Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Joe-anne Burgin Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, dementia, severe cognitive impairment, daily wandering, and documented exit-seeking behaviors was care planned for elopement risk with interventions such as 1:1 supervision while outside, close observation of location, and frequent monitoring and redirection. Despite these measures and facility policies requiring proactive assessment and management of elopement and wandering, the resident exited the building unsupervised when an exit door, not in staff’s line of sight, was remotely opened for another resident during a period when doors were unlocked due to a generator outage. The resident was subsequently found across the street near a college.
The facility failed to accurately reflect the code status of two residents in the EMR, leading to potential non-compliance with their documented wishes. One resident's EMR indicated DNR, while their POLST form showed a preference for resuscitation. Another resident's EMR showed Full Code, contrary to their POLST form indicating AND/DNR. Staff confirmed they would follow the EMR, risking non-compliance with residents' wishes.
An LPN failed to prime an insulin pen and did not leave the needle in a resident's arm for the required 10 seconds, contrary to facility policy and manufacturer's instructions. This oversight could potentially affect the resident's insulin dosage and blood glucose levels. Interviews revealed the LPN was unaware of these requirements, despite prior education provided by the facility.
An LPN failed to properly disinfect a glucometer between uses for three residents, using alcohol wipes instead of the required disinfecting wipes, contrary to the facility's policy and manufacturer's guidelines. The DON and Divisional Nurse Consultant confirmed the correct procedure was not followed, increasing the risk of infection transmission.
A resident with a high risk for elopement exited the facility through an unsecured door leading to a vacant hospital. The door was left ajar after meal carts were moved, allowing the resident to walk through the hospital and exit into the parking lot. The resident was found and returned without injury.
Failure to Supervise High-Risk Wanderer Resulting in Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for a resident with Alzheimer's disease and dementia who had documented daily wandering and rejection of care, severe cognitive impairment (BIMS score of 6), and a history of a fall prior to admission. The facility’s elopement and wandering policies required proactive assessment of elopement risk, identification of risk factors, and implementation of appropriate interventions in the care plan. The resident’s MDS documented daily wandering, and the care plan identified elopement risk and exit-seeking behavior, with interventions including 1:1 supervision while outside, close observation of the resident’s location, and frequent observation and redirection when exit-seeking behaviors were noted. Despite these identified risks and care plan interventions, the resident exited the building unsupervised. The facility’s own incident report concluded that the resident left the building when an exit door was remotely opened for another resident and that this door was not within staff’s line of sight. The assigned LPN reported that the resident had exhibited exit-seeking behaviors since admission, such as going to the door with personal belongings, and that staff were monitoring the resident every 15 to 30 minutes to ensure she remained in the building. On the day of the incident, the LPN stated the resident likely exited when doors were unlocked due to a generator outage and followed another resident, after which she was found across the street near a nearby college.
Inaccurate Code Status Documentation in EMR
Penalty
Summary
The facility failed to ensure that the code status of two residents was accurately reflected in the electronic medical record (EMR), which could potentially lead to their wishes not being honored in the event of a medical emergency. For one resident, the EMR indicated a Do Not Resuscitate (DNR) status, while a Physician Orders for Life-Sustaining Treatment (POLST) form signed by the responsible party and physician indicated that the resident wished to be resuscitated. Interviews with facility staff revealed that they would follow the EMR's DNR indication, potentially disregarding the resident's actual wishes as documented in the POLST form. For the second resident, the EMR and physician's orders incorrectly indicated a Full Code status, while the POLST form signed by the resident and physician indicated a preference for Allow Natural Death (AND) and Do Not Attempt Resuscitation. Facility staff confirmed they would follow the EMR's Full Code indication, which was contrary to the resident's documented wishes. The discrepancies in the EMR and the POLST forms were verified by the Division Nurse Consultant, Administrator, and Director of Nursing, highlighting a failure in accurately maintaining and reflecting residents' code status in the facility's records.
Failure to Prime Insulin Pen and Inadequate Needle Dwell Time
Penalty
Summary
The facility failed to ensure that insulin administration met professional standards of quality for a resident. During an observation, an LPN administered insulin using a Humalog KwikPen without priming the pen as required by both the facility's policy and the manufacturer's instructions. The LPN dialed the pen to four units and injected the insulin into the resident's arm without priming the pen with two units to clear air from the needle. Additionally, the LPN did not keep the needle in the resident's arm for the recommended 10 seconds, instead removing it after approximately six seconds. Interviews conducted with the LPN revealed a lack of awareness regarding the necessity of priming the insulin pen and the requirement to leave the needle in place for the full 10 seconds. The Director of Nursing and the Divisional Nurse Consultant confirmed that nurses had been educated on the proper use of insulin pens, including the priming process. A Registered Nurse also confirmed the requirement to prime the pen to ensure the correct insulin dose is administered. This deficiency in insulin administration practices could potentially affect the resident's blood glucose levels.
Improper Disinfection of Glucometer Between Residents
Penalty
Summary
The facility failed to ensure proper disinfection of a glucometer between uses by different residents, which increased the risk of transmitting blood-borne diseases. The facility's policy required that reusable point-of-care devices, such as glucose meters, be cleaned and disinfected according to the manufacturer's guidelines after each use. However, an LPN was observed using an alcohol wipe instead of the required CaviWipe or EPA-registered disinfecting wipe to clean the glucometer between uses for three residents. This practice did not align with the manufacturer's instructions or the facility's policy. The LPN admitted to not following the correct infection control procedures and stated she was instructed to use alcohol wipes instead of the appropriate disinfecting wipes. The Director of Nursing and the Divisional Nurse Consultant confirmed that the glucometers should be disinfected with purple-top Sani-cloth wipes between residents. The Medical Director suggested that alcohol swabs and antimicrobial cleaners could be interchangeable, but this was not in line with the facility's policy. The residents involved did not have communicable diseases, but the improper disinfection process posed a potential risk of infection transmission.
Resident Elopement Due to Unsecured Door
Penalty
Summary
The facility failed to ensure that doors leading into an attached vacant hospital were secured, resulting in an elopement incident involving a resident. The resident, who had a history of schizophrenia, dementia, and other behavioral disturbances, was identified as having a high risk for elopement. Despite this, the resident was able to exit the facility through a door that was left ajar, leading to the vacant hospital area. On the day of the incident, the resident was observed walking through the facility and eventually exited through a door that was not properly secured. The door was left open after meal carts were pushed through, allowing the resident to access the hospital area. The resident continued to walk through the hospital and exited through the main entrance doors, which were unlocked from the inside, leading to the hospital parking lot where the resident was found by staff. The incident was discovered when a Registered Nurse noticed the resident was missing and initiated a search. The resident was found in the parking lot and returned to the facility without injury. Interviews with staff revealed that the door was left open due to a failure to detach the magnet that held it ajar, allowing the resident to exit the facility unsupervised.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cuthbert
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calhoun Nursing Home | 15.6 mi | ★★★★★ | 0 | 0 |
| Reserve At Fort Gaines Of Journey Llc, The | 19.1 mi | ★★★★★ | 0 | 0 |
| Dawson Health And Rehabilitation | 21.3 mi | ★★★★★ | 5 | 0 |
| Four County Health And Rehabilitation | 22.2 mi | ★★★★★ | 0 | 0 |
| Crowne Health Care Of Eufaula | 22.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.