All citations for Burgess Square Healthcare Ctr

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Burgess Square Healthcare Ctr

Last standard health inspection on record

December 4, 2025

Showing 1 to 25 of 29 citations

  1. Harm to a resident

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

    Isolated (one or a few residents). CMS level G.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of May 21, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 4, 2026).

  2. Harm to a resident

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of November 20, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 3, 2025).

  3. Harm to a resident

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

    Isolated (one or a few residents). CMS level G.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of March 8, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 26, 2024).

  4. No harm, with potential for more than minimal harm

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

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 17, 2025).

  5. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  6. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0887, Infection Control Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  7. No harm, with potential for more than minimal harm

    Protect each resident from the wrongful use of the resident's belongings or money.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0602, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of February 11, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 26, 2025).

  8. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  9. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  10. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  11. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of November 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 28, 2023).

  12. No harm, with potential for more than minimal harm

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0805, Nutrition and Dietary Deficiencies. Inspection of November 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 28, 2023).

  13. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 16, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 28, 2023).

  14. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  15. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  16. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  17. No harm, with potential for more than minimal harm

    Ensure medication error rates are not 5 percent or greater.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0759, Pharmacy Service Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  18. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0883, Infection Control Deficiencies. Inspection of December 4, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  19. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 9, 2024).

  20. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  21. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0693, Quality of Life and Care Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  22. No harm, with potential for more than minimal harm

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0694, Quality of Life and Care Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  23. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2024).

  24. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of September 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 10, 2024).

  25. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of March 8, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 26, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.