A list of the most recent deficiencies for Burlington Convalescent Hospital. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-09 | 2024-03-01 | 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 | 2024-02-09 | 2024-03-01 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2024-02-09 | 2024-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-09 | 2024-03-01 | 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 | 2024-02-09 | 2024-03-01 | N |
| Keep all essential equipment working safely. | Health | 2024-02-09 | 2024-03-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-02-09 | 2024-03-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-09 | 2024-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-19 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-24 | 2023-04-27 | 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 | 2023-03-24 | 2023-04-27 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-24 | 2023-04-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-17 | 2023-04-10 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-17 | 2023-04-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-17 | 2023-04-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-17 | 2023-04-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-17 | 2023-04-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-17 | 2023-04-10 | 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 | 2023-03-17 | 2023-04-10 | 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 | 2023-03-17 | 2023-04-10 | N |
| Provide or obtain dental services for each resident. | Health | 2023-03-17 | 2023-04-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-17 | 2023-04-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-03-17 | 2023-04-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-17 | 2023-04-10 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-03-17 | 2023-04-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-11 | 2023-01-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-28 | 2023-01-09 | 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 | 2022-11-17 | 2022-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-26 | 2022-11-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-15 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-08 | 2022-07-19 | 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 | 2022-06-08 | 2022-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-08 | 2022-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-24 | 2022-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-05 | 2022-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-08 | 2021-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-09-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-30 | 2021-09-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-21 | 2021-05-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-21 | 2021-05-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-21 | 2021-05-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-11 | 2019-10-21 | 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 | 2019-09-11 | 2019-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-11 | 2019-10-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-06 | 2019-10-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-06 | 2019-10-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-06 | 2019-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-06 | 2019-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-06 | 2019-10-08 | 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 | 2019-09-06 | 2019-10-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-06 | 2019-10-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-06 | 2019-10-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-06 | 2019-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-06 | 2019-10-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-06 | 2019-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-06 | 2019-10-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-06 | 2019-10-08 | N |
