Bartram Crossing

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary conditions and proper food storage practices in the nourishment room on the 300 hallway, by failing to 1) Have a plate warming unit that was free of brown liquid residue, 2) Have a microwave free of food splatter, dried residue, and debris on the interior surfaces, including the top, sides, and base of the unit, and 3) Label and date bread stored in the cabinet above the microwave. These failures had the potential to negatively impact all residents who received food from the nourishment room. The findings include:On 3/25/2026 at 2:11 PM, an observation of the 300-hallway nourishment room revealed a cabinet containing a plate warming unit with visible accumulation of brown liquid residue, debris, and black particulate matter on the cabinet floor beneath the unit. The microwave was observed to have visible food splatter, dried residue, and debris on the interior surfaces, including the top, sides, and base of the unit. An opened loaf of bread was observed stored in the cabinet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide resident dignity by leaving a urinary catheter collection bag uncovered for one (Resident #13) of five residents observed with urinary catheters, from a total sample of 42 residents.The findings included:On 03/23/2026 at 12:29 PM, Resident #13 was observed lying in bed, eyes closed, with lower extremity in orthopedic boot, elevated on pillow. Her urinary catheter collection bag was observed uncovered and hanging on the bed frame with clear yellow urine visible in the bag and tubing visible to anyone walking past her room. (Photographic evidence obtained)Record review for Resident #13 revealed she was admitted to the facility on [DATE], with an initial admission date on 07/22/2022. Her diagnoses included obstructive reflux uropathy, dysuria and peripheral vascular disease. A review of the quarterly minimum data set (MDS) quarterly assessment, dated 01/08/2026, revealed the resident had a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility, by failing to 1) Date mark numerous open bundles of bread on the bread rack, 2) Clean grease buildup inside and around the door area of the convection oven, and 3) Clean food debris stuck on and around the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 05/22/2024 at 7:00 AM. During the tour, the bread rack adjacent to the juice machine was observed with four open bundles of bread with no date markings. The inside door area and oven floor of the convection oven next to the steamer was covered with food grime and grease build-up. The mixer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, interviews, and facility policy and procedure review, the facility failed to notify the resident, the resident's representative, and the office of the Long-Term Care Ombudsman of the resident's transfer and the reasons for the transfer in writing for one (Resident #1) of three residents reviewed for hospitalization. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on 9/16/23. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. Resident #1's medical record revealed that he had his wife designated as his primary emergency contact and responsible party. A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, interviews, and facility policy and procedure review, the facility failed to provide written information prior to hospital transfer that notified the resident/resident representative of the facility's bed hold policy for one (Resident #1) of three residents reviewed for hospital transfer. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on 9/16/23. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. Resident #1's medical record revealed that he had designated his wife as his primary emergency contact and responsible party. A discharge minimum data set (MDS) assessment with a reference date of 9/20/23, indicated unplanned discharge, return anticipated. Cognitive skills for decision making: moderately impaired.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to permit a resident to return after a transfer to the hospital for one (Resident #1) of three residents reviewed for transfer/discharge. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on 9/16/23. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. A telephone interview was conducted with the hospital discharge planner on 10/12/23 at 10:26 am regarding Resident #1. She stated the resident was previously sent to the hospital on 9/18/23 and returned to the facility the same day. Resident #1 returned to the hospital emergency department on 9/20/23 at approximately 3:30 pm for observation. The resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. The findings include: During a tour of the kitchen on 6/21/22 at 10:52 AM with Certified Dietary Manager (CDM) E, he stated he had been employed at the facility for approximately one year. At this time, he identified Food Service Utility Worker F as the primary dishwasher. He stated he completed weekly kitchen audits and all outdated and damaged food should be discarded. An observation of one of the kitchen freezers revealed an open pack of ground turkey labeled use by 6/15/2022. When asked about this, the CDM acknowledged it was out of date and stated, It's not on the menu. There was also an unopened package of veggie burgers labeled use by 6/18/2022. The CDM stated the burgers weren't open and were there just in case a vegetarian was admitted into the facility. As the tour of the kitchen continued, a box labeled red potatoes was observed sitting on a shelf in the kitchen. Upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure that two (Residents #23 and #73) of 25 sampled residents received care as ordered by the physician. Resident #73 had orders for follow up with oncology due to a history of breast cancer, and Resident #23 had orders for laboratory diagnostic tests. These orders were not carried out. The findings include: 1. On 06/21/22 at 3:41 PM, Resident #23 stated she did not always get her prescribed cream. Staff told her they didn't have it on hand and would use her personal Vaseline ointment instead. A review of Resident #23's clinical record revealed she was admitted on [DATE] with a re-entry on 7/20/19. Her diagnoses included inclusion body myositis, contracture of muscle unspecified upper arm, paranoid schizophrenia, and inclusive body mastitis. A review of the active physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to review gradual dose reduction recommendations for one (Resident #73) of five residents selected for psychotropic drug review from a total sample of 25 residents. The findings include: A review of Resident #73's clinical record revealed an admission on [DATE] with a re-entry on 2/27/16. Diagnoses included hemiparesis following unspecified cerebrovascular disease affecting unspecified cite, anxiety disorder, and major depressive disorder. A review of the June 2022 Physician's Order Sheets revealed active physician's orders for the following: Lexapro 20 milligrams (mg) every day (QD) for depression, Eliquis 2.5 mg every 12 hours for Deep Vein Thrombosis (DVT - blood clot), megace 400 mg one time a day for poor appetite, Dextromethorphan-quinidine 20-10 mg every 12 hours for pseudobablor affect PBA (sudden episodes of uncontrollable and inappropriate laughing or crying), and buspirone 15 mg BID (twice daily) for anxiety. A review of the active care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident and staff interviews, and resident and facility record reviews, the facility failed to maintain complete and accurate medical records for one (Resident #74) of two residents reviewed for non-pressure skin conditions, from a total of 25 residents in the sample. The findings include: An observation was conducted of Resident #74 on 06/21/22 at 1:29 PM. Multiple bruises were present on both forearms, and he had a dime-sized skin tear on the right forearm above his wrist. When he was asked what happened, Resident #74 replied he did not know; perhaps it was from his hospital bracelet. Observation confirmed a plastic snap-on medical identification bracelet secured loosely around his right wrist. On 06/22/22 at 11:07 AM, Resident #74 was observed in an activity on the 300 hall. The skin tear to his right forearm was visible and open to the air. The identification bracelet was still on the same wrist. Resident #74 reported the nurses were applying a salve to the area, and he would ask them to place the next bracelet on his left arm. An interview was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.