Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Will-o-bell during CMS and state inspections, most recent first.
Inaccurate MDS Assessment for Left Hand Limitation: A resident with CHF, Alzheimer’s disease, major depressive disorder, and muscle wasting/atrophy had an MDS that did not code a left hand limitation even though physician orders included gauze roll to the left hand for prophylactic treatment and the care plan reflected significant physical dependence. During observation, the resident’s left hand appeared impaired and closed, and the MDS nurse, DON, and ADM all acknowledged the hand limitation should have been coded on the assessment.
Failure to Place Ordered Gauze Roll in Left Hand: A severely cognitively impaired resident with CHF, Alzheimer's disease, depression, and muscle wasting had a physician order for a gauze roll to the left hand for prophylactic treatment and daily monitoring. Although the TAR was signed as completed by an LVN, surveyors observed the resident's left hand closed and no gauze roll in place, and an LVN and CNA confirmed the hand roll was not present. The DON and ADM stated the ordered hand roll should have been in place as ordered.
Failure to Implement EBPs for Resident with Pressure Ulcer: A resident with a Stage 3 pressure ulcer to the left buttock had wound care orders and a care plan for the injury, but there were no orders or room postings for Enhanced Barrier Precautions. The LVN, DON, and Administrator stated EBPs were used for wounds and other openings such as catheters or ostomies, while the facility policy stated EBPs are indicated for residents with wounds and/or indwelling medical devices, including chronic wounds such as pressure ulcers.
A CNA failed to properly dispose of a soiled brief and did not change gloves or perform hand hygiene after providing incontinent care to a resident with severe cognitive impairment. The soiled brief was placed on the floor in the hallway, then picked up and disposed of without the CNA removing gloves or sanitizing hands before continuing to assist the resident. Facility staff confirmed these actions were not in line with infection control policies.
Two residents in the facility did not receive care according to professional standards and their care plans. One resident was found in bed with feces and urine-soaked clothing, lacking proper skin assessments and treatment for MASD. Another resident was left in a urine-soaked brief without barrier cream application, leading to skin irritation. Staff failed to perform regular checks and provide necessary care, impacting the residents' quality of life.
The facility failed to provide accurate pharmaceutical services, resulting in a resident being discharged with another resident's medications. The error was discovered by the family member, who returned the incorrect medications to the facility. Interviews revealed a lack of adherence to the facility's discharge medication policy.
Inaccurate MDS Assessment for Left Hand Limitation
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, standardized, reproducible assessment of Resident #39’s functional capacity. Resident #39 was a [AGE]-year-old female admitted to the facility with diagnoses including CHF, Alzheimer’s disease, major depressive disorder, and muscle wasting and atrophy. Her quarterly MDS assessment documented no impairment to the upper extremities and a BIMS score of 00, indicating severe cognitive impairment, even though her physician’s orders included gauze roll to the left hand for prophylactic treatment with daily monitoring, and her care plan identified dependence on staff for emotional, intellectual, physical, and social needs due to immobility and physical limitations. During observation, Resident #39 was lying in bed with her left hand over her chest, and the hand appeared impaired and closed; she was not able to demonstrate that she could open it. In interview, the MDS nurse stated she was responsible for completing the MDS assessments, had been trained to complete them accurately, and acknowledged that any physical limitation to a resident’s extremities, including the hands, should have been coded on the MDS. She stated she was aware of Resident #39’s left hand limitation but was not sure why it was not coded. The DON and ADM also stated the left hand limitation should have been coded on the MDS and confirmed the MDS nurse was responsible for completing assessments correctly.
Failure to Place Ordered Gauze Roll in Resident's Left Hand
Penalty
Summary
The facility failed to ensure that Resident #39 received treatment in accordance with the physician order for a gauze roll to the left hand for prophylactic treatment and daily monitoring. Resident #39 was a severely cognitively impaired female with diagnoses including congestive heart failure, Alzheimer's disease, major depressive disorder, and muscle wasting and atrophy. Her quarterly MDS reflected no upper extremity impairment, but also identified her as at risk for pressure ulcers/injuries and indicated a BIMS score of 00. The physician order dated 06/26/25 directed staff to place a gauze roll to the left hand for prophylactic treatment and monitor it every day shift. The care plan and TAR both reflected this intervention. The TAR showed the gauze roll was signed as completed for 05/13/26 by LVN B, but during an observation that day at 2:29 PM, Resident #39 was lying in bed with her left hand over her chest, her left hand appeared impaired and closed, and no ordered gauze roll was present in her hand or in the area where her hand was resting. At 2:00 PM, LVN C observed the left hand being opened slightly and confirmed the hand roll was not in place. During interviews, LVN C stated he knew the resident's left hand was contracted and said residents with hand contractures should always have a gauze roll or something in place to prevent further closure. CNA D stated she was not aware the resident needed a gauze hand roll and acknowledged that without it, sores or open wounds could occur. The DON and ADM stated staff had been trained that an ordered gauze hand roll should be in place, and both said Resident #39's hand roll should have been in her left hand as ordered. LVN B stated she had ensured the gauze roll was placed in the resident's left hand and that she saw it there, despite the observation showing it was not present.
Failure to Implement Enhanced Barrier Precautions for Resident with Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident with a Stage 3 pressure ulcer to the left buttock. Resident #3 was a male admitted with encephalopathy, muscle wasting and atrophy, and polyosteoarthritis. His quarterly MDS dated 04/13/2026 showed a BIMS score of 14 with no cognitive impairment, and it identified a pressure ulcer/injury along with treatments including pressure-reducing devices for the chair and bed, nutrition or hydration intervention, pressure ulcer/injury care, and ointment/medication applications. The comprehensive care plan addressed a stage 3 pressure injury related to a history of ulcers and limited mobility, but it did not include Enhanced Barrier Precautions. The resident’s wound care orders changed over time and included cleansing the left buttock wound with normal saline or wound cleanser, applying honey and calcium alginate, then later packing the wound with gauze soaked in Dakins solution and covering it with a gauze island dressing. There were no orders for Enhanced Barrier Precautions. During observation on 05/13/2026, the resident’s room did not have any posting indicating Enhanced Barrier Precautions. In interviews, the LVN, DON, and Administrator stated that EBPs were expected for residents with wounds or other openings such as catheters or ostomies, but they also stated that non-chronic or acute wounds did not require EBPs. The facility policy stated that EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization, and that wounds generally include chronic wounds such as pressure ulcers.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing care to a resident with severe cognitive impairment and multiple diagnoses, including dementia and major depressive disorder. The resident required maximum assistance with toileting hygiene due to significant self-care deficits. After changing the resident's soiled brief, the CNA placed the soiled brief on the floor in the hallway instead of immediately disposing of it in a designated container as required by facility policy. The CNA then picked up the soiled brief with gloved hands and disposed of it in a nearby barrel, but did not remove the gloves or perform hand hygiene before continuing to walk with the resident. The CNA admitted to being aware that placing the soiled brief on the floor and wearing contaminated gloves in the hallway were not sanitary practices and could contribute to the spread of infection. The CNA also acknowledged that touching the resident with soiled gloves could cause infection. Interviews with the Infection Control Preventionist and the Director of Nursing (DON) confirmed that the CNA's actions were not in accordance with facility policies, which require soiled briefs to be placed in a bag and disposed of in a designated container, and mandate glove removal and hand hygiene after handling soiled items. Facility policies also prohibit walking in the hallway with gloves on and emphasize the importance of hand hygiene to prevent the transmission of infections.
Failure to Provide Adequate Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice and the comprehensive person-centered care plan for two residents. Resident #1 was found sitting in his bed with linens covered in feces and his pants saturated with urine. Despite being at high risk for pressure sores, accurate skin assessments were not completed, and there was no evidence of appropriate treatment for Moisture Associated Skin Damage (MASD) on his buttocks. Observations and interviews revealed that Resident #1 required frequent assistance with toileting and was unable to use the call light, necessitating regular checks by staff, which were not adequately performed. Resident #2, who was severely cognitively impaired and dependent for toileting hygiene, was often left in a soiled, wet brief for extended periods. During an assessment, Resident #2 was found sitting in a urine-soaked brief with a red area across her buttocks, indicating irritation from sitting in urine and possibly the start of MASD. There was no evidence of barrier cream application, which was supposed to be part of her care plan. Interviews with staff indicated a lack of communication and follow-through regarding skin issues and the application of necessary treatments. The facility's policies on routine resident checks and bathing procedures were not adhered to, leading to these deficiencies. The Director of Nursing acknowledged the issues, noting that the presence of feces and urine on residents was a dignity and infection control issue, which could lead to skin breakdown and illness. Despite the facility's policies, staff failed to perform regular checks and provide necessary care, resulting in a decreased quality of life for the residents involved.
Failure to Provide Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, specifically for two residents reviewed for medications. Resident #1 was discharged home with two medications, Trazodone and Tegretol, that belonged to Resident #2. This error occurred despite Resident #1 not having any physician orders for these medications. The incident was discovered when Resident #1's family member noticed the incorrect medications and contacted the facility to return them. The family member had initially been given a plastic bag of medications without proper documentation or instructions, leading to confusion and the discovery of the error at home. Resident #1, a male with chronic myelomonocytic leukemia, acute pulmonary edema, and hypertension, was discharged without proper medication reconciliation. His discharge summary did not include any medications, and the nurse responsible for his discharge, RN B, failed to verify the names on the medications. Resident #2, who had major depressive disorder, insomnia, stroke, vascular dementia, and unspecified convulsions, was the rightful recipient of the Trazodone and Tegretol. The error was not immediately reported to the Director of Nursing (DON), who later expressed shock and emphasized the potential serious outcomes of such a mistake. Interviews with the DON, RN B, and the Nurse Practitioner (NP) revealed a lack of adherence to the facility's discharge medication policy. The DON expected nurses to hand-write all medications and their administration times, which was not done in this case. RN B admitted to the chaotic nature of the evening and her failure to verify the medications properly. The NP highlighted the importance of reconciling medications with orders to prevent negative outcomes. The facility's policy required a thorough review of medication instructions with the resident or their representative, which was not adequately followed in this incident.
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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 Bartlett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spjst Rest Home 1 | 14.7 mi | ★★★★★ | 6 | 0 |
| Park Place Care Center | 16.2 mi | ★★★★★ | 17 | 3 |
| Creekside Terrace Rehabilitation | 18 mi | ★★★★★ | 3 | 0 |
| Morada Temple | 18.3 mi | ★★★★★ | 5 | 0 |
| Avir At Belton | 18.5 mi | ★★★★★ | 16 | 1 |
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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.