Below 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 Bartram Crossing during CMS and state inspections, most recent first.
Unsanitary nourishment room equipment and unlabeled bread were observed in the 300 hallway nourishment room. A plate warming unit had brown liquid residue, debris, and black particulate matter beneath it, and the microwave had food splatter, dried residue, and debris on the interior surfaces. An opened loaf of bread stored above the microwave was not dated. Staff stated nourishment rooms are cleaned by dietary staff, but there was no tracking log or set cleaning schedule.
A resident with an indwelling urinary catheter was repeatedly observed in bed with the catheter collection bag uncovered and visible from the hallway, with urine and tubing exposed to anyone passing the room. The resident had diagnoses including obstructive reflux uropathy and dysuria, and a BIMS score indicating severe cognitive impairment. Staff interviews confirmed the bag should be below the bladder, covered, and placed out of view in a privacy bag when visible from the room or hallway.
The facility failed to implement its QAPI program as written by not using adverse incident data to conduct RCAs and develop timely PIPs after two serious fall‑related injuries. One resident, recovering from joint replacement with osteoporosis, muscle weakness, and unsteadiness, fell during OT while performing a laundry task with a COTA and was not wearing a physician‑ordered hinged knee brace locked in extension; she sustained a proximal tibia/fibula fracture, medial meniscus tear, and hemarthrosis. Another high fall‑risk resident with a right femur fracture, brain metastasis, anticoagulant use, and prior falls was placed on the toilet by a PTA and left unattended despite fall‑risk signage and a fall protocol requiring frequent safety checks; she was later found on the bathroom floor and diagnosed with a subarachnoid hemorrhage. In both cases, the QAPI committee did not meet, did not conduct the RCAs, and did not develop PIPs, and leadership confirmed that RCAs and corrective actions were handled informally outside the formal QAPI structure, leading surveyors to cite Immediate Jeopardy with potential impact to all residents.
Two residents experienced serious fall-related injuries when therapy staff failed to follow established orthotic and fall-prevention precautions. In one case, a resident with recent hip surgery and an order for a hinged knee brace locked in extension during all weight-bearing activity was taken through a laundry task without the brace in place; the resident stepped back on the unsupported leg and fell, later found to have a tibia/fibula fracture, meniscal tear, and hemarthrosis. In the other case, a high fall-risk resident on anticoagulation, requiring assistance with toileting and identified by door signage and protocols, was placed on the toilet by a PTA who then left the resident unattended and did not notify nursing or CNAs; the resident was later found on the bathroom floor with head trauma and was diagnosed with a subarachnoid hemorrhage. Surveyors found that therapy staff did not consistently use or follow the EMR precautions, passports, and fall-risk signage, resulting in neglect and Immediate Jeopardy.
Two residents experienced serious injuries when staff failed to follow fall-prevention orders and bathroom safety protocols. One resident with prior hip surgery and documented RLE weakness had a physician order for a hinged knee brace locked in extension and non-weight bearing status, with this requirement noted on her mobility "passport" but not entered into OT/PT precautions. During an OT laundry task, she was ambulating without the brace when a walker basket shifted; she stepped back on her unsupported leg, fell, and sustained a proximal tibia/fibula fracture, meniscal tear, and hemarthrosis. Another high fall-risk resident with a recent fall history, multiple comorbidities, and on anticoagulation was placed on the toilet by a PTA, given a call light, and left unattended despite door signage and facility policy requiring arm’s-length or line-of-sight supervision and prohibiting leaving high fall-risk residents alone on the toilet. A CNA later found this resident on the bathroom floor with head trauma; hospital imaging showed a subarachnoid hemorrhage. Surveyors cited these events as Immediate Jeopardy due to failures in updating and following therapy precautions, orthotic device orders, and toileting supervision requirements.
The facility failed to follow proper sanitation and food handling practices, including not date marking bread, allowing grease buildup in the oven, and not cleaning the mixer properly. Milk served to residents was found at unsafe temperatures. Staff interviews revealed inconsistencies in cleaning practices and adherence to facility policies.
Unsanitary nourishment room equipment and unlabeled bread
Penalty
Summary
The facility failed to maintain sanitary conditions and proper food storage practices in the nourishment room on the 300 hallway. During an observation on 3/25/2026 at 2:11 PM, the nourishment room cabinet containing a plate warming unit had visible brown liquid residue, debris, and black particulate matter on the cabinet floor beneath the unit. The microwave in the same area had 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 stored in the cabinet above the microwave had no date marking to show when it was opened. A second observation on 3/26/2026 at 11:03 AM showed the same conditions continued, with residue and debris beneath the plate warming unit, dried food residue and debris on the interior surfaces, and the opened loaf of bread still lacking a date marking. At 11:28 AM that day, the plate warming unit was again observed with visible accumulation of dark residue, debris, and buildup along the interior surfaces and base. The General Manager of the kitchen stated that nourishment rooms are cleaned and maintained by dietary staff, but no tracking log or documentation was available to show routine cleaning or monitoring. Dietary Aide D stated there was no set schedule and tasks were completed if there was time, and Dietary Aide E stated staff were responsible for checking expiration dates, labeling items, and cleaning nourishment room equipment.
Uncovered urinary catheter bag visible to passersby
Penalty
Summary
The facility failed to provide resident dignity for a resident with an indwelling urinary catheter by leaving the catheter collection bag uncovered and visible to anyone walking past the room. On 03/23/2026, the resident was observed lying in bed with the urinary catheter collection bag hanging on the bed frame, uncovered, with clear yellow urine visible in the bag and tubing visible from the hallway. The resident had diagnoses including obstructive reflux uropathy, dysuria, and peripheral vascular disease, and a quarterly MDS dated 01/08/2026 showed a BIMS score of 6 out of 15, indicating severe impairment. The same condition was observed again on 03/24/2026 and 03/25/2026, with the resident in bed and the catheter collection bag still uncovered and visible from outside the room. The resident was asked if she was comfortable with the bag uncovered and facing the door, and she replied, "As far as I know, I can't see anything." Her care plan addressed risk for UTI and indwelling catheter care, and physician orders required catheter care every shift, ensuring the drainage bag was below bladder level, tubing was free of kinks, and the anchoring device was in place. During interviews, an LPN stated the bag should be below the bladder and should be covered, the DON stated urinary catheter bags should be positioned on the other side of the bed and not in view of people passing, and another LPN stated the catheter should be in the privacy bag when facing the room or when in a wheelchair.
Failure to Use QAPI and Adverse Event Data to Prevent Repeat Serious Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI process that used adverse incident data to conduct root cause analyses and develop timely, effective performance improvement activities after serious resident injuries. The facility’s written QAPI policy stated that the program would encompass all segments of care and services, track and investigate adverse events every time they occur, and use a systematic approach to identify gaps or patterns in care, prioritize high‑risk or problem‑prone issues, and determine which problems would become performance improvement projects (PIPs). Despite this, the QAPI committee did not meet or become involved after two serious fall incidents involving residents, and no PIPs were developed in response to those events. The Administrator, who served as QAPI chair, confirmed that the QA committee had not been involved with either incident and that RCAs and corrective actions were being handled outside the formal QAPI structure. One resident, admitted for aftercare following joint replacement surgery with additional diagnoses including osteoporosis, muscle weakness, presence of a right artificial hip joint, and unsteadiness on feet, was actively being prepared for discharge with goals of walking safely and being independent. Her orthopedic physician had ordered weight bearing as tolerated to the right lower extremity with a hinged knee brace locked in extension for all weight bearing, and an ARNP entered the brace order into the electronic record. However, the brace requirement was not added to the resident’s OT and PT precautions until nine days after she fell. During an OT session practicing a laundry task with a COTA, the resident was filling a basket attached to her walker when the basket started to fall; as the COTA attempted to adjust it, the resident lost her balance and fell. She was not wearing the ordered hinged knee brace locked in extension at the time of the fall and sustained a nondisplaced fracture of the proximal tibia/fibula, a tear of the medial meniscus, hemarthrosis, and associated pain and fear of using the right leg. Although an RCA was discussed informally by the interdisciplinary team, the QAPI committee did not conduct the RCA or initiate a formal PIP. A second resident, admitted with diagnoses including an unspecified right femur fracture, prior fall on the same level, malignant neoplasm of the lung with secondary brain neoplasm, long‑term anticoagulant use, history of TIAs, and severe protein‑calorie malnutrition, had been assessed as a high fall risk and had an active physician’s order for a fall risk protocol with frequent rounding and safety checks. Her care plan identified risk for falls and injury related to medical conditions and documented a prior fall with family present. Despite these identified risks and orders, a PTA transferred the resident to the toilet, placed the call light across her lap, instructed her to pull it when finished, and then left the room without notifying nursing staff or a CNA that the resident was on the toilet. The PTA did not see the sign on the door indicating fall risk. The resident was later found on the bathroom floor with a scalp hematoma and ear injuries and was sent to the hospital, where a CT scan showed a subarachnoid hemorrhage in the right posterior temporal lobe. The QAPI committee did not meet after this incident, did not conduct the RCA, and did not develop a PIP, even though the facility’s own policy required systematic review of adverse events and prioritization of high‑risk, high‑frequency, or problem‑prone issues for performance improvement. Interviews with facility leadership and the risk manager confirmed that RCAs and corrective actions were being handled through informal meetings and daily clinical discussions rather than through the formal QAPI committee structure described in the facility’s policy. The risk manager stated that when incidents with potential for injury occurred, she convened RCA meetings with selected staff within 24–48 hours, separate from QAPI meetings, and that the QAPI/QA committee was not involved in these post‑incident efforts. She also stated that the QA committee primarily reviewed PIPs after they were already developed and did not participate in PIP development or provide substantive input, and that no PIPs were created in response to the two fall incidents. The Administrator and Medical Director acknowledged that the QAPI process was not being followed as intended, and that the governing body was aware that RCAs and PIPs were being created without QA committee involvement. Immediate Jeopardy at scope and severity level L was identified, with the report stating that the failure to develop measures needed to ensure the safety and protection of other residents had the potential to affect all 97 residents should an injury incident occur.
Failure to Follow Orthotic and Fall-Prevention Precautions During Therapy Sessions
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient safeguards and supervision to protect residents from neglect, specifically by not ensuring that rehabilitation staff were aware of and implemented care plan interventions and physician orders related to fall prevention and orthotic use. For one resident with a history of hip replacement and right lower extremity weakness, the orthopedic physician ordered a hinged knee brace locked in extension for all weight-bearing activity, and an ARNP entered an order for non-weight bearing to the right lower extremity with the hinged brace locked in extension when weight bearing. The resident’s passport tip sheet, dated prior to the fall, included instructions for the brace to be locked in extension and specified no walking backwards or pivoting on the right leg. However, the OT and PT precaution sheets did not include the brace instructions until nine days after the fall, and the treating COTA reported that the leg brace was not on the daily notes or schedule and was not on the resident at the time of the incident. On the day of the first incident, the resident, who had been receiving OT and PT and was preparing for discharge home, was engaged in a simulated laundry task with a COTA. The resident was filling a basket attached to her walker when the basket came loose. As the COTA attempted to adjust the basket, the resident stepped back on her unsupported right leg, lost her balance, and fell backward. She was wearing a gait belt and non-skid socks but was not wearing the ordered hinged knee brace locked in extension. Following the fall, she complained of severe right knee pain and was unable to move the knee. Imaging later revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the medial meniscus, hemarthrosis, and swelling. The facility’s investigation concluded that the resident was not wearing her physician-ordered hinged brace, locked in extension, at the time of the accident, despite the brace requirement being present on the passport and in physician documentation. The second incident involved another resident with multiple diagnoses including a right femur fracture, history of falls, anticoagulant use, and moderately impaired cognition. This resident had been assessed as high fall risk, had an active fall risk protocol with frequent safety rounding, and required partial/moderate assistance with toileting and toilet transfers. The resident’s door displayed red rounding signage and a fall-risk star, and staff interviews confirmed that high fall risk residents were not to be left unattended on the toilet. On the day of the fall, a PTA transferred this resident onto the toilet, placed the call light across her lap, instructed her to pull it when finished, and then left the room to treat another resident without notifying a nurse or CNA that the resident was on the toilet. The PTA reported not seeing the fall-risk sign on the door. Shortly thereafter, a CNA responding to the call light found the resident on the bathroom floor with head and ear injuries. An ARNP assessed her and she was sent to the hospital, where a CT scan showed a subarachnoid hemorrhage in the right posterior temporal lobe. The facility’s investigation determined that the PTA left a known high fall risk resident unattended on the toilet and failed to recognize posted fall-risk signage and the requirement for stand-by supervision while toileting. Across both events, the facility did not ensure that therapy staff consistently used available tools and information—such as the passports, EMR precautions, and door signage—to follow physician orders and care plan interventions related to fall prevention and orthotic use. Therapy staff had access to the EMR and passports, which contained key information on weight-bearing status, orthotic devices, and fall precautions, yet in one case the brace order was not incorporated into therapy precautions before the fall, and in the other case the PTA did not heed the fall-risk indicators or the facility’s bathroom safety expectations. These failures resulted in two serious fall-related injuries and were determined by surveyors to constitute neglect and Immediate Jeopardy, with potential risk to all residents requiring orthotic devices and all residents on active therapy caseload.
Failure to Implement Fall-Prevention Orders and Bathroom Supervision Leading to Serious Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices to prevent falls, resulting in serious injuries to two residents. One resident with a history of hip replacement and documented right lower extremity weakness had an orthopedic follow-up visit where the physician specified weight bearing as tolerated with a walker and a hinged knee brace locked in extension with all weight bearing until quadriceps strength returned. An ARNP subsequently entered an order for the right lower extremity to be non‑weight bearing with a hinged knee brace locked in extension when weight bearing, every shift. The resident’s passport, dated several days before the fall, instructed that the brace be locked in extension, with hip precautions and no walking backwards or pivoting on the right lower extremity. However, the brace requirement was not added to the OT/PT precautions until nine days after the fall, and on the day of the incident the resident was not wearing the physician‑ordered hinged knee brace. During an OT session, the resident participated in a simulated laundry task with a COTA. The resident was filling a basket attached to her walker when the basket started to fall. As the COTA attempted to adjust the basket, the resident stepped back on her unsupported right leg, lost her balance, and fell to the floor. She was wearing a gait belt and non‑skid socks but did not have the hinged knee brace in place. She immediately complained of right knee pain and was unable to move the knee. Initial x‑rays were negative, but an MRI later revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the body and posterior horn of the medial meniscus, moderate hemarthrosis, and mild subcutaneous edema. The facility’s investigation concluded that the resident was not wearing her physician‑ordered hinged brace, locked in extension, at the time of the accident, and that the brace order had not been incorporated into therapy precautions or the daily therapy schedule prior to the fall. The second resident involved had multiple diagnoses including a right femur fracture with routine healing, a history of fall on the same level, malignant neoplasm of the lung with secondary brain neoplasm, long‑term anticoagulant use, history of TIAs, and severe protein‑calorie malnutrition. A fall risk assessment identified this resident as high risk, and she had active orders for Xarelto and a fall risk protocol including frequent rounding and toe‑touch weight bearing to the right lower extremity. She was care‑planned for risk of falls and injury related to falls, with interventions such as assessing footwear, observing for unsteadiness, and maintaining a clutter‑free environment. After an earlier fall event with family present outside the facility, her passport color was changed to indicate a fall, and red rounding signage was placed on her door to denote high fall risk and the need for frequent safety checks. On the day of the second incident, a PTA took this high‑risk resident to the bathroom at her request before therapy. He transferred her to the toilet, placed the call light across her lap, and instructed her to pull it when she was finished, then left the room to treat another resident without remaining in arm’s length or line of sight and without notifying the nurse or CNA that she was on the toilet. The PTA later stated he did not see the fall‑risk sign on the door. Staff interviews and facility policies confirmed that residents with a STOP sign or high fall‑risk indicators required staff to remain in the bathroom within arm’s length or line of sight and that high fall‑risk residents were not to be left unattended on the toilet. Shortly after the PTA left, a CNA responding to the call light found the resident on the bathroom floor with a hematoma to the left forehead, an abrasion and hematoma to the left ear, and additional abrasions. A CT scan at the hospital revealed a subarachnoid hemorrhage in the right posterior temporal lobe, and the resident was admitted. The facility determined that the PTA failed to recognize posted fall‑risk signage and the requirement for stand‑by supervision while toileting and failed to inform nursing staff that the resident was in the bathroom alone before leaving. The surveyors determined that these failures to ensure therapy orders were current, to integrate orthotic device orders into therapy precautions and passports, and to ensure therapy staff followed care‑plan safety interventions and bathroom safety protocols resulted in Immediate Jeopardy. The identified issues affected residents who required orthotic devices and those on the active therapy caseload, as the systems in place for communicating and implementing fall‑prevention measures, including passports, signage, and therapy precautions, were not consistently followed or updated.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices, which could potentially lead to foodborne illness among residents. During a kitchen tour, surveyors observed numerous open bundles of bread on the bread rack without date markings, grease buildup inside and around the door area of the convection oven, and food debris stuck on and around the safety guard of the mixer. Additionally, milk served to residents was found at unsafe temperatures, with one carton measuring 56 F and another at 62 F, both of which were discarded. Interviews with kitchen staff revealed inconsistencies in cleaning practices and adherence to the facility's policy for date marking bread and cleaning equipment. The Executive Chef and Certified Dietary Manager confirmed that the facility's policy required bread to be labeled, dated, and discarded after three days, and that kitchen equipment should be cleaned nightly, with deeper cleaning every two weeks. However, observations indicated that these practices were not consistently followed. The facility's policy and procedure review highlighted the importance of maintaining high standards of cleanliness and adhering to the First-In-First-Out (FIFO) method for food storage to prevent pathogen growth. Despite these policies, the facility's failure to implement them properly was evident in the observed deficiencies.
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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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