Burlington Health and Rehabilitation Center

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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.

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.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

PASARR screening for Mental disorders or Intellectual Disabilities

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide safe and appropriate respiratory care for a resident when needed.

Provide safe, appropriate pain management for a resident who requires such services.

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.

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.

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.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Ensure each resident receives an accurate assessment.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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.

Ensure residents have reasonable access to and privacy in their use of communication methods.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Provide and implement an infection prevention and control program.

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Provide and implement an infection prevention and control program.

Allow residents to self-administer drugs if determined clinically appropriate.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Ensure that residents are free from significant medication errors.

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.

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.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide enough food/fluids to maintain a resident's health.

Provide safe and appropriate respiratory care for a resident when needed.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Ensure medication error rates are not 5 percent or greater.

Ensure that residents are free from significant medication errors.

Provide and implement an infection prevention and control program.

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.

Respond appropriately to all alleged violations.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Assist a resident in gaining access to vision and hearing services.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Ensure that residents are free from significant medication errors.

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.

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.

Provide and implement an infection prevention and control program.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

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.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

Observe each nurse aide's job performance and give regular training.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide enough food/fluids to maintain a resident's health.

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.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Provide and implement an infection prevention and control program.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.