Bartram Crossing

In the surveyor’s words

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

• Immediate jeopardy, widespreadF867Dec 10, 2025

  Based on a review of the facility's policy titled QAPI (Quality Assurance and Performance Improvement) Plan, facility and resident records and staff interviews, the facility failed to have an effective QAPI process that utilized adverse incident data to identify root cause analyses (RCAs), develop effective performance improvement activities to prevent recurrence of an avoidable injury after one (Resident #2) of seven residents reviewed for falls fell in the presence of Certified Occupational Therapy Assistant (COTA) A while not wearing a physician's ordered leg brace during a therapy session. […]

• Immediate jeopardy, isolatedF600Dec 10, 2025

  Based on a review of facility and resident records, resident and staff interviews, and a review of facility policies titled Abuse, Neglect and Exploitation, Fall and Injury Reduction Best Practice Guidelines, and Bathroom Safety Best Practice, the facility failed to ensure sufficient safeguards and supervision to protect residents' right to be free from neglect by failing to ensure rehabilitation department staff were aware of, and implemented, care plan interventions to prevent two residents (Residents #2 and #1) from unavoidable falls with major injury, out of a total of seven residents reviewed for falls. […]

• Immediate jeopardy, isolatedF689Dec 10, 2025

  Based on a review of facility and resident records, resident and staff interviews, and a review of the facility policy titled Fall and Injury Reduction Best Practice Guidelines and the Bathroom Safety Best Practice guidelines, the facility failed to ensure residents received adequate supervision and assistive devices to prevent unavoidable falls for two (Residents #2 and #1) of seven residents reviewed for falls.On 11/10/25 when Resident #2 was not wearing her physician-ordered hinged knee brace, she attended a therapy session with Certified Occupational Therapy Assistant (COTA) A. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary conditions and proper food storage practices in the nourishment room on the 300 hallway, by failing to 1) Have a plate warming unit that was free of brown liquid residue, 2) Have a microwave free of food splatter, dried residue, and debris on the interior surfaces, including the top, sides, and base of the unit, and 3) Label and date bread stored in the cabinet above the microwave. These failures had the potential to negatively impact all residents who received food from the nourishment room. […]

• No harm, potential for more than minimal, widespreadF812May 23, 2024

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility, by failing to 1) Date mark numerous open bundles of bread on the bread rack, 2) Clean grease buildup inside and around the door area of the convection oven, and 3) Clean food debris stuck on and around the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. […]