Bartow Center
BARTOW CENTER in BARTOW, FL — inspection on July 30, 2024.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the [NAME] for Resident #3 revealed in the Resident Care section the resident was totally dependent on staff for ADLs (activities of daily living).
During an observation and interview on 7/29/24 at 1:46 p.m. Resident #3 was observed in bed with his specialized chair in the room.
Staff N, LPN observed the specialized chair and confirmed the specialized chair's foot and leg rest were crooked.
During an interview with Staff M, CNA on 7/28/24 at 3:51 p.m. she stated she would tell the housekeeper on the hall for that day if there was a concern related to housekeeping in a resident room or leave a note for the head of housekeeping.
For maintenance issues, she would use the [electronic work order system].
During an interview with Staff D, Licensed Practical Nurse (LPN) on 7/28/24 at 4:00 p.m. she stated if there was an issue with maintenance she would put a work order in [electronic work order system].
A review of the work orders from June 2024 to July 2024 revealed it was silent of any work orders for windows not sealing shut and Resident #3's crooked foot rest on his wheelchair.
During an interview on 7/29/24 at 12:25 p.m. the Director of Housekeeping stated housekeeping goes into rooms once a day.
They have a whole section and should clean something if they see something that needs cleaning.
Durning an interview with the Maintenance Director on 7/30/24 at 11:59 a.m. he stated the expectation is a work order is to be put in [electronic work order system] and he had not received anything related to the windows or Resident #3's wheelchair. He confirmed he does not check the windows and that is done during concierge rounds and he should be notified if there is a concern. He stated there are clips at the top to prevent the windows from opening any further.
Review of a procedure titled, Housekeeping Procedures, revised 9/5/21, showed for the section of Daily Patient Room Cleaning that every room was to be cleaned is that resident's home - treat it as such.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
concerns.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
Review of the Level I PASRR form located in the clinical record for Resident #11, dated 11/19/2018, revealed: Section I Part A-Schizophrenia and insomnia checked Section II: marked no.
Review of the care plan located in the clinical record, dated 5/5/2024, revealed: Resident #11 uses psychotropic medications and anticonvulsants to manage seizures.
The medical record for Resident #32 was silent of a revised Level I PASRR to include the new diagnoses.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
Review of a facility policy titled Care Plan-Interdisciplinary Plan of Care from Interim to Meeting, dated 2/24, showed the following: Policy The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility shall assess and address care issues that are relevant to individual residents, to include, but are not limited to, monitoring resident condition, and responding with appropriate interventions.
The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care.
The overall care plan should be oriented towards:
- Preventing avoidable declines in functioning or functional levels or otherwise clarifying why
another goal takes precedence (e.g., palliative approaches in end-of-life situation, coordination with Hospice plan of care).
Managing risk factors to the extent possible or indicating the limits of such interventions.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
(ADON), Staff C, Registered Nurse (RN)/Unit Manager (UM) and the Director of Nursing (DON).
Staff C,
hand hygiene in between washing dirty areas and rinsing clean areas and stated staff are taught to do
A review of the facility competency titled, Competency: Perineal Care/Catheter Care revealed the following steps under the section titled Female Resident: - Apply a small amount of liquid soap to each wash cloth as it is being used. - Clean in a downward motion from front to back. - Changes water and repeats procedure to remove soap, change gloves, wash hands, and re-glove.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
Review of the July 2024 MAR for Resident #170 revealed: Oxygen at 4 LPM (liters per minute) Via NC (nasal cannula) continuously for SOB. every shift for Shortness of Breath, ordered 7/24/24.
Review of the care plan for Resident #170, dated 7/25/24, revealed OXYGEN: The resident has Oxygen Therapy r/t SOB.
The interventions included: -Administer Oxygen as ordered. (Refer to current POS/MAR for current order).
On 7/28/24 at 9:53 a.m. Resident #170 was observed lying in bed with a nasal cannula with oxygen flowing via a concentrator set at 3 liters.
On 7/28/24 at 3:22 p.m. Resident #170 was observed lying in bed with a nasal cannula with oxygen flowing via a concentrator set at 3 liters.
During an interview on 7/29/24 at 2:38 p.m.
Staff L, RN confirmed the oxygen order for Resident #170 was for continuous oxygen at 4 liters.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
Review of a policy titled, Medication Storage, dated 9/18, showed the following: Policy Medication and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.
The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Procedures
- In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and
those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts.
Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access.
- An observation was conducted on 7/27/24 at 10:31 a.m. in Resident #62's room. Resident #62 was
observed resting in bed with his bedside table in front of him. An albuterol inhaler, a vial of eye drops, and a spray bottle of wound cleanser were observed on Resident #62's bedside table. Resident #62 stated he kept the medications in his room and administered the inhaler and eye drops to himself as needed.
An observation was conducted on 7/28/24 at 10:22 a.m. in Resident #62's room. Resident #62 was observed resting in bed with his bedside table in front of him. An albuterol inhaler, a vial of eye drops, and a spray bottle of wound cleanser were observed on Resident #62's bedside table.
A review of Resident #62's medical record did not reveal an assessment related to Resident #62's ability to self-administer medications.
An interview was conducted on 7/30/24 at 12:24 p.m. with the ADON, Staff C, RN/UM and the DON.
The ADON stated all resident medications should be stored inside of the medication carts unless a medication needs to be refrigerated and the medication would be stored in the medication refrigerator.
Staff C, RN/UM stated the facility did not have any resident's who self-administered medications.
Staff C, RN/UM also stated an assessment would need to be performed to determine if a resident would be able to self-administer their own medications.
The ADON and the DON both stated medications should not be stored at the resident's bedside and should be removed from the resident's room.
The DON stated she would expect Certified Nursing Assistant (CNA) staff to notify the nurse if they observe medication in a resident's room so the medication can be properly stored.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
The competency also revealed, under the section titled Catheter Care: Male and Female, CNA uses a
A review of the facility policy titled Quality Assessment and Assurance (QA&A) Compliance, effective July 2022, revealed under the section titled Policy, the purpose of the committee is to review and analyze facility related data, evaluate improvement plans effectiveness, and direct appropriate actions for the facility response.
The policy also revealed under the section titled Procedure, department heads/disciplines are required to develop department specific audit plans and report activities and audit findings to the committee at intervals determined by risk analysis, and at the direction of the NHA.
Negative findings are addressed through education, development of a Performance Improvement Plan, or other means as indicated.
addressed the signage appeared very dark.
precautions are used when the employee expects to be in direct or indirect contact with a patient
an infection with an organism transmitted fecal-orally, such as clostridium difficile or wound and skin infections or multi-drug resistant bacteria.
Personal Protective Equipment (PPE) required before entering a contact precaution designated room is always gloves and a gown.
The policy also revealed Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission or multi-drug resistant organisms (MDROs) that employ targeted gown and glove use during high contact activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP is indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO.
- An observation of the lunch meal service in the main dining room on 7/27/24 at 11:29 a.m. prior to
the lunch meal arriving a staff member was serving beverages to the residents.
She touched her N95 mask by pulling it down to ask a resident if they wanted coffee.
She served the coffee and failed to perform hand hygiene prior to serving the coffee.
An observation on 7/27/24 at 12:24 p.m. of the lunch trays being delivered on the 300 Hall revealed a lunch tray being delivered to room [ROOM NUMBER] Bed A.
The resident's bedside table had multiple personal items on it and it was uneven.
The lunch tray was slid onto the table and two staff members were observed touching the bedside table in an attempt to straighten it out for the resident.
They left room and each retrieved another tray and delivered those trays to other residetns with no hand hygiene performed.
An interview was conducted on 7/28/24 at 3:51 p.m. with Staff M, Certified Nursing Assistant (CNA) who stated they are to hand sanitize before they deliver a tray and after.
An interview was conducted on 7/29/24 at 1:48 p.m. with Staff N, Licensed Practical Nurse (LPN) and he confirmed staff should sanitize their hands between tray delivery.
An observation of the tray line for lunch on 7/29/24 at 11:10 a.m. revealed Staff P, Dietary Aide with her hands in her pockets as she was waiting for the cook to plate the food.
Staff Q, Dietary Aide was observed with her hands placed on her hips multiple times prior to the plating of lunch meal at 11:25 a.m.
Staff P and Staff Q did not perform hand hygiene.
Staff P was observed at 11:30 a.m. with her hands in her pockets then touched a tray with food to be served without performing hand hygiene.
Immediately following this observation an interview was conducted with the Certified Dietary Manager and she confirmed hand hygiene should have been performed after having their hands in pockets and on their clothes.
105286 07/30/2024
Bartow Center 2055 E Georgia St Bartow, FL 33830
Findings included:
A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE].
A review of Resident #7's physician orders revealed an order dated 7/30/2024 for urinary catheter care daily and as needed.
An observation of catheter care for Resident #7 was conducted on 9/9/2024 at 1:54 PM with Staff A, Certified Nursing Assistant (CNA) with the facility's Director of Nursing (DON) observing the procedure.
Staff A, CNA conducted hand hygiene and donned an isolation gown and gloves prior to providing catheter care.
Staff A, CNA gathered several towels, washcloths, soap, and a basin with clean water.
Staff A, CNA explained the procedure to Resident #7 prior to starting and confirmed a comfortable water temperature with the resident.
Staff A, CNA removed Resident #7's brief and assisted the resident to a comfortable position.
Staff A, CNA placed a washcloth in the water basin and added soap to the washcloth.
Staff A, CNA began to clean Resident #7's peri area using appropriate technique throughout and using a clean side of the washcloth with each pass.
Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure.
Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves.
Staff A, CNA placed a washcloth in the water basin and added soap to the washcloth.
Staff A, CNA began to clean Resident #7's catheter tubing using appropriate technique throughout and using a clean side of the washcloth with each pass.
Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure.
Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves.
Staff A, CNA placed a washcloth in the water basin and rinsed the previously cleaned areas using appropriate technique throughout and using a clean side of the washcloth with each pass.
Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure.
Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves.
Staff A, CNA used a clean towel to dry the previously rinsed areas using proper technique.
Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure.
Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves.
The DON donned an isolation gown and gloves and assisted Staff A, CNA with incontinence care for Resident #7.
After gathering trash, both staff members doffed their gowns and gloves and performed hand hygiene before exiting the room. An interview was conducted with Staff A, CNA and the DON following the observation.
Staff A, CNA stated he had received in-service training related to conducting hand hygiene in between glove changes and stated I completely forgot.
The DON stated facility nursing staff were provided in-service education related to proper hand hygiene and personal protective equipment (PPE) usage.
105286
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105286 B.
Wing 07/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bartow Center 2055 E Georgia St Bartow, FL 33830
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.