Inspection Reports for The Bartlett Skilled Nursing and Rehabilitation Facility
TX, 79912
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
206% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Aug 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, care planning, food safety, infection prevention, and staff training at The Bartlett Skilled Nursing and Assisted Living facility.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and grooming, incomplete care plans for residents on insulin, improper food storage and sanitation in the kitchen, failure to follow infection control protocols during meal service, and lack of mandatory infection control training for key staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to treat Resident #28 with respect and dignity by not ensuring proper grooming and appropriate dressing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive person-centered care plans for residents prescribed insulin medication (Residents #6, #33, and #44). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain kitchen food storage areas clean and free of food residues and drippings, including unsealed lettuce and open butter in refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly serve meals by touching Resident #9's food with bare hands, risking cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide mandatory infection prevention and control training to the MDS Nurse and the Administrator. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity: 15
Residents reviewed for care plans: 6
Kitchen units inspected: 3
Staff reviewed for infection control training: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in infection control deficiency for touching Resident #9's meal with bare hands and in grooming deficiency for Resident #28. | |
| CNA B | Interviewed regarding Resident #28's grooming and dressing. | |
| LVN C | Licensed Vocational Nurse | Interviewed regarding Resident #28's grooming and care plan responsibilities. |
| DON | Director of Nursing | Interviewed regarding Resident #28's grooming, care plan oversight, infection preventionist role, and staff training responsibilities. |
| Administrator | Interviewed regarding food safety, infection control, and staff training. | |
| MDS Nurse | Interviewed regarding care plan responsibilities and lack of infection control training. | |
| Dietary Director | Interviewed regarding kitchen cleanliness and food safety standards. | |
| Head [NAME] | Interviewed regarding kitchen sanitation and food safety. | |
| Dietary Cook | Interviewed regarding kitchen sanitation and food safety. | |
| Human Resources | Interviewed regarding staff infection control training documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse involving two residents, specifically an incident where Resident #2 physically struck Resident #1 causing injury.
Findings
The facility failed to ensure residents were free from abuse, neglect, exploitation, and misappropriation of property. Resident #1 sustained bruising from Resident #2 striking her. The facility also failed to develop and implement adequate policies to prevent abuse, failed to report the abuse incident timely to appropriate authorities, and failed to follow their own abuse reporting policies.
Complaint Details
The complaint investigation was triggered by an incident where Resident #2 physically struck Resident #1 resulting in bruising and hematoma. Resident #1 was sent to the hospital for evaluation. The facility failed to report the abuse to the State Survey Agency, law enforcement, and Ombudsman as required. Interviews and record reviews confirmed the incident and the facility's failure to follow reporting protocols.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect residents from all types of abuse including physical abuse. | Level of Harm - Actual harm |
| Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 5
BIMS score Resident #1: 3
BIMS score Resident #2: 4
Residents affected by deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Wrote incident report and progress notes regarding Resident #1's injury. |
| LVN B | Licensed Vocational Nurse | Provided progress notes and interviews regarding Resident #1's injury and reporting. |
| DON | Director of Nursing | Interviewed regarding investigation and failure to report abuse. |
| AIT | Administrator in Training | Interviewed regarding incident and failure to report abuse. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 13, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to maintain complete and accurate medical records for Resident #2, specifically concerning the documentation and administration of the medication Donepezil.
Findings
The facility failed to ensure accurate documentation of Resident #2's medication Donepezil, which was verbally ordered to be held due to an interaction with antibiotics but was not properly documented in the medical records. This documentation failure posed a risk of improper medication administration, although no negative outcomes were reported.
Complaint Details
The complaint investigation found that Resident #2 was not given the prescribed medication Donepezil due to a verbal hold order from the PCP related to drug interaction with antibiotics. The hold order was not documented properly in the medical records, leading to confusion among facility staff. The PCP confirmed the verbal hold and stated no adverse effects occurred. The facility's Director of Nursing acknowledged the documentation issue and confirmed no negative outcomes for the resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain complete and accurate medical records for Resident #2, specifically regarding the medication Donepezil and the verbal hold order from the physician. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 5
Residents affected: 1
Dates of PCP Progress Notes reviewed: 6
Discharge date: Dec 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Primary Care Physician (PCP) | Provided verbal hold order on Donepezil and clarified medication interaction | |
| Director of Nursing (DON) | Acknowledged documentation failure and confirmed no negative effects from medication hold |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 6, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to follow professional standards for PICC line care and medication cart security.
Findings
The facility failed to change a resident's PICC line dressing as ordered, placing the resident at risk of complications. Additionally, the facility failed to ensure a medication cart was secured when left unattended, risking drug diversion or accidental ingestion.
Complaint Details
The complaint investigation found substantiated issues with PICC line care and medication cart security, with minimal harm or potential for actual harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to change Resident #1's PICC line dressing as ordered, risking complications with infusion therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed; medication cart left unattended and unlocked. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for parenteral and intravenous care: 2
Medication carts reviewed: 2
PICC line dressing change frequency: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Interviewed regarding PICC line dressing change schedule and observations |
| LVN A | Licensed Vocational Nurse | Responsible for medication cart left unsecured |
| CNA B | Certified Nursing Assistant | Observed locking medication cart and interviewed about medication cart security |
| DON | Director of Nursing | Provided information on PICC line care and medication cart security policies and training |
| Administrator | Facility Administrator | Provided information on nursing staff responsibilities for PICC line and medication cart management |
Inspection Report
Routine
Deficiencies: 8
Jul 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and quality assurance at The Bartlett Skilled Nursing and Assisted Living facility.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with specific medical needs such as diabetes and dialysis, inadequate documentation and monitoring of dialysis treatments, failure to act on pharmacist recommendations regarding medication regimen, improper use and monitoring of psychotropic medications, food safety violations related to improper food storage and labeling, incomplete clinical records, and lapses in infection control practices including improper catheter care and hand hygiene. Additionally, the facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive person-centered care plan for Resident #40 addressing diabetes and dialysis needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dialysis services were provided consistently with professional standards for Residents #7 and #40, including lack of post-dialysis documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician responded to pharmacist recommendations regarding drug regimen irregularities for Resident #3 receiving Risperidone. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate diagnoses for psychotropic medication use and failed to limit PRN psychotropic orders to 14 days for Resident #98. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper labeling, uncovered foods, and improper thawing of meat. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate clinical records for Resident #7, including missing resident identifiers on dialysis communication forms and failure to scan forms into electronic chart. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection control program, including catheter drainage bag left on floor and inadequate glove use and hand hygiene by staff during incontinent care for Residents #252, #20, and #31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program to all staff. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dialysis services: 2
Residents reviewed for medication regimen response: 6
Residents reviewed for unnecessary medications: 8
Hemodialysis Communication forms: 17
Hemodialysis Communication forms missing resident identifiers: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding care plans, medication management, infection control, and documentation deficiencies |
| ADON | Assistant Director of Nursing | Interviewed regarding dialysis documentation and infection control practices |
| LVN A | Licensed Vocational Nurse | Interviewed regarding catheter care and infection control |
| CNA D | Certified Nursing Assistant | Observed and interviewed regarding incontinent care and infection control lapses |
| CNA E | Certified Nursing Assistant | Observed and interviewed regarding incontinent care and infection control lapses |
| CNA F | Certified Nursing Assistant | Observed and interviewed regarding incontinent care and infection control lapses |
| HR Manager | Provided employee hire dates and training records | |
| Administrator-in-training | Administrator-in-training | Interviewed regarding QAPI training deficiencies |
| Dietary Director | Dietary Director | Interviewed regarding food safety violations |
| Registered Dietician | Registered Dietician | Interviewed regarding food safety violations |
Inspection Report
Routine
Deficiencies: 13
Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (call light placement), failure to ensure resident council rights, lack of privacy for telephone use, failure to timely report abuse allegations, incomplete baseline and comprehensive care plans, inadequate catheter and respiratory care, improper pharmaceutical services including narcotic counts and expired medications, food safety violations in the kitchen, improper garbage disposal, inaccurate medical record documentation, and infection control breaches related to treatment cart and nebulizer mask.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure call lights were within reach for residents #50 and #204, risking inability to call for assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to inform resident council they could meet without staff present, risking reduced resident expression. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a private place for resident #259 to make telephone calls, risking privacy violations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report alleged verbal abuse for resident #259 and financial exploitation for resident #34 to State Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop baseline care plan within 48 hours for resident #11 that included oxygen use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for residents #10 (urinary catheter) and #11 (oxygen use). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care for resident #206; catheter tubing was cloudy with sediment and not properly anchored. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe respiratory care for residents #4, #11, #23, and #205; oxygen tubing not dated and oxygen signs not posted outside rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmaceutical services assuring accurate narcotic counts and monitoring of expired over-the-counter medications; missing narcotic count signatures and expired medications found. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards; issues included unlabeled/undated foods, unsealed containers, unclean equipment, staff not wearing hair nets, incomplete temperature logs, and improper hand hygiene by CNA. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly dispose of garbage and refuse; dumpsters lids open, trash on floor, utility trash cart without lid, and cigarette butts near grease. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safeguard resident-identifiable information and maintain complete and accurate medical records for resident #259; over-the-counter medication in possession not documented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection prevention and control program; uncovered nebulizer mask for resident #44 and open, reused dressing supplies in treatment cart risking cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed for call light placement: 14
Residents reviewed for telephone use: 6
Residents reviewed for abuse: 6
Residents reviewed for baseline care plan: 6
Residents reviewed for comprehensive care plans: 12
Residents reviewed for indwelling catheters: 6
Residents observed for oxygen management: 10
Halls with narcotic count issues: 3
Expired medication bottles found: 5
Kitchen sanitation issues: 10
Dumpsters with lids open: 3
Utility trash carts without lid: 1
Residents reviewed for infection control: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in verbal abuse allegation involving Resident #259 and failure to document over-the-counter medication | |
| MDS Nurse C | Responsible for baseline and comprehensive care plans for Residents #10 and #11; acknowledged care plan deficiencies | |
| MDS Nurse B | Responsible for comprehensive care plan for Resident #11; acknowledged oxygen use not documented | |
| RN H | Interviewed regarding oxygen orders and oxygen sign posting for multiple residents | |
| DON | Director of Nursing | Oversaw narcotic counts, oxygen sign posting, abuse reporting, and infection control |
| Administrator in Training | Investigated abuse and financial exploitation allegations; failed to report to State Agency | |
| CNA I | Responsible for stocking over-the-counter medications and audits; observed failing hand hygiene | |
| Director of Dietary | Interviewed regarding kitchen sanitation, food labeling, and staff hygiene | |
| LVN E | Interviewed regarding narcotic counts and oxygen sign posting | |
| RN M | Interviewed regarding narcotic count sheet audit | |
| RN D | Interviewed regarding catheter care for Resident #206 | |
| ADON | Interviewed regarding treatment cart infection control issues |
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