Ollie Steele Burden Manor

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to ensure:1. Food was properly labeled in the walk-in refrigerator;2. Food was properly labeled in the dry storage room;3. Food was properly sealed and labeled in the walk-in freezer;4. Dietary staff maintained documentation of dishwasher temperatures;5. Dietary staff maintained documentation of 3 compartment sink temperatures and chemical sanitation levels; and 6. Dietary staff maintained documentation of Breakfast and Lunch meal temperatures. This deficient practice had the potential to affect any of the 29 residents who were served food from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure:1. Nursing staff providing care to a resident who required Transmission Based Precautions (TBP) did not exit a resident's room wearing Personal Protective Equipment (PPE) or store a mask worn during resident care in their pocket for 1 (#62) of 2 (#2 and #62) residents reviewed on TBP; 2. Nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 2 of 2 (#2 and #66) residents reviewed for insulin administration; and 3. Documentation was maintained of the annual review of the Infection Prevention Policies and Procedures.

Inspectors wroteBased on record reviews and interviews, the facility failed to inform the resident or his/her legal representative in writing of Medicare services which may not be covered, and of the resident's/beneficiary's potential liability for payment for non-covered services. The facility failed to ensure liability notices were accurate and completed as required for 2 (#53 and #54) of 3 (#53, #54, and #61) residents reviewed for beneficiary protection notification.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan which met the needs of 1 of 1 (#50) residents reviewed for accidents. The facility failed to ensure Resident #50 was care planned for fall risk upon admission.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each residents' care plan was reviewed and revised for 1 of 1 (#21) residents reviewed for Activities of Daily Living (ADL). The facility failed to update Resident #21's care plan after 11/05/2024, when she required a mechanical lift for transfers.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the services provided as outlined in the comprehensive care plan met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 2 of 2 (#2 and #66) residents reviewed for insulin administration.

Inspectors wroteBased on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to properly label respiratory care equipment for 1 of 1 (#2) resident investigated for respiratory care. Review of the facility's undated policy titled, Departmental (Respiratory Infection)-Prevention of Infection revealed, in part:Steps in the Procedure:Infection Control Considerations Related to Oxygen Administration:7. Change the oxygen cannula and tubing every seven (7) days, or as needed. Review of Resident #2's Clinical record revealed an admission date of 06/26/2025 and diagnoses, which included Pulmonary Hypertension and Congestive Heart Failure. Review of Resident #2's current Physician Orders revealed an order for Oxygen at 2 Liters per minute per nasal cannula as needed. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure: 1. Insulin pens were labeled with an open date in 1 (Cart C) of 3 (Cart A, Cart B and Cart C) medication carts reviewed, and2. An expired medication was not available for use in 1 (Med Room A) of 2 (Med Room A and Med Room B) medication rooms reviewed.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpsters.

Inspectors wroteBased on interviews and record reviews, the facility failed to meet the following Hospice requirements by failing to: 1. Designate a member of the facility's interdisciplinary team (IDT) to be responsible for working with Hospice representatives to coordinate care of the resident provided by facility and Hospice staff for 1 of 1 (#4) residents reviewed for Hospice care; and2. Maintain a system to ensure a Hospice resident's Hospice Binder contained most current Hospice plan of care for 1 of 1 (#4) residents reviewed for Hospice care. A review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #4 was admitted to a local hospice agency on 06/07/2025 with a current Certification Period of 09/04/2025 thru 12/02/2025. [...]

Inspectors wroteBased on record reviews and an interview, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to the discontinuation of Medicare Part A services for 3 (#25, #228, and #229) of 3 (#25, #228, and #229) residents reviewed for Beneficiary Notification.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. Each residents' discharge was encoded in an MDS assessment for 3 (#7, #12, and #22) of 11 (#1, #5, #6, #7, #8, #12, #14, #15, #19, #20, and #22) residents reviewed for Resident Assessment; and 2. A resident's discharge assessment was completed and transmitted for 1 (#6) of 11 (#1, #5, #6, #7, #8, #12, #14, #15, #19, #20, and #22) residents reviewed for Resident Assessment. Review of the facility's policy titled, MDS Completion and Submission Timeframes with a revision date of July 2017 revealed the following, in part: Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident was assessed using the quarterly review instrument not less frequently than once every three months for 3 (#1, #19, and #20) of 11 (#1, #5, #6, #7, #8, #12, #14, #15, #19, #20, and #22) residents reviewed for Resident Assessment. Review of the facility's policy titled, MDS Completion and Submission Timeframes with a revision date of July 2017 revealed the following, in part: Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 1 (#21) resident reviewed for PASARR.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis which included the total resident census for 1 of 1 area reviewed for nurse staffing data. This deficient practice had the potential to affect any of the 20 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety as evidenced by failing to: 1. Ensure opened foods were sealed properly; and 2. Ensured expired food items were disposed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all medical records regarding the residents code status consistently reflected the resident's wishes for 1(#136) of 16 residents reviewed for advanced directives in the initial pool process.

Inspectors wroteBased on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required.

Inspectors wroteBased on interview and record review the facility failed to complete and transmit MDS assessments in the required timeframe for 4 of 4 (#8, #17, #22, and #24) residents reviewed for resident assessment.