Deficiency Records for Burlington Health and Rehabilitation Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-22 | 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-22 | 2021-12-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-12 | 2021-09-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-28 | 2021-08-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-28 | 2021-08-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-28 | 2021-08-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-08-27 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-17 | 2019-11-01 | 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 | 2019-10-17 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-17 | 2019-11-01 | 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 | 2019-10-17 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-17 | 2019-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-17 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-17 | 2019-11-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-10-17 | 2019-11-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-17 | 2019-11-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-17 | 2019-11-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-17 | 2019-11-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-17 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-17 | 2019-11-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-10-17 | 2019-11-01 | 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 | 2019-10-16 | 2019-11-01 | 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 | 2019-10-16 | 2019-11-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
