Ollie Steele Burden Manor

In the surveyor’s words

From the most serious findings on record at Ollie Steele Burden Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 17, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF882Oct 11, 2023

  Based 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. Findings: Review of the facility's Infection Control Binder revealed no documentation of S2DON and S11RN having completed specialized training in infection prevention and control. On 10/11/2023 12:26 p.m., an interview was conducted with S2DON. S2DON confirmed that neither she nor S11RN had completed the specialized infection prevention and control training. S2DON stated S15CRNC had the specialized infection prevention and control training and was overseeing them. On 10/11/2023 at 2:41 p.m., an interview was conducted with S2DON, S11RN, and S15CRNC. […]

• No harm, potential for more than minimal, patternF641Aug 12, 2026

  Based on interviews and record review, the facility failed to ensure residents' MDS assessments accurately reflected the resident's status for 6 (#1, #2, #4, #8, #11, and #62) of 16 residents reviewed for MDS assessments. The facility failed to ensure: 1. Resident #2 was accurately coded for Moisture Associated Skin Damage (MASD); and 2. Resident #1, #4, #8, #11, and #62 were accurately coded for The Unit Certification or Licensure Designation. Findings: 1. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #2 was diagnosed with MASD on 01/13/2026. Review of Resident #2's Quarterly MDS with an ARD of 06/24/2026 revealed Section M1040. Other Ulcers, Wounds and Skin Problems: H. […]

• No harm, potential for more than minimal, patternF880Sep 17, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF582Oct 30, 2024

  Based 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. Findings: On 10/30/2024, a review of the facility's policy titled Advance Beneficiary Notice with a Copyright date of 2024, revealed the following: Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility ore remaining in the facility. i. […]