Inspection Reports for
Bartram Lakes Assisted Living
6209 BROOKS BARTRAM DR BLDG 200, JACKSONVILLE, FL, 32258
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Inspection Report — Jun 24, 2026
Date: Jun 24, 2026
Visit Reason
The page covers the entire inspection history of Bartram Lakes Assisted Living, including all surveyor visits and their outcomes.
Findings
Across 31 inspections from October 11, 2013 to June 24, 2026, 10 visits cited deficiencies totaling 24 findings, none in the two most serious classes. Three legal actions with fines totaling $1,500 were recorded.
Citations (24)
Admissions - Continued Residency — cited November 4, 2025, corrected February 20, 2026
Resident Care - Elopement Standards — cited November 4, 2025, corrected February 19, 2026
Medication - Storage and Disposal — cited November 4, 2025, corrected February 19, 2026
Right of Inspection; Inspection Reports — cited June 16, 2023, correction not recorded
Resident Care - Elopement Standards — cited February 9, 2023, corrected May 16, 2023
Staffing Standards - Staff — cited February 9, 2023, corrected May 16, 2023
Records - Staff — cited February 9, 2023, corrected May 16, 2023
Admissions - Criteria — cited March 11, 2019, corrected April 19, 2019
Admissions - Health Assessment — cited March 11, 2019, corrected April 19, 2019
Resident Care - Third Party Services — cited March 11, 2019, corrected April 28, 2019
ECC - Admissions & Continued Residency — cited March 11, 2019, corrected April 25, 2019
Background Screening Clearinghouse — cited January 24, 2018, corrected March 22, 2018
Training - Staff In-service — cited August 17, 2017, corrected October 2, 2017
Training - Hiv/aids — cited August 17, 2017, corrected October 2, 2017
Training - Do Not Resuscitate Orders — cited August 17, 2017, corrected October 2, 2017
Staffing Standards - Staff — cited August 13, 2015, corrected September 16, 2015
Training - Staff In-service — cited August 13, 2015, corrected September 16, 2015
Training - Hiv/aids — cited August 13, 2015, corrected September 16, 2015
Training - Do Not Resuscitate Orders — cited August 13, 2015, corrected September 16, 2015
Training - Documentation & Monitoring — cited August 13, 2015, corrected September 16, 2015
ECC - Policies — cited September 11, 2014, corrected November 25, 2014
Food Service - Dietary Standards — cited April 28, 2014, corrected July 8, 2014
ECC - Health Assessment — cited April 28, 2014, corrected July 8, 2014
ECC - Service Plans — cited April 28, 2014, corrected July 8, 2014
Report Facts
Inspections: 31
Visits with deficiencies: 10
Clean visits: 13
Deficiencies: 24
Serious deficiencies: 0
Legal actions: 3
Total fines: 1500
Inspection Report — May 23, 2024
Routine
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.
Citations (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 — Nov 3, 2023
Complaint Investigation
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.
Citations (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 — Jun 23, 2022
Complaint Investigation
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.
Citations (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 — Dec 18, 2020
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.
Citations (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 |
4 CMS Surveys
CMS Survey — Nov 3, 2023
Nov 3, 2023
CMS Survey — Dec 18, 2020
Dec 18, 2020
CMS Survey — Jun 23, 2022
Jun 23, 2022
CMS Survey — May 23, 2024
May 23, 2024
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