Deficiency Records for Complete Care at Burlington Woods, LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Complete Care at Burlington Woods, LLC. 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? |
|---|---|---|---|---|
| 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 | 2023-12-13 | 2024-01-26 | 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 | 2023-12-13 | 2024-01-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-13 | 2024-01-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-13 | 2024-01-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-13 | 2024-01-26 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-12-13 | 2024-01-26 | 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 | 2023-12-13 | 2024-01-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-13 | 2024-01-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-13 | 2024-01-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-12-13 | 2024-01-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-13 | 2024-01-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-13 | 2024-01-26 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-12-13 | 2024-01-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-12-13 | 2024-01-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-12-13 | 2024-01-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-12-13 | 2024-01-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-13 | 2024-01-05 | 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 | 2021-07-29 | 2021-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-29 | 2021-08-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-29 | 2021-08-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-29 | 2021-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-29 | 2021-08-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-29 | 2021-08-30 | 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 | 2021-07-29 | 2021-08-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-29 | 2021-08-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-29 | 2021-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-29 | 2021-08-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-29 | 2021-08-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-29 | 2019-10-09 | 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 | 2019-08-29 | 2019-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-10-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-29 | 2019-10-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-29 | 2019-10-09 | N |
