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident, identified as R47, received the necessary assistance during her breakfast meal, which was a deficiency in providing adequate care. R47, who had diagnoses of dementia, dysphagia, and cognitive communication deficit, required supervision during meals according to her care plan. However, during an observation, it was noted that another cognitively impaired resident, R9, assisted R47 with eating her meal, which was against the facility's policy due to potential choking hazards. Despite being informed by a licensed nurse that R47 could feed herself, no staff member offered the necessary assistance to R47 during her meal. Further observations revealed that R47 struggled to eat her meal independently, using her hands to scoop oatmeal and getting food on her clothes and personal items. The staff's inaction in providing the required assistance was contrary to the facility's ADL policy, which mandates that residents receive the necessary help to maintain good nutrition and hygiene. The lack of staff intervention placed R47 at risk for choking, impaired nutrition, and a decline in her ability to perform activities of daily living.
Lack of Coordination with Hospice Services for Resident
Penalty
Summary
The facility failed to ensure proper collaboration between the hospice provider and the facility for a resident receiving hospice services. The resident, who had diagnoses of chronic obstructive pulmonary disease, congestive heart failure, and encephalopathy, was documented to have moderately impaired cognition and required varying levels of staff assistance for daily activities. The care plan for the resident, which was revised, indicated the need for hospice services but lacked critical information such as the hospice contact number, details on supplies, equipment, and medications provided by hospice, and the schedule of hospice staff visits. The deficiency was confirmed during an interview with an administrative nurse who verified the omissions in the care plan. Additionally, the hospice service agreement, signed by both the hospice and the facility's executive director, required the facility to designate a member of an interdisciplinary group to coordinate care with hospice staff. However, the facility did not fulfill this requirement, placing the resident at risk of impaired end-of-life care due to the lack of coordination and communication between the hospice provider and the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yates Operator, Llc | 23 mi | — | 0 | 0 |
| Medicalodges Iola | 26.6 mi | ★★★★★ | 7 | 0 |
| Anderson County Hospital Ltcu | 27.2 mi | ★★★★★ | 0 | 0 |
| Parkview Heights Nursing And Rehabilitation Center | 27.9 mi | ★★★★★ | 11 | 0 |
| Flint Hills Care And Rehabilitation Center | 29.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.