Bartow Center

In the surveyor’s words

From the most serious findings on record at Bartow Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF645Jul 30, 2024

  Based in interview and record review, the facility failed to ensure the accuracy of the Level I Pre-Admission Screening and Resident Review (PASRR) for twenty-three (#2, #3, #21, #16, #66, #87, #96, #53, #7, #31, #48, #32, #74, #62, #89, #10, #11, #27, #102, #51, #4, #33, and #20) of twenty-three residents reviewed. Findings included: 1. Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type and major depressive disorder according to the Admission Record. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed: -Section I: Active Diagnosis - Depression and Schizophrenia -Section N: Medications administered - Antidepressant. […]

• No harm, potential for more than minimal, patternF695Jul 30, 2024

  Based on observation, interview and record review, the facility failed to ensure oxygen therapy was administered as ordered for four residents (#50, #271, #170 and #114) of seven residents sampled. Findings included: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, and chronic obstructive pulmonary disease (COPD, according to the Admission Record. During an observation on 7/28/24 at 11:00 a.m., the resident's oxygen was observed to be set and administering at 2.5 liters per minute (LPM). (Photographic Evidence Obtained) During an interview with the resident at the time of the observation, the resident stated her oxygen should be at 3 liters all the time. […]

• No harm, potential for more than minimal, patternF761Jul 30, 2024

  Based on observations and interviews, the facility failed to ensure medication was stored properly in two (400 hall and 200 hall) out of two medication carts audited, one out of one medication rooms audited, for one resident (#62) out of 48 sampled residents and on three out of four hallways. Findings included: An observation was conducted on 7/27/24 at 9:29 a.m. of a medication cart unlocked on the 400 hall. The nurse was observed to be in a resident room and no other nurses were in the hall at the time. (Photographic Evidence Obtained) An observation was conducted on 7/27/24 at 9:38 a.m. of a medication cart on the 400 hall with a bag of IV (intravenous) medication (Ceftriaxone) sitting in the side compartment of the medication cart not locked up. […]

• No harm, potential for more than minimal, patternF880Jul 30, 2024

  Based on observations, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to prevent the spread of infection by 1.) failing to ensure transmission based precautions were implemented in a timely manner for one resident (#323) of one resident under transmission based precautions in the facility, 2.) failed to obtain physician's orders for transmission based precautions upon admission for one resident (#323) of one resident under transmission based precautions in the facility, 3.) failed to ensure appropriate signage for transmission based precautions was displayed outside of resident rooms under transmission based precautions for one resident (#323) of one resident under transmission based precautions in the facility, 4.)… […]

• No harm, potential for more than minimal, patternF759Oct 28, 2022

  Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 37 medication administration opportunities were observed with 13 medication errors for 2 residents (#9 and #10) of 4 residents sampled for medication administration, which resulted in a medication administration error rate of 35.14%. Findings included: A review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]