Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradford House Nursing And Rehab, Llc during CMS and state inspections, most recent first.
Two residents’ changes in condition were not properly identified and assessed, and both later died. One resident with DNR/comfort care status had an unwitnessed fall, vomiting, and then developed stroke-like symptoms including facial droop, unilateral weakness, slurred speech, and altered responsiveness; an LPN did not complete a full neuro assessment when notified and left the room after stating the resident was on comfort care. Records and staff interviews showed delayed escalation and inconsistent communication before the resident was sent to the hospital, where CT findings showed a large intracranial hemorrhage. The deficiency was cited at IJ level.
The facility failed to keep an ice machine scoop holder clean and properly stored. During a kitchen tour, the scoop holder was observed with black residue and the ice scoop was resting on it; the residue wiped away easily. The DM said the ice machine was used for residents' drinks and was cleaned weekly, while the DON and Administrator stated the scoop and holder should be cleaned daily. The facility policy required the ice scoop to be washed and sanitized daily and stored in a holder or bag.
Medication error rate exceeded the allowed threshold when 2 errors were found during 31 med pass observations. An LPN gave an eye med in a dose that did not match the MAR for one resident, and another LPN administered a BP med to a resident even though the resident’s pulse was below the ordered hold parameter; both nurses later acknowledged the errors, and the DON and Medical Director confirmed the BP med should have been held.
Infection control practices were not followed when an MDS Coordinator administered prescribed eye drops to a resident on contact isolation. The MDS Coordinator entered the room without PPE, handled a tissue near the resident’s face, discarded it, and left without sanitizing hands. The resident had CRAB wound infection, pressure ulcers, and paraplegia, and the room displayed contact isolation signage. The MDS Coordinator said she believed the resident was on EBP rather than contact isolation, while the IP and DON stated staff were expected to use the PPE indicated by the signage and perform hand hygiene before leaving the room.
Two residents who required two-person assistance for transfers were moved by a single CNA, resulting in falls and injuries. In both cases, the staff involved were aware of the care plan requirements but did not follow them, leading to head injuries and the need for medical evaluation. Facility policies and care plans specifying two-person assistance were not adhered to, and required incident reporting procedures were not followed.
A resident with dementia and other conditions was frequently given antianxiety medication for exit-seeking and wandering behaviors without attempts at non-medication interventions. The facility lacked a chemical restraint policy, and staff interviews revealed a reliance on medication over alternative methods. The DON expected non-medication interventions to be used first, but this was not consistently documented.
A resident with multiple diagnoses, including dementia and an unsteady gait, had a chair/bed alarm restraint added to their care plan due to falls. However, the facility failed to accurately document the use of this restraint on the resident's MDS, as it was incorrectly noted that no restraints were used. The discrepancy was discovered during a survey when the resident was observed with an active alarm restraint.
Failure to Assess Change in Condition Before Resident Deaths
Penalty
Summary
The facility failed to identify and assess two residents’ changes in condition, and both residents later died. One resident had multiple diagnoses including diabetes, Parkinson’s disease, epilepsy, hypertension, carotid artery disease, dementia, repeated falls, and a cognitive communication deficit. The resident’s care plan reflected DNR status, comfort care, do not transport, fall risk interventions, and monitoring for delirium, communication decline, and changes in behavior. After an unwitnessed fall with vomiting, nursing documentation showed neuro checks were started, but the resident later developed worsening neurologic findings including drooping of the left side of the face, inability to move the left arm and leg, slurred speech, and altered responsiveness. Staff interviews showed the LPN did not complete a full neuro assessment when notified of the resident’s drooping face and change in condition, and instead stated the resident was on comfort care and left the room without assessing. Multiple staff described that the resident had been vomiting, was clammy, had a headache, and later showed stroke-like symptoms. The record also showed inconsistent communication and delayed escalation, including a secure message that was not responded to, and staff statements that the provider was not aware of the change in condition until later. The resident was eventually sent to the hospital, where the emergency department documented facial droop, flaccid left arm and leg, and CT findings of a large parenchymal hemorrhage; the resident was then transitioned to comfort measures only. A second resident also had a significant change in condition that was not properly identified and assessed. The report states the facility failed to identify and assess this resident’s change in condition resulting in death. The deficiency was cited at Immediate Jeopardy level, and the survey findings were based on record review and interviews showing that the facility did not appropriately respond to the resident’s condition change before the resident died.
Dirty Ice Scoop Holder and Infrequent Cleaning
Penalty
Summary
The facility failed to ensure the food preparation equipment and environment were maintained to prevent contamination and potential development of foodborne pathogens. During a kitchen tour, the ice machine scoop holder attached to one of two ice machines was observed covered with a black residue, and the ice scoop was resting on that residue. When the surveyor asked the Dietary Manager to wipe the residue, it was easily removed. The Dietary Manager stated the scoop holder was dirty, that the ice machine was used by kitchen staff for ice in residents' drinks, and that the ice machine and scoop holder were cleaned weekly. The Director of Nursing stated the ice scoop and scoop holder should be cleaned as needed to prevent stomach upset and infections with residents, and the Administrator stated they needed to be cleaned daily to prevent infections. Review of the June cleaning schedule showed the ice machine had been cleaned once per week, and the facility policy stated the ice scoop was to be washed and sanitized daily and stored in a holder or bag.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% based on 2 medication administration errors identified during 31 medication administration observations for Resident #3 and Resident #27. For Resident #3, an LPN administered one drop of eye medication into each eye during a medication pass, but the resident’s MAR order required 2 drops in both eyes 3 times daily for dry eyes. The LPN later confirmed he had given one drop per eye, while the MAR documented that 2 drops had been administered and charted by the same nurse. For Resident #27, an LPN assessed the resident’s blood pressure and pulse before giving a medication for high blood pressure. The resident’s pulse was documented as 58, and the medication order required the medication to be held if the heart rate was under 60 BPM, with the nurse to report to the provider. The LPN administered the medication anyway and later stated she should not have given it because the pulse was 58, explaining she did not see the pulse parameter and only saw the blood pressure parameter. The DON and Medical Director both stated the medication should have been held and the provider notified when the pulse was below the ordered parameter.
Infection Control Practices Not Followed During Eye Drop Administration
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration for one resident who was on contact isolation precautions. Resident #9 was admitted with diagnoses including stage 3 and stage 4 pressure ulcers, osteomyelitis of the vertebra, a stage 3 sacral pressure ulcer, and paraplegia. The resident’s care plan identified Carbapenem-Resistant Acinetobacter Baumannii (CRAB) infection of wounds with an intervention for contact isolation, and the physician’s orders included contact isolation precautions. During a concurrent observation, the MDS Coordinator was observed in the resident’s room without PPE while holding a tissue near the resident’s face, then dropping the tissue into a trash can and leaving the room without sanitizing hands. The MDS Coordinator stated she had just administered the resident’s prescribed eye drops. During interview, she said she believed the resident was on Enhanced Barrier Precautions rather than contact isolation and reported she did not need PPE because she was not getting close to the resident’s wounds or catheter. The Infection Preventionist and DON stated staff were expected to recognize contact isolation by the signage and wear the proper PPE before entering the room, and to wash hands before leaving. Facility policy stated hand hygiene is the final step after removing and disposing of PPE.
Failure to Provide Required Two-Person Assistance During Resident Transfers Resulting in Falls
Penalty
Summary
The facility failed to ensure that residents requiring two-person assistance for transfers were transferred by the appropriate number of staff, resulting in falls and injuries for two residents. In the first case, a resident with a history of a femur fracture, pressure ulcer, and periorbital cellulitis, who was cognitively intact and required two-person assistance for transfers, was transferred by a single CNA from bed to a shower chair. During the transfer, the resident's feet slipped, resulting in both the resident and the CNA falling. The resident sustained an abrasion to the head. The CNA admitted to transferring the resident alone despite knowing the resident required two-person assistance, and did not report the fall to the charge nurse as required by facility policy. The care plan and employee training records confirmed the resident's need for two-person assistance and the CNA's awareness of this requirement. In the second case, another resident with multiple diagnoses including a right arm fracture, muscle wasting, anemia, unsteadiness, blindness, and gait abnormalities, and who was on a blood thinner, was also transferred by a single CNA despite a care plan specifying maximum two-person assistance. During the transfer from bed to wheelchair, the resident fell back and was lowered to the floor by the CNA, resulting in an abrasion to the scalp and a bruise to the forearm. The resident was subsequently sent to the emergency department for evaluation due to head trauma and anticoagulant use. The CNA acknowledged knowing the resident required two-person assistance but did not reference the care plan prior to the transfer. Both incidents were substantiated through interviews with staff, residents, and family members, as well as review of care plans, medical records, and facility policies. The facility's policies required staff to follow care plans and report all incidents and accidents immediately. In both cases, the staff involved failed to follow the established care plans for transfer assistance, directly leading to resident falls and injuries.
Improper Use of Antianxiety Medication as Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident's antianxiety medication was not used as a chemical restraint for staff convenience. The resident, who was diagnosed with dementia, a malignant neoplasm of the frontal lobe, anxiety disorder, and other conditions, was cognitively intact according to the Minimum Data Set assessment. Despite this, the resident was frequently administered an as-needed antianxiety medication for behaviors such as exit-seeking and wandering, without documented attempts of non-medication interventions like redirection or distraction. The facility did not have a policy for chemical restraints, as stated by the Administrator, and relied on staff education about resident rights to be free from restraints. However, the care plan for the resident included the use of psychotropic medication for anxiety and depression, with goals to avoid complications from these drugs. Despite these goals, the resident's progress notes repeatedly documented the use of antianxiety medication for behaviors such as trying to leave the facility, wandering, and mild agitation, without evidence of alternative interventions being attempted first. Interviews with staff and the resident's family member revealed that the facility often resorted to medication rather than non-pharmacological interventions. The Director of Nursing acknowledged that antianxiety medication should not be used for exit-seeking behaviors and expected staff to use three non-medication interventions before administering medication. The family member also noted a decline in the resident's cognitive and motor functions, which they associated with the frequent use of medication.
Inaccurate MDS Assessment of Restraint Use
Penalty
Summary
The facility failed to accurately assess the use of a chair/bed alarm restraint for a resident on their Quarterly Minimum Data Set (MDS). The resident, who was admitted with multiple diagnoses including dementia, a malignant neoplasm of the frontal lobe, and an unsteady gait, had experienced nine falls. As a fall intervention, a chair/bed alarm restraint was added to the resident's care plan. However, the MDS did not reflect the use of this restraint, as it was incorrectly documented that no restraints were used. This discrepancy was identified during a survey when the resident was observed with an active pad alarm restraint in both their wheelchair and bed. The Administrator acknowledged the oversight, noting that the MDS was signed by a former Assistant Director of Nursing who was terminated partly due to issues like this MDS discrepancy. The facility did not have a specific policy for MDS/Assessments and followed the Resident Assessment Instrument (RAI) Manual. The Administrator confirmed that an updated MDS identifying the alarm restraint had already been submitted, but this corrective action is not part of the deficiency itself.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bentonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Green House Cottages Of Northwest Arkansas | 1.7 mi | ★★★★★ | 0 | 0 |
| Promenade Health And Rehabilitation | 2.1 mi | ★★★★★ | 5 | 0 |
| Ashley Rehabilitation And Health Care Center | 2.3 mi | ★★★★★ | 17 | 0 |
| Innisfree Health And Rehab, Llc | 2.7 mi | ★★★★★ | 3 | 0 |
| Hampton Place Healthcare, Llc | 3.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.