Bradford Square Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF624Jun 27, 2024

  Based on interview, record review, and review of the facility's documents and policies, the facility failed to provide a safe transfer to the appropriate level of care to meet a resident's needs to ensure a safe and orderly discharge from the facility for 1 out of 3 sampled residents (Resident (R) 197). Record review revealed R197 was discharged from the facility to a homeless shelter on 05/01/2023. The resident's diagnoses included type 2 diabetes with ketoacidosis (a serious complication of diabetes when too many ketones build up to dangerous levels in the body) and unspecified lack of normal physiologic development in childhood. […]

• No harm, potential for more than minimal, widespreadF802Apr 26, 2024

  Based on interview, record review, review of the facility's local health department inspection, and review of the local health department's website, the facility failed to provide education to food handlers related to safe food handling practice to enable food handlers to effectively carry out the functions of the food and nutrition service department. This deficient practice affected 85 residents receiving meals from the kitchen. The findings include: Review of the local health department's Health Department Inspection, dated [DATE], revealed the facility was cited for improper glove use, hand hygiene, and staff needing food handlers' cards. […]

• No harm, potential for more than minimal, widespreadF812Sep 17, 2021

  Based on observation, interview, and review of the facility's policies, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as determined by observations during the initial tour and revisits to the kitchen. Staff did not use appropriate hand hygiene between glove changes, and there was improper sanitization of the utility cart and the thermometer between foods. The findings include: Review of the facility's policy titled, Hand Washing, dated 06/15/2018, revealed hand washing was performed frequently and using correct hand washing technique. The policy stated hand washing was performed after touching the body and after removing disposable gloves. […]

• No harm, potential for more than minimal, patternF812Mar 26, 2026

  Based on observation, interview, and review of the facility's policy, the facility failed to store food items in accordance with professional standards to prevent the use of outdated products and reduce the risk of foodborne illness.The findings include:Review of the facility's policy titled, Food brought in from Outside Sources and Personal Food Storage, dated 2019, revealed all foods should be covered, labeled, and dated. Further review revealed all foods will be checked to assure that all foods will be consumed by their safe use by dates, or frozen (where applicable), or discarded.Observation of the kitchen on 03/24/2026 at 12:25 PM revealed an opened box of Sysco baking soda with the top covered in plastic wrap, labeled as opened on 11/18/2023, with a manufacturer's best by date of… […]

• No harm, potential for more than minimal, patternF584Apr 26, 2024

  Based on observation, interview, and review of the facility's documents and policies, the facility failed to ensure residents had a clean environment for 46 of 46 residents who resided on the 100 and 200 Halls. The findings include: Review of the facility's policy titled, Homelike Environment, revised February 2021, stated residents were provided with a safe, clean, comfortable, and homelike environment. Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised March 2017, stated the resident had a right to a safe, clean, comfortable, and homelike environment. Review of the facility's document Daily Cleaning Schedule revealed common area bathrooms and resident bathrooms were to be cleaned daily. […]