The Bradford Skilled Nursing and Rehabilitation

In the surveyor’s words

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

• Actual harm, patternF684Mar 8, 2022

  Based on record review and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for a resident with a known critically high white blood count for 1 (#1) resident out of 5 (#1-#5) sampled residents by: 1. Failing to give antibiotics in a timely manner and 2. Failing to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice resulted in an actual harm on [DATE] at approximately 6:00 PM when Resident #1 was found to have altered mental status, clammy skin, decreased blood pressure, and increased heart rate. Resident #1 was transferred to the hospital where he was found to be lethargic and minimally responsive. […]

• No harm, potential for more than minimal, patternF656Sep 24, 2025

  Based on record review, observations and interviews the facility failed to ensure residents' plans of care were developed and implemented for 2 (#5, #44) of 2 (#5, #44) residents out of a total sample of 37 residents. The facility failed to provide a palm roll for Resident #5 and failed to develop a plan of care for nebulizer treatments for Resident #44. Finding: Resident #5Review of Resident #5's medical record revealed an admit date of 05/20/2024 with a diagnosis of but not limited to muscle wasting and atrophy, lack of coordination, contractures, encephalopathy, atrial fibrillation, essential hypertension, cerebral infarct, and idiopathic progressive neuropathy.Review of Resident #5's annual MDS (Minimum Data Set) dated 08/20/2025 revealed Resident #5's BIMS (brief interview mental… […]

• No harm, potential for more than minimal, patternF677Sep 24, 2025

  Based on record reviews, observations and interviews, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain nail care for 2 (#35, #86) of 3 (#5, #35, #86) residents reviewed for ADLs.Findings:Review of Facility's Care of Fingernails/Toenails Policy revised October 2010 revealed: Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming.Resident #35Review of Resident #35's medical record revealed an admit date of 07/25/2024 with diagnoses that include in part muscle wasting and atrophy, lack of coordination, and legally blind. […]

• No harm, potential for more than minimal, patternF693Sep 24, 2025

  Based on record review, observation and interview, the facility failed to provide appropriate treatment and services for 1(#1) of 1(#1) resident reviewed for tube feedings. The facility failed to ensure Resident #1's tube feeding bag and water flush bag were changed daily.Findings:Review of Resident #1's medical record revealed an admit date of 07/30/2025 with the following diagnoses, including in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction and gastrostomy status. […]

• No harm, potential for more than minimal, patternF695Sep 24, 2025

  Based on record reviews, observations and interviews, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for 4 (#18, #19, #44, #75) of 4 (#18, #19, #44, #75) residents reviewed for respiratory therapy. The facility failed to ensure respiratory supplies were changed weekly and stored in a covered device.Findings: Review of the facility's Oxygen Administration policy revised February 2025 revealed in part:Purpose: The Purpose of this procedure is to provide guidelines for safe oxygen administration, and infection prevention associated with respiratory therapy tasks,Steps in the Procedure: 4. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and /or nasal catheter).5. […]