Burgh Care Center

In the surveyor’s words

From the most serious findings on record at Burgh Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Sep 8, 2021

  Based on observations, review of facility policies, and staff interviews, it was determined that the facility failed to maintain a sanitary kitchen, store food in proper conditions, maintain kitchen equipment, and prevent potential food borne illness due to potential food contamination from damage from a water leak and leaking ceiling in the kitchen, for all residents creating an Immediate Jeopardy (IJ) situation for one of one kitchens. Findings include: Review of the facility policy Food Safety and Sanitation last reviewed on 8/2/21, with previous review date of 4/28/21, indicated that all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. […]

• Immediate jeopardy, patternF689Jun 21, 2024

  Based on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who was identified as high risk for elopement (Resident R1). The facility failed to provide adequate supervision during smoking times for 11 of 11 residents observed (Residents R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13), failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have… […]

• Immediate jeopardy, patternF686Jun 4, 2023

  Based on review of facility policy, observations, clinical record reviews, facility documentation, and interviews, it was determined the facility failed to implement interventions to prevent pressure ulcer and injury (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin.) development for residents who were admitted without PU/PIs, but who had multiple co-morbidities; and failed to provide ongoing skin assessments for four of four residents (Resident R5, R63, R68, and R231) that resulted in deterioration of one or more PU/PIs for two of four residents (R5 and R63) and infection for one of four (R68), which resulted in an immediate jeopardy situation for four of 74 residents. […]

• Immediate jeopardy, isolatedF689Jul 9, 2026

  Based on review of facility policy, facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to create an environment free of accidents when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke (a serious health condition when the body temperature rises to 104 degrees or more due to exposure to high temperatures) while out of the facility. […]

• Immediate jeopardy, isolatedF695Apr 5, 2025

  Based on observation, review of clinical record, review of facility policies, interview with staff and resident, it was determined the facility failed provide tracheostomy care consistent with professional standards of practice for two of two residents. This failure resulted in an Immediate Jeopardy situation for Resident R32 and R34 who had a tracheostomy obstruction, experienced respiratory and emotional distress and potential death. (Resident R34) Findings include: Review of the facility policy Tracheostomy Care Protocol Licensed Staff last reviewed [DATE], indicates respiratory care must be provided per professional standards, physician orders are required for all aspects of tracheostomy (trach) care, including suctioning and oxygen use. […]