Inspection visit
Inspection
Citations
20 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F761 - Labeling of Drugs and Biologicals
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.
F801 - Staffing
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F711 - Physician Visits
Provide a written emergency evacuation plan.
FAQ · About this visit
Common questions about this visit
What happened during the May 8, 2023 survey of BURLINGTON HOUSE REHAB & ALZHEIMER'S CARE CENTER?
This was a inspection survey of BURLINGTON HOUSE REHAB & ALZHEIMER'S CARE CENTER on May 8, 2023. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BURLINGTON HOUSE REHAB & ALZHEIMER'S CARE CENTER on May 8, 2023?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.