Inspection Reports for
Bickford of Burlington

Investigation of Incident #128590-I involving Tenant #1 leaving the building through the alarmed front exit door without staff knowledge on 5/10/25. Tenant #1 was found uninjured outside by a family member and returned to the program.

The program failed to implement its policy regarding exit door alarms, resulting in Tenant #1 leaving the building unnoticed for approximately six minutes. Staff did not perform an accountability check after the door alarm sounded, contrary to policy requirements.

Investigation #128590-I

The program failed to implement its policy regarding exit door alarms, resulting in Tenant #1 leaving the building unnoticed for approximately six minutes. Staff did not perform an accountability check after the door alarm sounded as required by policy.

The complaint investigation found no regulatory insufficiencies related to Incident #120563-I but identified deficiencies during the investigation of Complaint #120852-C involving Tenant C1's admission evaluations and service plan development.

The program failed to complete thorough evaluations prior to admission to ensure services were available to meet the needs of one tenant (Tenant C1). Additionally, the preliminary service plan was not developed and signed by all parties prior to occupancy for Tenant C1.

Complaint #119510-C was investigated and found to have no regulatory insufficiencies.

No regulatory insufficiencies were cited during the complaint investigation or the recertification visit.

Investigation into Complaint #110186-C found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the complaint investigation.

Investigation into complaints #107955-C and #108055-C revealed incidents involving Tenant #2 and Tenant #3, including allegations of sexual assault, verbal and physical aggression, and failure of staff to adequately document and address these issues.

The facility failed to complete incident reports for all unusual occurrences involving tenants, failed to ensure tenant dignity and respect, and did not update a tenant's service plan to address significant changes in behavior including verbal, physical, and sexual aggression. Multiple staff interviews and incident reports documented ongoing aggressive and inappropriate behavior between tenants, which staff had to frequently intervene in.

Investigations 107955-C and 108005-C

The program failed to ensure Tenant #3 was treated with consideration, respect, and full recognition of personal dignity. Multiple staff interviews and incident reports documented repeated aggressive, possessive, and inappropriate sexual behavior by Tenant #2 toward Tenant #3, including physical and verbal aggression and unwanted sexual contact.

The investigation into Complaint #101470-C found that staff did not meet the identified toileting needs of Tenant C1, who required two-person assistance and frequent toileting care. Staff reported difficulty providing timely incontinence care due to insufficient staffing, especially during overnight shifts. Tenant C1 passed away on 2022-03-17.

No regulatory insufficiencies were found for complaints #102752-C and #101471-C. However, a deficiency was cited for complaint #101470-C regarding insufficient staffing to meet the toileting and care needs of Tenant C1, who required frequent assistance and was not adequately supported during multiple shifts.

Investigations related to complaints 93888-C, 95233-C, 96118-C, 97248-C, 97295-C, 97607-C, and 97245-C were conducted during the recertification visit.

The facility failed to include one of twelve current and discharged tenants' identified needs in their service plans. Specifically, Tenant C3's service plan did not reflect directives given by the former Registered Nurse Coordinator regarding toileting and mobility assistance.

The inspection was triggered by complaints #93888-C, #95233-C, #96118-C, #97248-C, #97295-C, #97607-C and #97245-C.

The program was found deficient in multiple areas including failure to complete incident reports, inconsistent adherence to policies and procedures, inadequate infection control, failure to isolate symptomatic tenants, staff abuse and neglect allegations, inadequate care and services to tenants, failure to respond reasonably to tenant requests, medication administration errors, narcotics protocol violations, incomplete background checks, retention of tenants requiring two-person assistance without proper waivers, incomplete service plans, and failure to conduct nurse reviews after significant changes in tenant condition.