Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Bartley Nursing & Rehab during CMS and state inspections, most recent first.
Unclean dining room kitchenette drawers and steam table wells were observed in the Main and Dogwood dining rooms. A surveyor found a bug and spilled residue in the kitchenette drawers, along with dirty water and food debris in the steam table wells. The FSD acknowledged the drawers were unclean and could not provide cleaning records, while the HLD could not say when the dining rooms were last deep cleaned. The LNHA stated the drawers and steam table wells should be clean and free of food particles, and the facility policy required regular cleaning and sanitizing per manufacturer guidance.
A resident with a BIMS score of 14/15 and diagnoses including a left femur fracture and post-procedure infection was observed during wound care with the room door open, the privacy curtain not pulled, and the window shades not lowered while the bed was next to the window. The resident later confirmed that privacy was not maintained, and the ADON, Infection Preventionist, and DON stated that privacy during wound care required closing the door, pulling the curtain, and lowering the shades for a window bed.
Improper urinary catheter care was identified for a resident with an indwelling catheter and intact cognition. The catheter drainage bag was observed draped over the foot of the bed, not fully inside the privacy bag, with urine visible in the bag. Staff confirmed the bag should have been fully contained in the privacy bag, secured to the side of the bed with the provided hook, and positioned parallel to the resident for proper drainage.
The facility failed to administer medications within scheduled time parameters for two residents, leading to deficiencies in professional standards of practice. One resident received diabetes medication after breakfast instead of 30 minutes prior, and another resident received a blood clot medication outside the one-hour window allowed by the facility's policy.
A resident with multiple medical conditions did not receive their scheduled shower due to the assigned CNA running out of time and failing to inform the Nurse Supervisor. The facility's policy on maintaining residents' ability to perform ADLs was not followed.
The facility failed to store potentially hazardous foods properly, maintain kitchen equipment in a clean and sanitary manner, and keep cold food at acceptable temperatures during meal service. Opened boxes of food were found unsealed in the freezer, and kitchen equipment had significant sediment and debris. Cold food items were not maintained at the required temperatures during meal service.
The facility failed to maintain complete and accurate skin assessments for a resident with multiple diagnoses. The DON acknowledged that staff backdated documentation to appear complete, which was against policy.
The facility failed to ensure appropriate storage for respiratory equipment for a resident, as the nebulizer mask and tubing were not disinfected and were improperly stored. The resident's LPN did not follow the facility's policy, which required cleaning and drying the equipment before storage.
The facility failed to maintain a safe, sanitary, and homelike environment in the Birch Unit, with issues such as unsecured doorknob backplates, an exposed PTAC unit, and holes in the walls. Staff members confirmed that these conditions should have been identified and addressed promptly.
Unclean dining room kitchenette drawers and steam table wells
Penalty
Summary
The facility failed to provide an environment that was safe, functional, sanitary, and comfortable in two of three dining rooms, the Main and Dogwood dining rooms. During a tour of the Main dining room, a surveyor observed a bug in the second drawer of the kitchenette and a black, ground substance in the fourth drawer, which the AD identified as coffee; the fourth drawer was also sticky to the touch. In the same area, the surveyor observed that the kitchenette drawers were unclean and contained spilled material. The surveyor also observed that all five steam table wells in the Main and Dogwood dining rooms had residual water marks approximately half an inch above the water level, and the wells contained dirty water with food debris that was not consistent with the day's lunch meal. The FSD acknowledged that the kitchenette drawers were unclean and should not contain bugs or spilled substances, and confirmed that the steam table wells should be cleaned according to the manufacturer's specifications but could not provide cleaning records or accountability logs. The HLD stated that both dining rooms are deep cleaned monthly but could not specify when they were last deep cleaned. The LNHA stated that there should be no bugs or spills in the dining room kitchenette drawers and that the steam table wells and water should be clean and free of food particles; the facility's dietary equipment cleaning policy required equipment to be cleaned and sanitized regularly following manufacturer guidelines and facility-specific schedules.
Failure to Maintain Privacy During Wound Care
Penalty
Summary
The facility failed to interact with a resident in a dignified and respectful manner by not providing privacy during wound care. During a tour of the Dogwood Unit, the surveyor observed two nurses performing wound care to Resident #8 in a room with the door open, the privacy curtain not pulled, and the window shades not lowered, while the resident’s bed was next to the window. The surveyor continued to observe the room and noted that the resident’s privacy was not maintained during the procedure. The resident’s record showed diagnoses including fracture of the left femur and infection following a procedure/surgical site, and the most recent MDS dated 7/17/2025 reflected a BIMS score of 14 out of 15, indicating the resident was cognitively intact. The resident later confirmed that the nurses did not pull the curtain, shut the door, or pull the window shade during wound care. Facility staff, including the ADON, Infection Preventionist, and DON, confirmed that privacy during wound care was to be maintained by closing the door, pulling the privacy curtain, and lowering the window shades when the resident was in a window bed.
Improper Urinary Catheter Drainage Bag Placement
Penalty
Summary
Appropriate catheter care was not provided for a resident with an indwelling urinary catheter. During an initial tour, the surveyor observed the resident’s catheter drainage bag draped over the foot of the bed, not fully contained inside the privacy bag, with urine visible inside the bag. The resident stated he was not sure how long the drainage bag had been in that manner and denied pain at the time of the observation. The resident’s record showed diagnoses including rhabdomyolysis, hemiplegia, and hemiparesis following cerebrovascular disease, and the MDS indicated intact cognition with a BIMS score of 15 and the presence of an indwelling catheter. The resident’s care plan directed that the catheter bag and tubing be positioned below the level of the bladder and away from the entrance room door and privacy cover. Staff interviews confirmed that urinary drainage bags were expected to be fully encased in privacy bags, secured on the side of the bed with the provided hook, and positioned parallel to the resident to allow proper drainage. The RN/CN acknowledged that the bag’s placement at the end of the bed could potentially cause a pulling sensation and pain to the catheter site. The Infection Preventionist and DON also confirmed that the bag should have been fully contained within the privacy bag, placed parallel to the resident, and secured with the provided hook on the bed frame.
Failure to Administer Medications Within Scheduled Time Parameters
Penalty
Summary
The facility failed to administer medications within scheduled time parameters for two residents, leading to deficiencies in professional standards of practice. For Resident #20, the LPN administered glipizide, a diabetes medication, after the resident had already consumed their breakfast, despite the physician's order to administer it 30 minutes prior to the meal. The LPN acknowledged the error, and the DON confirmed that the medication should have been given before the meal to regulate blood sugar levels properly. The facility's policy allows for a one-hour window before and after the scheduled time for medication administration, which was not adhered to in this case. For Resident #213, the facility failed to administer Xarelto, a medication for venous thrombosis and embolism, within the scheduled time. The medication was supposed to be given at 9:00 AM but was administered at 10:39 AM, outside the one-hour window allowed by the facility's policy. The DON acknowledged this discrepancy upon reviewing the Medication Admin Audit Report. Both instances highlight a failure to follow professional standards of practice and the facility's own medication administration policy.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received their scheduled showers, as evidenced by the case of a resident who did not receive a shower on a scheduled day. The resident, who had diagnoses including chronic obstructive pulmonary disease, pleural effusion, diabetes mellitus, edema, and end-stage renal disease, reported not receiving their scheduled shower on a Friday during the 3:00 PM to 11:00 PM shift. The resident's medical record indicated they required set-up assistance for showering and had a fully intact cognition with a BIMS score of 14 out of 15. The facility's records confirmed that the resident was scheduled for showers on Mondays and Fridays during the 3-11 shift, and there was no documentation of the resident refusing the shower on the missed date. Interviews with the Director of Nursing (DON) and other staff revealed that the Certified Nursing Aide (CNA) assigned to the resident on the missed shower day had four residents to shower and ran out of time, failing to inform the Nurse Supervisor. The DON confirmed that the resident did not receive the shower and acknowledged that the aide did not notify anyone about the inability to provide the scheduled care. The facility's policy on Activities of Daily Living (ADL) indicated that residents should be provided with care and services to maintain or improve their ability to carry out ADLs, which was not adhered to in this instance.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store potentially hazardous foods properly, maintain kitchen equipment in a clean and sanitary manner, and keep cold food at acceptable temperatures during meal service. During a kitchen tour, the surveyor observed opened boxes of sliced cheese pizza and Salisbury steaks in the walk-in freezer, both of which were unsealed and exposed to air, with ice crystals forming on the food. The Food Service Director (FSD) and Dietary Manager (DM) were unsure when the boxes were opened. Additionally, the cooktop catch tray, fryer, and double door steamer box were found to have significant sediment and debris, indicating a lack of thorough cleaning and maintenance. The FSD acknowledged that these conditions did not meet the facility's expectations for cleanliness and sanitation. The surveyor also observed that cold food items were not maintained at the appropriate temperatures during meal service. Cantaloupe, pudding, and sandwiches were found to be held above the required 41 degrees Fahrenheit. The Dietary Aide (DA) responsible for preparing and placing these items on the trayline confirmed that the food had been removed from the refrigerator shortly before the surveyor's observation. The FSD acknowledged that the cold food items were not being held at the correct temperature, which is a violation of the facility's Food Temperatures policy. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged the concerns raised by the surveyor. The facility's policies on food storage and environmental cleanliness were reviewed, revealing that all foods should be stored wrapped or in covered containers, labeled and dated, and that all food preparation and service areas should be maintained in a clean and sanitary condition. The deficiencies observed indicate a failure to adhere to these policies, potentially leading to foodborne illnesses and contamination.
Incomplete and Inaccurate Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate skin assessments for one resident. Resident #61, who has diagnoses including chronic obstructive pulmonary disease, pleural effusion, diabetes mellitus, edema, and end-stage renal disease, reported not receiving a scheduled shower. Upon review, the resident's Weekly Skin Assessments were found to be incomplete for several dates, with missing documentation and initials from the nurse, CNA, and supervisor. The Director of Nursing (DON) later provided completed assessments, which were backdated after the surveyor's initial inquiry, a practice the DON acknowledged was inappropriate. The surveyor's review of the facility's policies revealed that skin assessments should be conducted weekly during bath days and documented accordingly. Interviews with staff confirmed that skin assessments were expected to be completed after showers. The DON admitted that the records were not accurately maintained and that staff had improperly altered documentation to appear complete. This deficiency was identified during the survey and acknowledged by the DON in the presence of other staff and the survey team.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure appropriate storage for respiratory equipment for infection prevention, specifically for one resident who was observed placing their nebulizer mask and tubing directly on the nebulizer machine after use. The resident's Licensed Practical Nurse (LPN) admitted to not verifying the completion of the treatment and subsequently placed the mask and tubing into a plastic bag without disinfecting them. The Unit Manager and Director of Nursing (DON) confirmed that the facility's policy required the nurse to stay with the resident until the treatment was completed, clean the nebulizer equipment with water, dry it with a paper towel, and then store it in a bag. The resident involved had a history of chronic obstructive pulmonary disease, pleural effusion, and diabetes mellitus, and was cognitively intact with a BIMS score of 14 out of 15. The facility's policies for cleaning and storing respiratory equipment were not followed, as evidenced by the observations and interviews conducted by the surveyor. The Infection Preventionist and DON reiterated that the nebulizer equipment should be rinsed and dried before storage, which was not done in this case.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficiency was observed in the Birch Unit, where multiple rooms had issues with doorknob backplates not being secured properly, resulting in them hanging loosely with gaps between the doorknob and the door. Additionally, a packaged terminal air unit (PTAC) in one of the rooms had its cover detached, exposing internal components, and there were holes in the walls of the same room. These issues were confirmed by various staff members, including a Certified Nursing Assistant (CNA), a Licensed Practical Nurse (LPN), the Unit Manager (UM), the Director of Maintenance (DOM), and the Director of Nursing (DON), who all acknowledged that these conditions should have been identified and addressed promptly. The report highlights that the facility's policy, dated January 2023, states that residents have the right to a safe, clean, comfortable, and homelike environment. Despite this policy, the deficiencies were not addressed in a timely manner, as evidenced by the observations and interviews conducted by the surveyor. The staff members interviewed confirmed that everyone in the building was responsible for reporting and ensuring the maintenance of a safe environment, yet the issues persisted, indicating a lapse in the facility's maintenance and reporting procedures.
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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 Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlantic Coast Rehab & Health | 5.4 mi | ★★★★★ | 2 | 1 |
| Fountainview Care Center | 5.4 mi | ★★★★★ | 0 | 0 |
| Leisure Chateau Rehabilitation | 6.2 mi | ★★★★★ | 15 | 0 |
| Wedgwood Gardens Care Center | 6.4 mi | ★★★★★ | 0 | 0 |
| Concord Healthcare & Rehabilitation Center | 6.4 mi | ★★★★★ | 6 | 0 |
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