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Deficiency Records for Burcham Hills Retirement Ctr
A list of the most recent deficiencies for Burcham Hills Retirement Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Burcham Hills Retirement Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-08 | 2024-09-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-08 | 2024-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-08 | 2024-09-04 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-08-08 | 2024-09-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-24 | 2024-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-24 | 2024-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-24 | 2024-06-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-24 | 2024-06-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-24 | 2024-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-24 | 2024-06-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-24 | 2024-06-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-05-24 | 2024-06-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-24 | 2024-06-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-24 | 2024-06-25 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-25 | 2024-02-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-25 | 2024-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-28 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-10-24 | 2023-11-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-24 | 2023-11-28 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-24 | 2023-09-01 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-09 | 2023-08-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-06 | 2023-07-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | 2023-07-21 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-09 | 2023-06-30 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-03-09 | 2023-05-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-08 | 2023-03-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-08 | 2023-03-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-08 | 2023-03-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-08 | 2023-03-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-08 | 2023-03-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-08 | 2023-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-03-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-08 | 2023-03-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-08 | 2023-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-08 | 2023-03-30 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-09 | 2023-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-09 | 2023-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-09 | 2023-03-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-09 | 2023-03-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-09 | 2023-03-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-18 | 2021-12-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-18 | 2021-12-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-18 | 2021-12-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2021-12-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-18 | 2021-12-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-18 | 2021-12-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-11-18 | 2021-12-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-25 | 2021-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-25 | 2021-11-30 | Y |
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