Bradford House Nursing and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Bradford House Nursing and Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jul 9, 2026

  Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to identify and assess two (Resident #72 and Resident #78) of three residents' change in condition resulting in their death. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to, Appendix PP, CFR 483.35 at a scope and severity of J. […]

• Immediate jeopardy, patternF689Sep 27, 2022

  Based on record review and interview, the facility failed to ensure a resident who had exhibited multiple exit seeking behaviors had resident specific interventions in place to prevent an actual elopement for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents who were at risk of elopement. This failed practice resulted or could have resulted in serious injury, impairment, harm, or death. The facility was notified of the Past Immediate Jeopardy on 9/26/22 at 4:39 PM. This failed practice had the potential to affect 11 residents who were at risk for elopement per a list provided by the Administrator on 9/26/22 at 4:47 PM. The findings are: 1. Resident #1 had diagnoses of Unspecified Dementia, Polyneuropathy and Hypertension. […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2026

  Number of residents sampled: Number of residents cited: Based on observation, interview and facility document review, the facility failed to ensure the food preparation equipment and environment were maintained to prevent contamination and potential development of foodborne pathogens. Specifically, the facility failed to properly clean and store the ice scoop for one of two ice machines reviewed. The findings include: During the tour of the kitchen on 07/06/2026 at 10:30 AM with the Dietary Manager (DM), the ice machine scoop holder which was attached to the ice machine was covered with a black residue and the ice scoop was observed to be currently resting on the black residue. This surveyor asked the DM to wipe the black residue off. The DM did so, the residue was easily wiped away. […]

• No harm, potential for more than minimal, widespreadF842May 30, 2025

  Based on observations, interviews, and policy review, it was determined that the facility failed to ensure archived medical records were stored in a secure location to safeguard resident health information against loss or unauthorized use for 1 of 1 medical records storage system reviewed. The findings include: During an observation on 05/27/2025 by a Life Safety Code (LSC) Surveyor, archived medical records dated 2016 through 2020 stored in cardboard boxes were observed on a shelf in the maintenance department garage. The LSC surveyor reported the incident to this surveyor for investigation. […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2021

  Based on observation and interview, the facility failed to ensure kitchen employees washed their hands before handling clean equipment or food and rinsed fresh produce before slicing to prevent potential cross contamination and food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 68 residents who received meals from the kitchen (total census: 69), according to a list provided by the Dietary Supervisor on 7/29/2021. The findings are: 1. On 7/28/21 at 1:20 p.m., Dietary Employee #1 was wearing gloves on her hands when she opened the refrigerator door and took out a bag that contained lettuce, which she placed on the counter. She turned on the sink faucet, removed a head of lettuce from the bag and rinsed it. […]