Joe-Anne Burgin Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Joe-Anne Burgin Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 27, 2023

  Based on observation, record review, resident and staff interviews, and review of facility policy/procedure titled Clinical Resource Tool; Topical Treatment of Wounds, the facility failed to ensure 1 (Resident #17) of 3 residents with pressure ulcers received treatment and services to promote healing. Actual harm was identified when a deep tissue injury (DTI, which is a purple or maroon localized area of discolored skin due to damage of the underlying soft tissue from pressure and/or shear) was identified on 3/10/2023 to the right ischium (buttock) of Resident #17 and the facility failed to assess/monitor the wound and provide necessary treatment to prevent the wound from worsening. […]

• No harm, potential for more than minimal, widespreadF812Apr 27, 2023

  Based on observation and staff interviews, the facility failed to serve food, monitor food and drink expiration dates, and maintain cooking equipment in a manner to prevent potential food safety issues. Specifically, the facility failed to: 1. allow 77 plate covers to air dry prior to assemblage and stacking in preparation for use during 1 of 2 meal observations; and 2. discard expired perishable foods and milk from 1 of 1 walk-in refrigerators; and 3. clean the convection oven weekly. These practices had the potential to affect 72 of 76 residents who received meals from the kitchen. […]

• No harm, potential for more than minimal, patternF582Oct 21, 2021

  Based on record review and staff interview, the facility failed to provide the skilled Notice of Medicare Non-Coverage Form CMS (Center for Medicare and Medicaid Services) -(NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two of three residents (R) R#18 and R#38) reviewed that were discharged from Medicare Part A coverage. Findings Include: Review of facility policy titled Financial Liability Notices (updated January 2020) revealed It is the intent of this nursing center to issue all required Financial Liability Notices in compliance of CMS (Centers for Medicaid and Medicare Services) or other payer regulations. 1. R#18 was discharged from Medicare Part A services on 5/29/21 and remained in the facility. […]

• No harm, potential for more than minimal, isolatedF689Mar 19, 2026

  Based on staff interviews, record review, and review of the facility's policies titled, Elopement and Wandering Patients, the facility failed to ensure adequate supervision to prevent elopement for one of 28 sampled residents (R) (R13) resulting in the resident exiting the facility unsupervised. This deficient practice had the potential for injury and inability to safely navigate outside the facility.Findings include:Review of the facility's policy titled, Elopement dated 12/27/2024 revealed an Intent to promote person-centered care for patients at risk for elopement. Section titled Definition defined elopement as when a patient leaves the premises or a safe area without authorization and/or necessary supervision. […]

• No harm, potential for more than minimal, isolatedF578Feb 14, 2025

  Based on record review, interview and review of the facility's policy titled, Advance Directives, the facility failed to ensure two of 30 residents (R) (R54 and R31) code status was accurately reflected in the electronic medical record (EMR). As a result, the residents' code status had the potential to not be honored in the event they would have coded. Findings include: Review of the facility's policy titled, Advance Directives with a review date of [DATE], stated, Each patient with decision making capacity has the right to make their own decisions related to their medical care .including the right to refuse or alter treatment plans, to accept or refuse medical or surgical treatment .and formulate advance directives. […]