Burnett Medical Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Oct 23, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2022

  Based on observations and interview, the facility did not prepare and serve foods under sanitary conditions in accordance with professional standards for food service safety. The deficient practices have the potential to affect 37 of 37 residents. Kitchen staff wore single use disposable gloves to touch ready to eat foods which does not adhere to professional standards of practice for infection control while preparing food for service to residents. This is evidence by: The facility policy, entitled Use of Gloves, stated: .3) Gloves are changed when they become soiled or torn, when changing from one task to another, or after two hours of continuous use Disposable gloves are a single use item and should be discarded after each use . […]

• No harm, potential for more than minimal, patternF605Jan 29, 2026

  Based 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. Findings include: The facility policy, titled Depression-Clinical Protocol dated 2001, states in part: 1. […]

• No harm, potential for more than minimal, patternF761Oct 23, 2024

  Based 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). Findings include: 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, Medication Labeling and Storage dated [DATE], which stated in part: -Medication Storage: #2: The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner. […]

• No harm, potential for more than minimal, patternF880Jul 26, 2023

  Based 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.) Findings include: Surveyor reviewed policy for hand washing/hand hygiene which stated in part, .residents will be encouraged to practice hand hygiene through the use of alcohol-based hand rub or alternatively, soap and water before and after eating or handling… […]