Bradford Place Care Center

In the surveyor’s words

From the most serious findings on record at Bradford Place Care Center, in the surveyor’s own words.

• Actual harm, isolatedF791Nov 25, 2025

  Based on record review, observations, staff interviews, and policy review, the facility failed to ensure Resident #19 received prompt dental care services. This resulted in Actual Harm when Resident #19, who had persistent dental pain, developed a dental infection and had significant weight loss. On 06/19/25 at 6:50 P.M., Resident #19, who was nonverbal, screamed loudly for most of the shift due to dental pain and was unable to be redirected. On 06/20/25, Resident #19 ' s oral intake decreased related to ongoing dental pain. Resident #19 was seen by the nursing staff on 06/25/25 for continued behaviors including a decrease in oral intake, biting on her fingers, and was suspected of having a dental infection. […]

• Actual harm, isolatedF686Jun 20, 2023

  Based on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. This resulted in Actual Harm to Residents #03 and #65 who were at risk for pressure ulcers and the facility found Resident #03's pressure ulcer as an unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) and Resident #65's pressure ulcer as a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). […]

• Actual harm, isolatedF686Jan 7, 2022

  Based on medical record review, observation, staff interview, wound nurse interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP) the facility failed to accurately assess, measure and document a residents' open sacral wound upon discovery, failed to ensure an individualized care plan was developed to prevent further skin breakdown, failed to complete weekly skin assessments as ordered, failed to implement physician ordered interventions for pressure relieving measures and failed to document a physician order to treat an open sacral wound resulting in an increase in size and discomfort. […]

• No harm, potential for more than minimal, widespreadF804Nov 25, 2025

  Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure food was served in an appetizing manner. This affected two (Residents #86 and #16) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: Observation on 09/23/25 at 12:15 P.M. of a test tray revealed there were two tacos wrapped in foil with liquid pooled up underneath the plate. There was a significant amount of liquid contained within the foil and the tortilla of the taco was saturated with liquid. Interview on 09/23/25 at 12:16 P.M. with District Manager (DM) #600 verified there was liquid in the foil which altered the texture of the tortillas. Observation on 09/23/25 at 12:25 P.M. […]

• No harm, potential for more than minimal, widespreadF807Nov 25, 2025

  Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure beverage preferences and requests were honored. This affected one (Resident #16) of one residents reviewed for food preferences and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents.Findings include: Observation on 09/22/25 at 11:46 A.M. revealed Certified Nursing Assistant (CNA) #525 entered Resident #16's room to deliver a lunch tray. Resident #16 asked CNA #525 for milk. CNA #525 stated there was no milk in the refrigerator, but otherwise she would give it to him. Interview on 09/22/25 at 11:47 A.M. with CNA #525 verified Resident #16 asked for milk and she told him it was not available. […]