Bradford Hills Nursing & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 22, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse from another resident that resulted in actual harm with a serious injury of a left femoral neck fracture for one of two residents reviewed for resident-to-resident interactions. (Resident 399 [Resident 90], Unit 1 East). Findings include: Clinical record review for Resident 399 revealed that she was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other mental functions related to brain cell connections and the cells degenerate and die). […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2024

  Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen and on two of five nursing units (Second Floor East, Third Floor West) Findings include: Observation of the facility's main kitchen on November 19, 2024, at 11:00 AM revealed the following: Handwashing sinks located inside the kitchen entrance, beside the three-compartment sink area, snack preparation are, and dishwashing area were observed with brown staining, and with dust, dirt, and debris buildup on the surrounding faucet area. […]

• No harm, potential for more than minimal, patternF684May 27, 2026

  Based on clinical record review, and staff interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered treatments for three of three residents reviewed (Residents 1, 2, and 3).Findings include: A review of current physician orders for Resident 1 revealed an order dated May 19, 2026, for staff to use Acetic Acid Irrigation Solution (a rinse to aid in the prevention of bacteria), one dose every night shift for wound care, and cleanse right hip wound with acetic acid, pat dry, and apply Santyl (topical ointment used to remove dead or damaged tissue from wounds to promote healing) to the base of the wound, and secure with bordered dressing. […]

• No harm, potential for more than minimal, patternF697Dec 12, 2025

  Based on clinical record review, review of select facility policies and procedures, and staff and resident interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of two residents reviewed for pain (Resident 3).Findings include: The facility policy entitled Pain-Clinical Protocol, last reviewed without changes April 2, 2025, revealed the physician and staff will identify individuals who have pain, or who are at risk for having pain. The nursing staff will assess residents for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. […]

• No harm, potential for more than minimal, patternF759Dec 12, 2025

  Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 13 and 17).Findings include: The facility's medication error rate was 23 percent based on 38 medication opportunities with nine medication errors. Interview with Employee 1 (registered nurse) on December 10, 2025, at 9:24 AM during the observation of the preparation of medications for administration to Resident 17, revealed that Employee 1 did not have artificial tears (liquid medication administered in the eye for lubrication to treat dryness of the eye) or Lidocaine patches (topical anesthetic to treat pain) included with the medications for the 9:00 AM medication pass because they were not available in… […]