Inspection Reports for
Bartram Lakes Assisted Living
6209 BROOKS BARTRAM DR BLDG 200, JACKSONVILLE, FL, 32258
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2013 to 2025 with deficiency history and inspection statuses.
Findings
Across the inspections, the facility had periods with no deficiencies, cited deficiencies, and corrected deficiencies. The most recent inspections show no deficiencies cited.
Report Facts
Inspections on page: 30
Inspection Report
Routine
Deficiencies: 1
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with food sanitation and handling standards to prevent foodborne illness outbreaks.
Findings
The facility failed to follow proper sanitation and food handling practices, including failure to date mark open bread bundles, clean grease buildup in the convection oven, and clean food debris on the mixer, posing a potential risk of pathogen exposure to residents.
Deficiencies (1)
F0812: The facility failed to date mark numerous open bundles of bread on the bread rack as required. The convection oven had grease buildup inside and around the door area, and the mixer had food debris stuck on and around the safety guard.
Report Facts
Open bread bundles without date markings: 4
Open bread bundles without date markings: 8
Milk temperature: 56
Milk temperature: 62
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to notify a resident and his representative about hospital transfer and discharge, failure to provide written bed hold information, and failure to permit the resident to return after hospitalization.
Complaint Details
The complaint investigation focused on Resident #1's hospital transfer and discharge process. The resident was transferred to the hospital due to profusely bleeding sores and was not allowed to return to the facility. The resident's wife and the hospital discharge planner reported lack of proper notification and discharge paperwork. The facility failed to notify the resident and representative in writing, failed to provide bed hold information, and refused readmission due to the resident's condition.
Findings
The facility failed to notify Resident #1, his representative, and the Long-Term Care Ombudsman in writing about the transfer and discharge. The facility also failed to provide written information about the bed hold policy and did not permit the resident to return after hospitalization due to excessive bleeding and care needs. The resident's wife and hospital staff confirmed lack of proper communication and discharge documentation.
Deficiencies (3)
F 0623: The facility failed to notify the resident, resident's representative, and Long-Term Care Ombudsman in writing about the resident's transfer and reasons for transfer for one resident.
F 0625: The facility failed to provide written information about the bed hold policy prior to hospital transfer for one resident.
F 0626: The facility failed to permit a resident to return after hospitalization that exceeded the bed hold policy for one resident.
Report Facts
Residents reviewed: 3
Date of hospital transfer: Sep 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E | Registered Nurse (RN)/Unit Manager (UM) | Summoned by therapist and assessed resident's bleeding wounds on 9/20/23 |
| Employee G | Business Office Manager (BOM) | Interviewed regarding bed hold communication failures |
| Director of Nursing (DON) | Interviewed multiple times regarding resident transfer, discharge, and bed hold issues | |
| Social Services Director (SSD) | Discharge Planner | Interviewed regarding resident discharge paperwork and transfer process |
| Administrator | Interviewed regarding refusal to readmit resident and bed hold policy |
Inspection Report
Complaint
Deficiencies: 1
Date: Jun 16, 2023
Visit Reason
One Class 3 deficiency related to right of inspection and inspection reports.
Findings
One Class 3 deficiency related to right of inspection and inspection reports.
Deficiencies (1)
Tag CZ824 — RIGHT OF INSPECTION; INSPECTION REPORTS
Inspection Report
Standard
Deficiencies: 3
Date: Feb 9, 2023
Visit Reason
Three Class 3 deficiencies related to resident care elopement standards, staffing standards, and staff records.
Findings
Three Class 3 deficiencies related to resident care elopement standards, staffing standards, and staff records.
Deficiencies (3)
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0161 — RECORDS - STAFF
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 23, 2022
Visit Reason
The inspection was conducted based on complaints alleging failure to provide ordered treatments and care, failure to review gradual dose reduction recommendations for psychotropic drugs, improper food sanitation and storage practices, and failure to maintain accurate medical records.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to provide ordered care and treatment, failure to review psychotropic medication dose reductions, improper food sanitation, and incomplete medical records. The complaints were substantiated as the facility was found deficient in these areas.
Findings
The facility failed to ensure residents received care as ordered, including missed physician orders and appointments for residents. The facility did not review gradual dose reduction recommendations for psychotropic medications. Food sanitation and storage practices were inadequate, including use of a malfunctioning dishwasher and expired food items. Medical records were incomplete and failed to document a resident's skin tear and bruising.
Deficiencies (4)
F684: The facility failed to provide treatment and care according to physician orders for two residents, including missed oncology follow-up and laboratory tests.
F758: The facility failed to review gradual dose reduction recommendations for psychotropic medications for one resident.
F812: The facility failed to ensure proper sanitation and food storage practices, including use of a dishwasher with inadequate rinse temperature and presence of expired food items.
F842: The facility failed to maintain complete and accurate medical records for one resident, including failure to document a visible skin tear and bruising.
Report Facts
Expired chocolate milk cartons: 19
Medication doses: 20
Medication doses: 15
Dishwasher rinse temperature: 158
Dishwasher rinse temperature: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Interviewed regarding appointment scheduling and care orders for Resident #23 |
| LPN C | Unit Manager | Interviewed regarding appointment orders and dressing for Resident #23 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding chart reviews, appointment scheduling, and follow-up for Residents #23 and #73 |
| Certified Dietary Manager E | Certified Dietary Manager | Interviewed and observed during kitchen tour regarding food sanitation and dishwasher issues |
| Food Service Utility Worker F | Food Service Utility Worker | Observed operating dishwasher and interviewed about sanitation testing |
| Maintenance Director H | Maintenance Director | Observed testing dishwasher rinse temperature |
| CNA A | Certified Nursing Assistant | Interviewed regarding skin assessments and reporting for Resident #74 |
| LPN B | Licensed Practical Nurse | Interviewed regarding skin assessments and documentation for Resident #74 |
| Unit Manager C | Unit Manager | Interviewed regarding skin assessments and documentation for Resident #74 |
Inspection Report
Monitor
Deficiencies: 1
Date: Mar 25, 2021
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Deficiencies (1)
None
Inspection Report
Complaint
Deficiencies: 1
Date: Feb 2, 2021
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Deficiencies: 3
Date: Dec 18, 2020
Visit Reason
The inspection was conducted to assess compliance with physician's orders and regulatory standards related to resident care, including treatment for edema, respiratory care, and medication administration.
Findings
The facility failed to carry out physician's orders for edema treatment for one resident, failed to discontinue oxygen therapy as ordered for another resident, and failed to document apical pulses before administering Digoxin for a resident. These deficiencies were noted based on observations, record reviews, and interviews.
Deficiencies (3)
F0684: The facility failed to carry out physician's orders to apply ace wrap compression bandages and elevate bilateral lower extremities for one resident with edema.
F0695: The facility failed to discontinue oxygen therapy as ordered for one resident, resulting in continued oxygen administration after the order was stopped.
F0842: The facility failed to document apical pulses before administering Digoxin for one resident, despite parameters requiring pulse monitoring.
Report Facts
Residents sampled: 33
Residents sampled for unnecessary medications: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (Employee D) | Interviewed regarding lack of treatment order for edema care | |
| Unit Manager, Registered Nurse E | Verified failure to follow physician's orders for edema treatment | |
| Employee A | Licensed Practical Nurse (LPN) | Interviewed about oxygen therapy and Digoxin administration documentation |
Inspection Report
Complaint
Deficiencies: 1
Date: Sep 8, 2020
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Complaint
Deficiencies: 1
Date: Jan 15, 2020
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Standard
Deficiencies: 1
Date: Sep 26, 2019
Visit Reason
No deficiencies noted during this standard inspection.
Findings
No deficiencies noted during this standard inspection.
Deficiencies (1)
None
Inspection Report
Monitor
Deficiencies: 4
Date: Mar 11, 2019
Visit Reason
Four Class 3 deficiencies related to admissions criteria, health assessment, resident care third party services, and ECC admissions & continued residency.
Findings
Four Class 3 deficiencies related to admissions criteria, health assessment, resident care third party services, and ECC admissions & continued residency.
Deficiencies (4)
Tag A0007 — ADMISSIONS - CRITERIA
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0031 — RESIDENT CARE - THIRD PARTY SERVICES
Tag AE204 — ECC - ADMISSIONS & CONTINUED RESIDENCY
Inspection Report
Complaint
Deficiencies: 1
Date: Nov 16, 2018
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Complaint
Deficiencies: 1
Date: Jan 24, 2018
Visit Reason
One Class 4 deficiency related to background screening clearinghouse.
Findings
One Class 4 deficiency related to background screening clearinghouse.
Deficiencies (1)
Tag AZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Standard
Deficiencies: 3
Date: Aug 17, 2017
Visit Reason
Three Class 3 deficiencies related to staff in-service training, HIV/AIDS training, and DNRO training.
Findings
Three Class 3 deficiencies related to staff in-service training, HIV/AIDS training, and DNRO training.
Deficiencies (3)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Inspection Report
Complaint
Deficiencies: 1
Date: Sep 13, 2016
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Complaint
Deficiencies: 1
Date: Jul 18, 2016
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Deficiencies (1)
None
Inspection Report
Standard
Deficiencies: 5
Date: Aug 13, 2015
Visit Reason
Five Class 3 deficiencies related to staffing standards, staff in-service training, HIV/AIDS training, DNRO training, and training documentation & monitoring.
Findings
Five Class 3 deficiencies related to staffing standards, staff in-service training, HIV/AIDS training, DNRO training, and training documentation & monitoring.
Deficiencies (5)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Inspection Report
Monitor
Deficiencies: 1
Date: Jun 10, 2015
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Deficiencies (1)
None
Inspection Report
Monitor
Deficiencies: 1
Date: Dec 4, 2014
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Deficiencies (1)
None
Inspection Report
Monitor
Deficiencies: 1
Date: Sep 11, 2014
Visit Reason
One Class 3 deficiency related to ECC policies.
Findings
One Class 3 deficiency related to ECC policies.
Deficiencies (1)
Tag AE201 — ECC - POLICIES
Inspection Report
Monitor
Deficiencies: 3
Date: Apr 28, 2014
Visit Reason
Three Class 3 deficiencies related to dietary standards, ECC health assessment, and ECC service plans.
Findings
Three Class 3 deficiencies related to dietary standards, ECC health assessment, and ECC service plans.
Deficiencies (3)
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Tag AE205 — ECC - HEALTH ASSESSMENT
Tag AE206 — ECC - SERVICE PLANS
Inspection Report
Monitor
Deficiencies: 1
Date: Jan 30, 2014
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Deficiencies (1)
None
Inspection Report
Standard
Deficiencies: 1
Date: Oct 11, 2013
Visit Reason
No deficiencies noted during this standard inspection.
Findings
No deficiencies noted during this standard inspection.
Deficiencies (1)
None
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