Bradford Heights Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bradford Heights Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 20, 2024

  Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 90 of the facility's 94 residents who consumed food from the kitchen. Observation during the initial kitchen tour revealed numerous food items in the reach-in cooler not labeled or dated. In addition, continued observation of the kitchen revealed [NAME] 2 failed to have a beard covering in place. Further observation revealed [NAME] 2 failed to utilize utensils when serving food, using his gloved hands and not changing gloves. […]

• No harm, potential for more than minimal, isolatedF584May 29, 2026

  Observation, interview, and facility policy review revealed the facility failed to maintain a homelike environment for residents related to peeling paint on the walls in room [ROOM NUMBER], holes in the wall in rooms [ROOM NUMBER], and stained ceiling tiles in rooms 100, 107, 109, and 119. This affected four (4) out of 20 sampled residents, R11, R12, R19, and R20.The findings include: Review of the facility's policy, titled, Resident Rights Policy, reviewed 04/2026, revealed residents had a right to a safe, clean, comfortable, and homelike environment.Request for the facility's maintenance policy revealed that they didn't have any policies pertaining to maintenance of their building.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:00 PM revealed three (3) stained ceiling tiles in the… […]

• No harm, potential for more than minimal, isolatedF677May 29, 2026

  Observation, interview, and review of facility policies revealed the facility failed to provide assistance with incontinence care in a timely manner for four (4) of 10 sampled residents (R1, R6, R7, and R14).The findings include: Review of the facility's policy titled, Resident Rights Policy, reviewed 04/2026, revealed residents had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences.Review of the facility's policy titled, Activities of Daily Living Policy, revised 04/2026, revealed residents who were unable to carry out activities of daily living would receive the necessary services to maintain good personal hygiene.Review of the facility's policy titled, Perineal Care Policy, reviewed 04/2026, revealed it was the practice of… […]

• No harm, potential for more than minimal, isolatedF697May 29, 2026

  Based on interview, record review, and review of the facility policies, the facility failed to ensure pain assessments were completed prior to and after the administration of as needed (PRN) narcotic pain medications for four (4) out of four (4) sampled residents, Resident (R)4, R8, R16, and R18.The findings include: Review of the facility's policy, titled, Pain Management Policy, revised 04/2026, revealed the facility would utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. It further revealed, the facility would use a pain assessment tool, appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. […]

• No harm, potential for more than minimal, isolatedF761Apr 10, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications with expired or post discard dates were not available for resident use for one of four sampled residents (Resident (R) 1). Observation on 04/08/2026 revealed an intravenous (IV) antibiotic (Meropenem) container hanging on an IV pole in R1's room labeled with directions to discard the medication after 03/03/2026.The findings include: Review of the facility's policy titled, Medication Storage last revision date of 02/01/2026, revealed A. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. B. […]