Barton Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Barton Hospital D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 4, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent an avoidable fall accident for one of three sampled residents (Resident 1), who was identified at high risk for falls.This failure resulted in Resident 1 falling, hitting his head and fracturing his right femur (thighbone), causing severe pain, and transfer to the hospital. Resident 1 was placed on comfort care in the hospital and died on [DATE], 3 days after the fall incident.A review of the admission record indicated the facility admitted Resident 1 in November of 2025 with multiple diagnoses which included aftercare following right hip arthroplasty (a surgical procedure to replace the fractured joint and restore mobility) and dementia (when a person has… […]

• Actual harm, isolatedF689Apr 29, 2025

  Based on interview and record review, the facility failed to provide adequate supervision when staff left Resident 1 unattended to prevent an avoidable accident from occurring for 1 of 3 sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a hip fracture (broken bone). Findings: During a review of Resident 1 ' s Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated, Resident 1 was admitted to the facility in December 2024 with multiple diagnoses which included Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). […]

• No harm, potential for more than minimal, patternF689Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure that wheelchairs were maintained in safe condition when found with cracked and exposed armrest for three of 13 sampled residents (Resident 13, Resident 30, and Resident 43). This failure had the potential to place Resident 13, Resident 30, and Resident 43 at risk for injury and infection. A review of Resident 13's admission Record (AR), dated 4/10/26 (print date), indicated Resident 13 was admitted in Winter 2023 with the diagnoses which included right artificial hip joint (replaced joint for damaged hip), polymyalgia rheumatica (severe stiffness of neck, shoulders and hips), and chronic pain. […]

• No harm, potential for more than minimal, patternF755Apr 10, 2026

  Based on interview and record review, the facility failed to ensure the administration time for morphine (a narcotic controlled medication) on the Medication Administration Record (MAR) matched with the Controlled Drug Record (CDR - a log used to track the administration and disposition of Schedule II drugs, substances with a high potential for abuse) for one of 13 sampled residents (Resident 5).This failure resulted in inconsistency in morphine administration for Resident 5 and had the potential to impact accountability of the controlled drug.A review of Resident 5's admission Record indicated she was admitted to the facility in 2022, with diagnoses that included chronic pain and osteomyelitis (a serious infection in the bone, caused by bacteria or fungi, resulting in inflammation and… […]

• No harm, potential for more than minimal, patternF761Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to store medications in accordance with professional standards for a census of 45, whenAn expired bottle of carboxymethylcellulose sodium 0.5% solution (artificial tears eye drops for dry eyes) was still being administered to Resident 17;An open tube of hydrocortisone cream 1% (a topical steroid used to reduce inflammation and itching caused by conditions like allergic rashes) for general resident use was found without an open date; An open bottle of Resident 20's ascorbic acid (Vitamin C) had a smudged illegible expiration date written on it;A treatment cart containing prescription creams and ointments was left unlocked in the hall accessible to residents;Treatment Cart 1 contained a tube of Mupirocin 2% ointment (a… […]