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Deficiency Records for Elderwood at Burlington
A list of the most recent deficiencies for Elderwood at Burlington. 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 Elderwood at Burlington. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-15 | 2024-09-27 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-08-15 | 2024-09-27 | 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 | 2024-08-15 | 2024-09-27 | Y |
| 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 | 2024-08-15 | 2024-09-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-04-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-11 | 2024-04-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-11 | 2024-04-12 | 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 | 2024-01-11 | 2024-04-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-23 | 2024-03-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-23 | 2024-03-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-01-11 | 2024-02-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-11 | 2024-02-14 | 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 | 2024-01-11 | 2024-02-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-11 | 2024-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-11 | 2024-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-14 | 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 | 2024-01-11 | 2024-02-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-11 | 2024-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-11 | 2024-02-14 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-01-11 | 2024-02-14 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-01-11 | 2024-02-14 | 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 | 2024-01-11 | 2024-02-14 | N |
| 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 | 2024-01-11 | 2024-02-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-11 | 2024-02-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-02-14 | 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 | 2024-01-11 | 2024-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-14 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-11 | 2024-02-14 | 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 | 2024-01-11 | 2024-02-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-11 | 2024-02-14 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-01-11 | 2024-02-14 | 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 | 2023-05-15 | 2023-06-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-15 | 2023-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-15 | 2023-06-02 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-21 | 2023-04-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-21 | 2023-04-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-21 | 2023-04-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-07 | 2023-03-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-01-11 | 2023-02-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-21 | 2023-02-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-28 | 2023-01-20 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-12-28 | 2023-01-20 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-28 | 2023-01-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-28 | 2023-01-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-07 | 2023-01-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-07 | 2023-01-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-07 | 2023-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-17 | 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 | 2022-12-07 | 2023-01-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-18 | 2022-07-02 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-18 | 2022-07-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-18 | 2022-05-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-29 | 2022-04-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-08 | 2022-04-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-08 | 2022-03-08 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-02-07 | 2022-03-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-07 | 2022-03-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-17 | 2021-12-31 | 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 | 2021-11-17 | 2021-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-17 | 2021-12-31 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-11-17 | 2021-12-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-17 | 2021-12-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-17 | 2021-12-31 | N |
| 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 | 2021-11-17 | 2021-12-31 | 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 | 2021-11-17 | 2021-12-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-17 | 2021-12-31 | 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 | 2021-11-17 | 2021-12-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-09 | Not Fixed | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-06 | Not Fixed | N |
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