Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Terrace Rehab & Healthcare during CMS and state inspections, most recent first.
Surveyors found that frozen vegetables were stored uncovered and without expiration dates in the facility's freezer. Both the Assistant Dietary Manager and the Dietary Manager confirmed that food items should be covered, labeled, and dated according to facility policy.
Eight residents requiring feeding assistance were not provided with individualized attention during meals, as each staff member was responsible for feeding two residents at the same time. Staff also referred to these residents as 'feeders,' a term the Administrator confirmed was inappropriate and not respectful of resident dignity.
A resident with Alzheimer's and bipolar disorder was involved in a physical altercation with another resident, resulting in a small skin tear. Despite some improvement with medication, the resident continued to exhibit aggressive behaviors. The facility's investigation confirmed the abuse, highlighting a deficiency in protecting residents from such incidents.
The facility failed to implement effective infection control measures during a COVID-19 outbreak, resulting in 42 residents testing positive. Testing was limited, and staff did not consistently wear PPE. A COVID-19 positive resident was not isolated properly, and the facility did not follow CDC guidelines for ending transmission-based precautions. Inadequate staffing and cross-contamination further contributed to the outbreak.
The facility failed to maintain safe water temperatures below 120°F in resident bathrooms, with several instances of temperatures ranging from 121.2°F to 127.3°F. This poses a risk of burns, especially to residents with cognitive impairments. The Environmental Services Director checks temperatures weekly, but the survey found multiple instances of elevated temperatures, indicating a failure to adhere to the facility's policy.
The facility failed to provide a dignified dining experience and adequate care for residents, as evidenced by delayed meal service, lack of assistance with soiled clothing, and inadequate supervision during meals. Residents were observed with soiled clothing, food on their faces, and without timely assistance for activities of daily living (ADLs), compromising their dignity and quality of life.
The facility failed to provide detailed care plans for residents with ADL self-care performance deficits, affecting their ability to achieve or maintain their highest practicable well-being. Observations showed residents were not given necessary assistance, and interviews confirmed care plans lacked specific interventions for feeding, transferring, ambulation, and hygiene care.
The facility failed to provide adequate assistance to residents with ADL needs, leaving them unattended during meals and neglecting personal hygiene. Residents with swallowing difficulties were left alone with food, and several had long, dirty fingernails. Additionally, residents lacked access to call bells or timely assistance, resulting in prolonged periods without necessary care.
The facility failed to provide engaging activities for residents, including a resident who expressed interest in music and audio books but was not supported. Multiple residents on Unit B wanted to spend time outdoors, but their preferences were not accommodated due to limited staffing and lack of specific interventions in care plans. Additionally, there were no scheduled activities on weekends, and the facility was short-staffed, impacting the activities program.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident lacked an assessment for triggers and a care plan to prevent re-traumatization, while another resident was observed in distress without a care plan addressing their PTSD history. Staff interviews revealed a lack of awareness and incomplete psychosocial assessments.
The facility failed to provide adequate nursing staff, resulting in delayed care and assistance for residents. A resident experienced a 32-minute delay in receiving pain medication, while others faced late medication administration due to insufficient staffing. Several residents lacked access to call bells, leading to prolonged waits for assistance. Additionally, residents requiring help with eating were left unattended for significant periods, highlighting systemic staffing issues.
The facility experienced a high medication error rate of 72% due to delayed administration of medications for several residents. Medications for two residents were administered over an hour late due to the large unit size and high volume of medications. Additionally, two other residents received their medications late because the LPN was interrupted by staffing shortages and the need to assist aides.
A resident in an LTC facility experienced an unwitnessed fall and refused assessment and care for apparent injuries. Despite a request from the resident's POA to send them to the ER, the staff did not act due to the resident's initial refusal. The following morning, the resident was found in a compromised state and was emergently transferred to the hospital with altered mental status and other medical issues. The facility failed to notify the DON or on-call provider about the resident's condition, not adhering to policy and advance directives.
The facility failed to remove expired medications and biologicals from use. In the A-Wing medication storage room, expired glucose control solution and BinaxNow COVID tests were found. In the B-Wing, a Diabetic Hypoglycemic Emergency Kit contained expired Glucagon. A RN confirmed the expired items and stated that checking for expired medications is a shared responsibility among nurses.
A resident with cognitive intactness was not notified in writing of their involuntary discharge or their right to appeal, despite being their own guardian. The facility only informed the resident's family member, leading to the resident's confusion and continued hospital stay while awaiting long-term placement.
Failure to Properly Store Frozen Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. During an initial kitchen tour, three uncovered boxes containing frozen vegetables were found open to air in the freezer room, and none of the items had expiration dates. The Assistant Dietary Manager confirmed that items should be covered in the storage area. A review of the facility's Food Safety Requirements policy, revised in February 2024, indicated that food should be kept covered or in tight containers. The Dietary Manager also confirmed in an interview that items in storage should be covered or in a container, labeled, and dated.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to provide dignity and respect to residents requiring feeding assistance, as observed during a meal service where four staff members were feeding eight residents, with each staff member feeding two residents simultaneously. During interviews, a Licensed Nursing Assistant (LNA) acknowledged that due to insufficient staffing, it was common practice for one staff member to feed more than one resident at a time. The LNA also referred to residents needing assistance as 'feeders,' a term confirmed by the Administrator as inappropriate and not in line with respecting residents' dignity. All eight sampled residents requiring feeding assistance were affected by this practice.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse during a resident-to-resident altercation. Resident #1, who was admitted to the Memory Care Unit with Alzheimer's disease and dementia with behavioral disturbances, threw a clipboard at Resident #2, hitting them in the elbow and causing a small skin tear. Resident #2, who was admitted for nursing and rehabilitative services with Alzheimer's disease and bipolar disorder, retaliated by throwing the clipboard back. The incident was observed by staff, and the facility's investigation confirmed the occurrence of physical abuse between the two residents. Resident #2 had a history of verbal and physical aggression towards other residents, including Resident #1, which was documented in a physician's note. Despite some improvement with an increased dosage of an SSRI, Resident #2 continued to exhibit behaviors that posed a safety risk to themselves and others. The facility's policy on abuse, neglect, and exploitation, which was last revised in January 2024, defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish, including certain resident-to-resident altercations. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from abuse.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in accordance with CDC and state health department guidelines during a COVID-19 outbreak. The outbreak began on 7/13/2024, and by the time of the survey, 42 residents had tested positive. The facility did not conduct broad-based testing of all residents and staff, as recommended, to identify and contain the spread of the virus. Instead, testing was limited to symptomatic individuals and those with known close contact, which was insufficient to control the outbreak. The Infection Control Nurse admitted there was no process in place to monitor close contacts or symptoms effectively. Staff on Units B and C were observed not consistently wearing facemasks, and there was a lack of adherence to PPE protocols, particularly in the Special Care Unit (SCU) for dementia patients. Resident #9, who was symptomatic and COVID-19 positive, was not isolated properly, and staff did not use appropriate PPE when interacting with the resident. The resident was observed in communal areas without a mask, potentially exposing other residents. The facility's policy required the use of N95 masks and other PPE for confirmed COVID-19 cases, but this was not followed. The facility's approach to ending transmission-based precautions was also inadequate. The Medical Director confirmed that the facility ended precautions after one negative test, contrary to CDC guidelines that require two consecutive negative tests. Additionally, there was no dedicated staffing for affected units, leading to potential cross-contamination. The facility's failure to follow recommended testing and isolation protocols, along with inconsistent use of PPE, contributed to the uncontrolled spread of COVID-19 among residents and staff.
Unsafe Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident environments were free of accident hazards by not maintaining safe water temperatures below 120 degrees Fahrenheit. During an observation on the Special Care Unit, which houses residents with dementia or cognitive impairments, water temperatures in several resident bathroom sinks were found to exceed the facility's policy limit of 120 degrees Fahrenheit. Temperatures ranged from 121.2 to 127.3 degrees Fahrenheit, posing a risk of burns to residents, particularly those with cognitive impairments who may not recognize the danger of scalding water. The Environmental Services Director (ESD) stated that water temperatures are checked weekly in random resident bathrooms, and adjustments are made if temperatures are high. However, during the survey, multiple instances of elevated water temperatures were recorded, indicating a failure in maintaining consistent safe water temperatures. The facility's policy on safe water temperatures was not adhered to, as evidenced by the repeated findings of water temperatures exceeding the maximum allowable limit, which could potentially lead to accidents or injuries among the residents.
Failure to Provide Dignified Dining Experience and Adequate Care
Penalty
Summary
The facility failed to provide a respectful and dignified dining experience for residents, as evidenced by several observations of neglect and inadequate care. Residents were not served meals at the same time, leading to some residents observing others eat without having their own meals. Additionally, there were instances where residents were left soiled and unattended for extended periods. For example, one resident was observed with visibly soiled pants and was not assisted until much later, despite expressing discomfort and needing help. Another resident was found with coffee spilled on the floor and wet socks, yet remained in the same position for a significant time without assistance. Further observations revealed that residents were not adequately supervised or engaged during meal times, with some residents left with food on their faces and clothes from previous meals. There were also instances where residents were not assisted with their activities of daily living (ADLs), such as a resident with bowel movement on their hands and another with food caked in their teeth and a white film at the gum line. The lack of timely assistance and supervision during meals and ADLs compromised the residents' dignity and quality of life.
Inadequate Resident Care Plans for ADL Support
Penalty
Summary
The facility failed to ensure that resident care plans were adequately detailed to describe the specific care and services required for residents to achieve or maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency was identified for 10 of 40 sampled residents who had deficits in activities of daily living (ADL) self-care performance. The care plans for these residents lacked specific interventions, such as the type of assistance needed for feeding, transferring, ambulation, and hygiene care. For instance, Resident #65 required constant supervision and verbal cues while eating, and was dependent on staff for all ADLs, but this information was not included in the care plan. Similarly, Resident #109 was on aspiration precautions and required supervision while eating, yet these details were omitted from the care plan. Observations during the recertification survey revealed that the residents were not provided with the necessary assistance to complete ADL tasks. Interviews with facility staff, including a Nurse Consultant, confirmed that care plans should be person-centered and specify the type of assistance required for proper ADL care. However, the care plans reviewed did not meet these standards, as they failed to include resident-specific interventions for hygiene task support and other ADL needs. This lack of detailed care planning contributed to the deficiency identified by the surveyors.
Inadequate Assistance and Supervision for Residents with ADL Needs
Penalty
Summary
The facility failed to provide adequate assistance to residents who were unable to perform activities of daily living (ADLs) independently. Multiple residents with swallowing difficulties and cognitive impairments were left unattended during meals, despite care plans indicating the need for constant supervision and assistance. For instance, one resident with dysphagia was observed alone in the dining room and in their room with food in front of them, without receiving the necessary verbal cues or physical assistance to eat safely. Another resident with Parkinson's disease struggled to feed themselves due to the timing of their medication, yet staff left them unattended with their meal. In addition to meal-related deficiencies, the facility neglected to maintain proper hygiene for several residents. Observations revealed that multiple residents had long, dirty fingernails, despite expressing a desire for them to be cut. This lack of attention to personal care needs was consistent across several residents, indicating a broader issue with the facility's ability to meet the basic hygiene requirements of its residents. Furthermore, the facility failed to ensure that residents had access to call bells or assistance when needed. Several residents were observed calling out for help to use the bathroom or to be repositioned, but staff did not respond in a timely manner. In one case, a resident was left in a reclined wheelchair for an extended period, calling out for assistance to use the bathroom, but was not attended to for over 40 minutes. These observations highlight significant lapses in the facility's ability to provide necessary care and assistance to its residents, as outlined in their care plans.
Deficiency in Resident Activities and Outdoor Access
Penalty
Summary
The facility failed to provide engaging activities for residents, as evidenced by the case of a resident who was observed in bed without stimulation and expressed interest in more independent and one-on-one activities. Despite the resident's care plan indicating a need to break the cycle of inactivity and establish a list of enjoyable activities, the Activities Director was unaware of these interventions and did not track participation or refusals. The resident's interest in music and audio books was not adequately addressed, and there were no specific interventions in the care plan to support these preferences. Multiple residents on Unit B expressed a desire to spend time outdoors, but the facility did not support this interest. Record reviews and interviews revealed that residents had preferences for outdoor activities, but their care plans lacked specific interventions to facilitate this. The Activities Director acknowledged the issue of limited outdoor access and insufficient staffing to accommodate residents' preferences, with only three outdoor activities scheduled over two months. The facility also failed to provide weekend activities, as observed on a Sunday when no activities took place on Unit B. The activity calendars for July and August showed no scheduled activities on weekends, and the Activities Director confirmed that the department was short-staffed, making it difficult to maintain the activities program. The SCU Unit Manager noted that nursing staff attempted to provide activities when none were scheduled, but there was no consistent presence in the dining room to engage residents.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD. Resident #92 was admitted with PTSD and dementia, but there was no evidence of an assessment for triggers that could re-traumatize the resident. The resident's care plan lacked information on how staff could avoid re-traumatizing the resident. Interviews with staff revealed a lack of awareness about the resident's PTSD diagnosis and triggers. The Medical Social Worker admitted that psychosocial assessments were not up to date and that there was no specific trauma care plan in place for Resident #92. Similarly, Resident #18, who also had a history of PTSD related to abuse, was observed in distress, asking for help, and showing signs of discomfort. Despite a completed psychosocial assessment indicating PTSD, there was no care plan addressing the resident's trauma history or identifying triggers. The Director of Social Services confirmed the absence of an active care plan for Resident #18, acknowledging the importance of having such a plan to guide staff in providing appropriate care.
Staffing Deficiencies Lead to Delayed Care and Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple incidents of delayed assistance and care. Resident #79 experienced a significant delay in receiving pain medication, waiting 32 minutes after initially calling for help. The delay was attributed to the LPN being occupied with other residents' medication administration. Similarly, medication administration for four other residents was delayed due to the large unit size and insufficient staffing, causing interruptions in medication passes. Several residents were observed without access to their call bells, leading to prolonged periods without assistance. Resident #34 was unable to reach the bathroom for 40 minutes due to the lack of a call bell, resulting in distress. Resident #76 also lacked access to a call bell and was unable to reach the common area for lunch, waiting 2.5 hours before receiving assistance. These incidents highlight the facility's failure to ensure residents have the means to request help and receive timely assistance. Residents requiring assistance with eating were also neglected. Resident #50, who needs supervision due to aspiration precautions, was left without assistance for 26 minutes during a meal. Similarly, Resident #65, who requires constant supervision and prompting while eating, was left unattended for significant periods during meals. These observations indicate a systemic issue with staffing levels and the facility's ability to meet the care needs of its residents, particularly those requiring assistance with activities of daily living.
High Medication Error Rate Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that medication error rates were below 5%, with a calculated error rate of 72% for four of ten sampled residents. During observations, it was noted that medications for two residents were administered over an hour late. For Resident #13, medications including Tylenol, Aspirin, Vitamin D, Apixaban, Gabapentin, a multivitamin, and Oxycodone were scheduled for 8:00 AM but were administered between 10:15 AM and 10:30 AM. Similarly, Resident #45's medications, including Allopurinol, Amlodipine, Zoloft, Hydrochlorothiazide, and Metformin, were also administered late. The RN attributed the delay to the large unit size and the high volume of medications to be administered. Further observations revealed that Resident #50 received Carbidopa-Levodopa and Entacapone over an hour late, and Resident #20 received Ensure and Artificial Tears late as well. These medications were scheduled for 5:00 PM but were administered at 6:28 PM and 6:52 PM, respectively. The LPN explained that the unit was very busy, and medication passes were interrupted due to insufficient staffing, as aides required assistance. These delays contributed to the high medication error rate observed during the survey.
Failure to Assess and Respond to Resident's Fall and Subsequent Condition
Penalty
Summary
The facility failed to ensure that a resident was assessed for injuries and complications in accordance with professional standards and facility policy after sustaining a fall. Resident #22, who was admitted for short-term rehabilitation, experienced an unwitnessed fall while attempting to use the bathroom. Despite having apparent injuries, including bruising and a skin tear, the resident refused a head-to-toe assessment and care for the injuries. The staff noted the resident's refusal and aggressive behavior, but did not take further action to ensure the resident's safety and well-being. On the morning following the fall, Resident #22 was observed in a compromised state, slumped in a wheelchair, unable to control their upper body, and eventually vomiting. Despite these concerning signs, there was no staff monitoring the resident in the dining/activity area. The resident was emergently transferred to the hospital with altered mental status and low blood pressure, where they were diagnosed with pyelonephritis, dehydration, and low blood pressure. The facility's staff, including the LPN and RN, failed to notify the Director of Nursing or the on-call provider about the resident's change in mental status. The resident's Power of Attorney had requested that the resident be sent to the emergency room, but this was not acted upon due to the resident's initial refusal. The facility's policy on notification of changes and the resident's advance directive were not adequately followed, leading to a delay in necessary medical intervention.
Expired Medications and Biologicals Found in Storage
Penalty
Summary
The facility failed to ensure that medications and biologicals were removed from use when expired. During an observation on 8/29/2024, a vial of glucose control solution with an expiration date of 8/3/24 was found in the A-Wing medication storage room, labeled as opened on 7/9/24. Additionally, one opened BinaxNow COVID test with an expiration date of 1/7/2024 and two with expiration dates of 2/14/2024 were present. The Unit Manager confirmed these items were expired. In the B-Wing medication storage room, a Diabetic Hypoglycemic Emergency Kit contained a tube of Glucagon 1mg Emergency Injection Kit and Glucose Gel 40% with an expiration date of 6/2024. A Registered Nurse confirmed the Glucagon was expired and stated that it is the responsibility of all nurses to check for expired medications.
Failure to Notify Resident of Discharge
Penalty
Summary
The facility failed to provide timely written notification of a transfer or discharge to a resident, who was identified as their own guardian, following an incident. The resident, admitted for rehabilitation after a fall, was diagnosed with Down syndrome, anxiety, mild intellectual disabilities, and obsessive-compulsive behavior. Despite having a BIMS score indicating cognitive intactness, the resident was not informed in writing about the involuntary discharge or their right to appeal. Instead, the facility only communicated the discharge to the resident's family member by phone and email. The deficiency was confirmed through interviews and record reviews, which revealed no evidence of a written discharge notice given to the resident. The resident expressed confusion about the discharge and stated they were unaware of the facility's decision, indicating they would have preferred to return to the facility. The resident remained in the hospital while awaiting long-term placement, highlighting the facility's failure to adhere to proper notification procedures for discharge or transfer.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Burlington | 0.4 mi | ★★★★★ | 15 | 0 |
| Premier Rehab And Healthcare At Burlington | 3.6 mi | ★★★★★ | 12 | 0 |
| Green Mountain Nursing And Rehabilitation | 5.4 mi | — | 0 | 0 |
| Wake Robin-linden Nursing Home | 11 mi | ★★★★★ | 1 | 0 |
| Clinton County Nursing Home | 14.9 mi | ★★★★★ | 0 | 0 |
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