Burnett Medical Center

Inspectors wroteBased on interview and record review, the facility did not conduct a thorough investigation of abuse and neglect for 1 of 9 sampled residents (R)(R9). The facility failed to conduct a thorough investigation by not interviewing other residents to ensure no other residents may have been affected by staff verbal abuse. The facility policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last reviewed 03/15/22, states under section F(a). Procedures must be in place to provide the resident with a safe, protected environment during the investigation .iv. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identity and immediate clinical interventions necessary. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's care plan is reviewed and revised based on the resident's needs and preferences. This occurred for 6 of 9 sampled residents (R) whose care plans were reviewed (R3, R4, R5, R6, R7, R8) for sleeping hour preferences. R3, R4, R5, R6, R7, and R8 preferred to be allowed to sleep during the night without being woken up during sleeping hours and their care plans were not updated by 6/12/26 as indicated by the facility investigation of incontinence care and resident preferences.

Inspectors wroteBased on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the State Agency and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1). On 03/22/26, the facility was made aware of R1's allegation of abuse. The facility did not report this allegation to the State Agency (SA) or to local law enforcement within 2 hours. This is evidenced by:Facility policy titled, Abuse, neglect, Mistreatment and Misappropriation of Resident Property, with revised date of 07/10/25, states: G. Reporting and Response Components. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 of 3 residents (R) reviewed (R1). On 03/22/26, the facility was made aware of R1's allegation of abuse by staff. The facility did not complete a full body assessment of R1, complete interviews with staff and other residents to ensure a thorough investigation into the allegation. This is evidenced by: Facility policy titled, Abuse, neglect, Mistreatment and Misappropriation of Resident Property, with revised date of 07/10/25, states in part: The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident. Collecting and preserving physical and documentary evidence.interviewing the alleged perpetrator. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 3 of 4 residents (R) reviewed were free from chemical restraints. (R1, R4, R14)The facility is not monitoring resident-specific targeted behaviors for R14's, R1's, and R4's psychotropic medication use. There is no evidence the facility is tracking targeted behaviors to assess the therapeutic effects of the psychotropic medications and ensure R14 is receiving the desired benefits and lowest possible dose.

Inspectors wroteBased on interview and record review, the facility did not formulate an advance directive for 2 of 16 residents (R)(R32, R33) reviewed. R32 did not have a physician order or code status of DNR documented. R33 did not have R33's code status documented in the medical record or in the binder at the nurse's station, which is for full code status residents. This is evidenced by: Facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support, with a revised date of 04/2025, states in part: General Gudielines.2. If the resident's DNR status is unclear, CPR will be initiated and continued until it is determined there is a DNR or a physician's order not to administer CPR.Preparation for Cardiopulmonary Resuscitation.f. Provide information on advance directives to each resident/representative upon admission. g. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R4 and R31) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, name and address with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R4 and R31 received written information on reserve bed payment policy. R4 was transferred to the Emergency Department (ED) on 10/15/25 and 10/23/25. R4 was not provided with a complete written transfer or bed hold notice. R31 was discharged to home and facility did not have any documentation that Ombudsman was notified.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R14) reviewed for falls. R14 fell on 1/2/26 and 1/25/26. The facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall, and review and revise care plan fall interventions at time of fall or after IDT meeting.

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts and controlled substances. This occurred for 2 of the 3 medication carts/storage rooms observed. During the three-day survey, 1 of 4 observations were made of medication cart left unlocked when unattended and out of view of staff. One observation was made of a lorazepam liquid bottle that was opened and not stored in a double locked compartment while being stored in the medication storage room.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Certified Nursing Assistant (CNA) D did not use Enhanced Barrier Precautions (EBP) when providing direct care for R7. Licensed Practical Nurse (LPN) F did not perform hand hygiene while changing R4's Libre Sensor (glucose monitoring device). This is evidenced by: Example 1 Facility policy titled, Transmission Based Precautions, with a revised date of 06/04/25, states in part: Procedure: .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the provider was notified of significant change in condition for one resident (Resident (Resident (R) 1) of three sampled residents reviewed for change in condition in a total sample of six. This failure placed residents at risk of increased medical complications.

Inspectors wroteBased on interviews, record review and review of facility policy, the facility failed to provide a transfer form to the hospital at the time of the transfer for one resident (Resident (R) 2) in a total sample of six. This failure placed residents at risk of lack of information being shared with the hospital.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure a complete and accurate medical record for two residents (Residents (R) 1, R2) in a total sample of six. The facility failed to completely describe an accurate description of a fall and document the neurological checks at the time of the fall for R1. This failure placed the residents at risk of unmet care and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 1 of 3 residents (R) (R1) reviewed. R1 was a brittle diabetic who did not receive medications per physician orders and provider was not notified of abnormal blood glucose levels. This is evidenced by:Facility policy, titled, Change in a Resident's Condition or Status, with a revised date of 02/2021, states in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility did not keep a complete surveillance line list which affects all residents (R), did not perform hand hygiene with glove changes during wound cares for 1 of 2 residents (R4), touched medications to be administer with bare hands for 2 of 8 (R6, R7) observations, and did not dispose of PPE properly when caring for residents on enhanced barrier precaution for 2 of 5 residents (R1, R17). This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure medication was labeled to determine the expiration date of opened medications for 7 of 13 residents (R) (R2, R12, R25, R3, R20, R14, and R18).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used clothing protector to wipe resident's face while assisting to eat. This affected 3 of 3 residents observed. (R17, R22, and R7)

Inspectors wroteBased on interviews and record review, the facility did not investigate, resolve, and record resolution of grievance for 1 of 13 residents (R) R28. R28's Activated Power of Attorney (APOA) K reported a personal item missing and a grievance was not completed.

Inspectors wroteBased on record review and interview, the facility did not develop a comprehensive care plan for 1 of 1 resident (R) R12 reviewed for indwelling catheter. R12 had an indwelling catheter in place. The facility did not develop a care plan to direct care for indwelling catheter.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure care plans were revised and implemented to reflect changes in care for 2 of 5 residents (R) R12 and R22. R12 had a recent fall and care plan was updated with intervention to include 30 minute - 1 hour safety checks to be completed. This intervention was not completed. Facility did not follow fall care plan interventions for 15-minute checks for R22.

Inspectors wroteBased on interview and record review, facility did not ensure pharmacy recommendation reports were acknowledged by a physician for 1 of 5 residents, (R) R12, reviewed. R12 had a pharmacy recommendation that was not acknowledged or acted upon by a physician.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 2 residents (R25) reviewed for antibiotic use without adequate indication for its use. R25 was ordered and administered cefuroxime avetil (antibiotic) for Urinary Tract Infection (UTI). No documented symptoms to indicate antibiotic. No laboratory results indicating necessity for prescribed antibiotic.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 8 residents (R), R12 and R15, observed for medication pass. The facility had 26 opportunities and 3 medication errors resulting in an 11.54% error rate. Registered Nurse (RN) D administered insulin medication without checking the expiration date and without holding the insulin injection in the abdomen for at least 10 seconds for R12. Licensed Practical Nurse (LPN) C administered Morphine sulfate oral medication without checking the expiration date for R15. This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy titled, Administering oral medications dated on September 4, 2024, stated in part: -Steps in the procedure: [...]

Inspectors wroteBased on record review and interview, the facility did not review and revise the comprehensive care plan for 1 of 3 sampled residents, Resident (R)3.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 of the 3 residents reviewed for transfers (R3, R2), received adequate supervision and assistance to prevent accidents. This is evidenced by: The policy titled, Low lift program/safety with Mechanical lifts, including in part, .facility uses EZ Way, INC equipment and follow their operating instructions, accuracy care/replacement guidelines, and safety/maintenance checklist as found in the EZ Way manual attached to each machine, or online at http://www.ezlifts.com/downloads/ . The manufacturing instructions for the EZ stand titled, EZ way smart stand operating instructions, included in part, .As patients vary in size, shape, and weight, these conditions must be taken into consideration when deciding EZ way harness; the weight of patient and circumference of patients torso where the harness is applied . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a system was in place to adequately assess and supervise residents more closely to prevent elopement for 2 of 3 residents (R) who were reviewed for wandering/elopement (R1, R3). R1, upon admission to the facility on [DATE], was not assessed for wandering/elopement. R3 was admitted to the facility on [DATE]. R3 has never had an assessment conducted for wandering/elopement.

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not assist residents (R) with hand hygiene prior to meals in the dining room during observations of breakfast meal on 07/25/23 and breakfast meal on 07/26/23. This affected 13 of 37 residents. (R28, R1, R4, R3, R17, R9, R6, R32, R12, R13, R10, R23, and R18.)

Inspectors wroteBased on observations, interviews and record review, the facility did not report injuries of unknown source to the proper authorities and failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for resident (R). (R15) R15 had an injury to right wrist on 05/25/23 with unknown origin. This serious injury was not reported to the state agency or reported as a reasonable suspician of a crime.

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation was completed to identify the cause of the injury to rule out abuse.

Inspectors wroteBased on interview and record review, the facility did not complete the quarterly Minimum Data Set (MDS) assessments within the required timeframe for 1 of 13 residents (R) reviewed. (R27) R27's quarterly Minimum Data Set was not completed timely.

Inspectors wroteBased on interview and record review, the facility did not revise care plans to reflect the current transfer and repositioning status being performed for 2 of 12 sampled residents (R) (R15, R32). R15's care plan was not updated to identify how often repositioning was to occur. R32's care plan was not updated to identify the current transfer status being performed with transfers. This is evidenced by: Example 1 R15 was admitted on [DATE] with diagnoses including, in part, dementia, glaucoma, depression with anxiety, bradycardia, and hypothyroidism. Surveyor reviewed R15's care plan which, stated in part, .for prompted toileting plan: take to bathroom every two hours; for risk/fall prevention: toilet every two hours; for Risk/alteration in skin integrity: reposition in chair every hour and every two hours when in bed . [...]

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 1 of 3 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. (R15) R15 did not receive repositioning or toileting every two hours as care plan stated.

Inspectors wroteBased on interviews and record review, the facility did not ensure residents received care consistent with professional standards of practice for 1 of 1 resident (R36) sampled for pressure injury (PI). The weekly wound assessment documentation did not include measurements or descriptions to show the weekly progression of R36's PIs. This is evidenced by: The Resident Assessment Instrument (RAI) manual classifies a stage 2 PI as, Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. [...]