Deficiency Records for Burlington House Rehab and Alzheimer's Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Burlington House Rehab and Alzheimer's Care 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 or obtain dental services for each resident. | Health | 2023-06-28 | 2023-07-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-17 | 2023-07-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-17 | 2023-07-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-08 | 2023-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-08 | 2023-06-12 | 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 | 2023-05-08 | 2023-06-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-08 | 2023-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-08 | 2023-06-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-08 | 2023-06-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-08 | 2023-06-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-08 | 2023-06-12 | N |
| Keep all essential equipment working safely. | Health | 2023-05-08 | 2023-06-12 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-05-08 | 2023-06-12 | 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 | 2023-05-08 | 2023-06-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-08 | 2023-06-12 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-17 | 2023-06-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-17 | 2023-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-17 | 2023-06-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-17 | 2023-06-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-17 | 2023-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-17 | 2023-06-12 | 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 | 2023-01-31 | 2023-02-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-31 | 2023-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-31 | 2023-02-24 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-31 | 2023-02-24 | Y |
| 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 | 2023-01-31 | 2023-02-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-14 | 2022-10-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-14 | 2022-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-14 | 2022-10-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-05 | Y |
| 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 | 2022-09-14 | 2022-10-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-14 | 2022-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-01-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-16 | 2022-01-14 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-12-16 | 2022-01-14 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-16 | 2022-01-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-10 | 2022-01-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-10 | 2022-01-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2022-01-14 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2021-11-10 | 2022-01-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-20 | 2021-10-01 | Y |
| 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 | 2021-09-20 | 2021-10-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-12 | 2021-10-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-12-16 | 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 | 2019-11-07 | 2019-12-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-07 | 2019-12-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-07 | 2019-12-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-07 | 2019-12-16 | 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 | 2019-11-07 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-07 | 2019-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-07 | 2019-12-16 | 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 | 2019-11-07 | 2019-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-07 | 2019-12-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-06 | 2019-12-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-09-27 | 2018-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-27 | 2018-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-27 | 2018-10-31 | 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 | 2018-09-27 | 2018-10-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-09-27 | 2018-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-25 | 2018-10-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-25 | 2018-10-31 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-25 | 2018-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-25 | 2018-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-25 | 2018-10-31 | N |
