Bartow Center: Hand Hygiene Failures During Care - FL
The violation occurred during a September inspection at Bartow Center, where federal inspectors observed two certified nursing assistants repeatedly skip hand hygiene steps during intimate care procedures for residents with urinary catheters.
Staff A performed catheter care for Resident #7 on September 9, changing gloves four separate times during the procedure but never washing his hands between glove changes. Each time he removed dirty gloves and put on clean ones, he skipped the required hand hygiene step.
The nursing assistant gathered towels, washcloths, soap and a basin of clean water before beginning the procedure. He explained each step to the resident and confirmed the water temperature was comfortable. But as he moved through cleaning the resident's genital area and catheter tubing, changing gloves multiple times, he consistently failed to perform hand hygiene.
When interviewed immediately after the procedure, Staff A acknowledged he had received training on conducting hand hygiene between glove changes. "I completely forgot," he told inspectors.
The facility's Director of Nursing observed the entire procedure.
Staff B made similar errors during catheter care for Resident #8 later that same day. She used the same basin of water to both wash and rinse the resident, instead of using separate basins as required by facility protocol.
When questioned about her technique, Staff B explained she was "in a hurry and needed to leave at 3:00 PM." She acknowledged that two basins should have been used during the procedure - one for washing and one for rinsing.
Staff B also failed to perform hand hygiene when changing gloves, claiming the resident's bathroom was occupied. When inspectors asked why she didn't change gloves after cleaning the resident and before rinsing, she couldn't explain.
Both nursing assistants had completed competency training on catheter care procedures and hand hygiene on August 14 and 15, just weeks before the violations occurred. Training records showed no concerns were identified during their competency assessments.
The facility's competency checklist specifically required staff to "change water and repeat procedure to remove soap, change gloves, wash hands, and re-glove" during catheter care procedures.
Administrators told inspectors they had discussed findings from a previous survey with the interdisciplinary team and used facility policies to determine what education was needed. Nursing staff received hands-on training using a mannequin to practice proper catheter care technique.
Following the training, administrators conducted audits during actual resident catheter care to ensure staff were using proper technique. The nursing home administrator and Director of Nursing said no concerns were identified during those audits.
The inspection also revealed broader infection control failures throughout the facility.
A resident with C. diff infection went two days without proper isolation signage outside their room. Resident #323 was admitted to the facility on contact isolation precautions for C. diff, but no signage indicating the precautions was posted outside the room until July 29.
When signage was finally posted, it incorrectly indicated the resident required droplet precautions in addition to contact precautions. The facility's Director of Clinical Services acknowledged the signage should have indicated contact isolation only.
Staff told inspectors that orders for transmission-based precautions should be in place upon admission because they're notified of the need for precautions before residents arrive. Proper signage should also be posted at admission.
During wound care for Resident #96, staff failed to follow enhanced barrier precautions despite clear signage outside the room. The Licensed Practical Nurse performing the procedure couldn't explain what enhanced barrier precautions were or why they were implemented for the resident.
A bag of isolation gowns hung on the back of the resident's door, but neither the nurse nor the nursing assistant donned gowns during the wound care procedure. The nursing assistant acknowledged afterward that isolation gowns should have been worn.
The signage outside the resident's room was so dark the Licensed Practical Nurse had difficulty reading it even with corrective lenses.
Dietary staff also violated hand hygiene protocols during meal service. One dietary aide was observed with her hands in her pockets while waiting for food to be plated, then touched a food tray without washing her hands.
Another dietary aide repeatedly placed her hands on her hips before meal service began, failing to perform hand hygiene. When questioned, the Certified Dietary Manager confirmed hand hygiene should have been performed after touching pockets and clothing.
Staff delivering meal trays to residents also skipped hand hygiene between deliveries. Two staff members were observed touching a resident's bedside table to straighten it, then retrieving and delivering trays to other residents without sanitizing their hands.
Multiple staff members confirmed during interviews that hand hygiene should be performed before and after each tray delivery.
The facility's infection control policy requires enhanced barrier precautions for residents with wounds or indwelling medical devices to reduce transmission of multi-drug resistant organisms. The policy specifies that gowns and gloves must be worn during high-contact activities like wound care.
For contact precautions, the policy requires gloves and gowns before entering a designated room for residents with infections like C. diff or wound and skin infections.
The violations occurred despite the facility's quality assurance policy requiring department heads to develop audit plans and report findings to address negative results through education or performance improvement plans.
Training records showed both nursing assistants who violated hand hygiene protocols during catheter care had successfully completed competency assessments on the same procedures just weeks before inspectors observed the failures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bartow Center from 2024-07-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BARTOW CENTER in BARTOW, FL was cited for violations during a health inspection on July 30, 2024.
Each time he removed dirty gloves and put on clean ones, he skipped the required hand hygiene step.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.