Cycle 1
Health 2024-07-30 · Fire 2024-07-30
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Bartow, FL
Bartow Center
2-star overall rating with 2-star inspections with $8,034 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2055 E Georgia St, Bartow, FL
(863) 533-0578
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Hearthstone Senior Communities
Operator or chain grouping
Approved since
1975-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,230
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.21
Baseline 55.10% · Performance 46.47% · Measure score 4.21 · Achievement 4.21 · Improvement 2.36
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 5.81% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 26.03% |
95.27%
69.2 pts worse
|
Numerator 19 · Denominator 73 |
| Falls with major injury | 1.37% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 73 |
| Discharge self-care score | 37.5% |
53.69%
16.2 pts worse
|
Numerator 18 · Denominator 48 |
| Discharge mobility score | 12.5% |
50.94%
38.4 pts worse
|
Numerator 6 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 2.74% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 73 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 3.1% |
42%
38.9 pts worse
|
Numerator 4 · Denominator 129 |
| Discharge function score | 35.42% |
56.45%
21 pts worse
|
Numerator 17 · Denominator 48 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.28% |
25.2%
8.9 pts worse
|
Numerator 7 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
3.7%
3.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.9%
0.9 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.3% · Q3 4.4% · Q4 3.4% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
15.7%
8.2 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 20.2% · Q3 24.7% · Q4 27.5% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
9.8%
3.5 pts worse
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 12.1% · Q3 15.6% · Q4 18.6% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.1% |
11.7%
6.6 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 13.9% · Q4 4.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
9.8%
4.8 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 9.0% · Q4 7.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
12.5%
7.5 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.6% · Q3 5.7% · Q4 5.0% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.1%
0.2 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.1% · Q3 7.1% · Q4 2.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.3%
5.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.3%
0.5 pts worse
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 10.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 1.4% · Q4 4.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.7%
4.4 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.2% |
26.2%
5 pts worse
|
23.9%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.2% · Observed 34.8% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-08 · Fire 2022-04-08
3 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-02-05 · Fire 2021-02-05
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-30
D · Potential for more than minimal harm
2022-04-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-05-08
D · Potential for more than minimal harm
2021-02-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-03-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-07-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-09
D · Potential for more than minimal harm
2023-04-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
E · Potential for more than minimal harm
2022-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-05-08
D · Potential for more than minimal harm
2021-02-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-02-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-03-05
Penalties and ownership
What sits behind the stars
$4,017
2024-07-30
Fine
Fine · fine $4,017
Fine
$4,017
2024-07-30
Fine
Fine · fine $4,017
Fine
Ownership
Bartow Rehabilitation Center LLC
5% Or Greater Direct Ownership Interest · Organization
Hearthstone Senior Communities, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Facility Support Company, LLC
Operational/Managerial Control · Organization
Garner, Alvin
Corporate Officer · Individual
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Mcmillan, Delmetra
Operational/Managerial Control · Individual
Rombold, Lori
Corporate Officer · Individual
Smith, Tammie
Operational/Managerial Control · Individual
Themis Health Management, LLC
Operational/Managerial Control · Organization
Wyatt, Brian
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Scott Lake Health And Rehabilitation Center
Lakeland, FL
2-star overall rating with 1-star inspections with abuse icon flag with $27,231 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Highlands Lake Center
Lakeland, FL
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Winter Haven Health And Rehabilitation Center
Winter Haven, FL
2-star overall rating with 2-star inspections with $4,190 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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