Bancroft Healthcare Center

In the surveyor’s words

From the most serious findings on record at Bancroft Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 8, 2025

  Based on interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3 sampled residents (Resident 1). Resident 1 had been prescribed oxycodone (narcotic) since 2024 and was in hospice (end-of-life care for a terminal illness.) When Resident 1 could no longer swallow her pills, facility staff did not have a plan in place to address withdrawal symptoms from the oxycodone.This resulted in Resident 1 experiencing unnecessary pain, agitation and distress.During a review of Resident 1's clinical document titled admission Record, the admission record indicated, the facility admitted Resident 1 on 12/14/2023 with multiple medical diagnoses including multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. […]

• No harm, potential for more than minimal, widespreadF700Mar 1, 2022

  Based on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and benefits and obtain informed consent from the resident and resident representative (RR) prior to installment of the bed side rails for 29 out of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25). Also, there was no side-rail assessment conducted prior to initiation of the bed side rails for Resident 30. The facility's failure to assess bed side rail use for Resident 30 placed Resident 30 at risk for entrapment and injuries. Also, these failures resulted in 29 of 29 residents and their RR's to be unaware of risks and benefits of side rails and to be able to make an informed decision. […]

• No harm, potential for more than minimal, widespreadF835Mar 1, 2022

  Based on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed to administer bed side rails without reviewing risks and benefits; obtaining an informed consent from residents/ resident representatives; and without using less restrictive alternatives prior to installing bed side rails to 29 of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25) residing at the facility. This failure placed all 29 residents residing at the facility at risk for avoidable injuries. […]

• No harm, potential for more than minimal, patternF578Oct 10, 2024

  Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 14 sampled residents (Residents 17, 2, 22 and 24). This failure had the potential for the facility to provide treatment and services against the residents' wishes. […]

• No harm, potential for more than minimal, patternF584Oct 10, 2024

  Based on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 21) rooms had comfortable and safe temperature levels. This failure had the potential to cause overheating in residents and discomfort during severe hot weather. Findings: During a review of Resident 4's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/24/24, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 14 and indicated intact mental status. […]