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Deficiency Records for Burlington Health and Rehabilitation Center

A list of the most recent deficiencies for Burlington Health and Rehabilitation Center. 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 Burlington Health and Rehabilitation Center. 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 appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-05-14 2024-07-05 Y
Conduct risk assessment and an All-Hazards approach. Fire Safety 2024-05-08 2024-06-14 N
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 2024-05-14 2024-06-13 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2024-05-14 2024-06-13 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2024-05-14 2024-06-13 N
Assist a resident in gaining access to vision and hearing services. Health 2024-05-14 2024-06-13 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 2024-05-14 2024-06-13 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2024-05-14 2024-06-13 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-05-14 2024-06-13 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2024-05-14 2024-06-13 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 2024-05-14 2024-06-13 N
Ensure that residents are free from significant medication errors. Health 2024-05-14 2024-06-13 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 2024-05-14 2024-06-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-05-14 2024-06-13 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2024-05-14 2024-06-13 N
Provide and implement an infection prevention and control program. Health 2024-05-14 2024-06-13 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-05-14 2024-06-13 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-06-06 2024-06-12 Y
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-05-08 2024-06-11 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-05-08 2024-06-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-05-08 2024-06-06 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-05-08 2024-06-04 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-05-08 2024-06-04 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 2024-05-08 2024-05-29 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2024-03-27 2024-04-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-02 2023-12-06 Y
Respond appropriately to all alleged violations. Health 2023-11-02 2023-12-06 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-11-02 2023-12-06 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2023-11-02 2023-12-06 Y
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Health 2023-11-02 2023-12-06 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-09-14 2023-12-06 Y
Respond appropriately to all alleged violations. Health 2023-09-14 2023-12-06 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2023-09-14 2023-12-06 Y
1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to. Health 2023-09-14 2023-10-17 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-09-14 2023-10-17 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-09-14 2023-10-17 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 2023-09-14 2023-10-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-14 2023-10-17 Y
Observe each nurse aide's job performance and give regular training. Health 2023-09-14 2023-10-17 Y
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2023-09-14 2023-10-17 Y
Provide properly protected cooking facilities. Fire Safety 2023-03-01 2023-04-19 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-03-21 2023-04-18 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-03-21 2023-04-18 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 2023-03-21 2023-04-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-03-21 2023-04-18 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2023-03-21 2023-04-18 N
Provide and implement an infection prevention and control program. Health 2023-03-21 2023-04-18 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-03-21 2023-04-18 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-03-21 2023-04-18 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-03-21 2023-04-18 Y
Respond appropriately to all alleged violations. Health 2023-03-21 2023-04-18 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-03-21 2023-04-18 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-03-21 2023-04-18 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-03-21 2023-04-18 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-03-21 2023-04-18 Y
Have simulated fire drills held at unexpected times. Fire Safety 2023-03-01 2023-04-11 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-03-01 2023-04-10 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-03-01 2023-03-04 N
Install proper backup exit lighting. Fire Safety 2023-03-01 2023-03-04 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 2023-03-01 2023-03-02 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 2023-03-01 2023-03-02 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-03-01 2023-03-02 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-03-01 2023-03-02 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2023-03-01 2023-03-02 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-03-01 2023-03-02 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 2022-12-15 2023-01-09 Y
Provide activities to meet all resident's needs. Health 2022-12-15 2023-01-09 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-15 2023-01-09 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-12-15 2023-01-09 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2022-12-15 2023-01-09 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-12-15 2023-01-09 Y
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2022-12-15 2023-01-09 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-05-10 2022-05-12 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-05-10 2022-05-12 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-10 2022-05-12 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-03-24 2022-05-10 Y
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-03-24 2022-05-10 Y
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2022-03-24 2022-05-10 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-06 2022-01-28 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-12-06 2022-01-28 Y
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 2021-12-06 2022-01-20 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-12-06 2022-01-20 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2021-12-06 2022-01-20 Y
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2021-12-06 2022-01-20 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2021-12-06 2022-01-20 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-12-06 2022-01-20 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-06 2022-01-20 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-12-06 2022-01-20 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 2021-12-06 2022-01-20 Y
Provide enough food/fluids to maintain a resident's health. Health 2021-12-06 2022-01-20 Y
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2021-12-06 2022-01-20 Y
Post nurse staffing information every day. Health 2021-12-06 2022-01-20 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2021-12-06 2022-01-20 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-12-06 2022-01-20 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 2021-12-06 2022-01-20 Y
Provide and implement an infection prevention and control program. Health 2021-12-06 2022-01-20 Y
Keep all essential equipment working safely. Health 2021-12-06 2022-01-20 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2021-12-06 2022-01-20 Y
Establish staff and initial training requirements. Fire Safety 2021-11-30 2021-12-31 N
Conduct testing and exercise requirements. Fire Safety 2021-11-30 2021-12-31 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-11-30 2021-12-31 N
Provide properly protected cooking facilities. Fire Safety 2021-11-30 2021-12-31 N
Install an approved automatic sprinkler system. Fire Safety 2021-11-30 2021-12-31 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-11-30 2021-12-31 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-11-30 2021-12-31 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2021-11-30 2021-12-31 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-11-30 2021-12-31 N

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