Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradford Heights Nursing & Rehabilitation during CMS and state inspections, most recent first.
Unsafe and Unhomelike Resident Room Conditions: Surveyors observed stained, moisture-damaged ceiling tiles in several rooms and a supply closet, along with peeling paint and holes in resident rooms. A resident reported the room condition did not feel homelike, another said paint dust was getting onto belongings, and others said the holes made them feel unsafe or bothered them. The Maintenance Director linked the ceiling damage to a prior roof leak from clogged gutters, and the Administrator said repairs were usually handled promptly when reported.
Delayed Incontinence Care and Brief Changes: The facility failed to provide timely incontinence care for four residents who were unable to manage ADLs. One resident waited about 26 minutes after using the call light for bowel incontinence, another reported waiting over 3 hours in a wet brief, a third said she sat in feces for 2 hours because two CNAs were needed for care, and a fourth waited about 40 minutes after repeated call light requests. Facility policy required perineal care as needed, and the DON stated soiled briefs should be changed within 10 to 15 minutes.
Incomplete PRN Narcotic Pain Documentation: The facility failed to document pain assessments and reevaluations for PRN narcotic pain meds for four residents. MARs and controlled substance records showed multiple Hydrocodone-Acetaminophen and Tramadol doses removed or administered without the required documentation, despite care plans addressing pain and opioid use. Staff interviews confirmed awareness that PRN meds must be documented on the MAR and that missing documentation could allow a narcotic to be given too soon.
A resident admitted with acute osteomyelitis, renal abscess, and perinephric abscess had an active order for IV Meropenem when surveyors observed a full IV Meropenem bag hanging in the room with a discard date that had already passed. An LPN reported she had set up the antibiotic before discovering the PICC would not flush, did not notice the expired discard date, and left the bag on the IV pole. Facility policy addressed expiration and beyond-use dates but did not direct staff on handling medications past discard dates, while the DON and Administrator stated that nurses and unit managers were expected to check medication rooms and ensure expired medications were removed.
A resident with acute osteomyelitis, renal and perinephric abscesses requiring IV antibiotics was placed on enhanced barrier precautions with ordered isolation and twice-daily spinal wound care. Surveyors observed that there was no enhanced barrier precaution signage outside the resident’s room and that the ADON performed direct wound care without donning a PPE gown, contrary to the facility’s infection prevention and control policy requiring staff education and demonstrated competence in infection control practices. The DON reported that precaution signs are taped and believed the sign had fallen, while both the DON and Administrator stated their expectation that staff follow infection control signage and adhere to ordered precautions.
Improper food storage, hair restraint, and kitchen sanitation were observed in the dietary area. A DM wore a hairnet that left hair exposed, food in refrigeration and freezer units was found moldy, uncovered, undated, or unsealed, and heavy grease buildup was seen around the stove and fryer. Staff interviews confirmed that food should be covered, labeled, and dated, and that the grease accumulation and improper hair coverage were not consistent with facility expectations.
Failure to Follow Infection Control Practices During Wound Care: A wound care nurse failed to disinfect bedside tables before placing clean dressing supplies on them and did not perform hand hygiene or change gloves at the required points during wound care for two residents. One resident had moderate cognitive impairment and the other had severe cognitive impairment, and both had wounds requiring dressing changes. The nurse acknowledged the errors during interview, and the DON/IP stated staff were expected to use a clean barrier, perform hand hygiene, and change gloves during wound care.
A facility failed to follow food safety and hygiene standards, affecting most residents. Observations revealed unlabeled and undated food items in the cooler, improper food handling by a cook without a beard covering, and the use of gloved hands instead of utensils. Despite reminders, the cook continued these practices, which were against facility policies.
A resident with morbid obesity expressed a desire for showers instead of bed baths, but the facility failed to accommodate this preference due to assumptions about the resident's size and lack of communication among staff. Despite having bariatric shower equipment, the facility did not use it, and the resident did not receive a shower for four months.
The facility failed to follow its grievance policy, resulting in unresolved grievances for two residents. A resident reported missing clothing that was neither returned nor replaced, and the grievance form was incomplete. Another resident and a family member reported missing items to the Administrator, who handled complaints via her personal cell phone without documentation. The Administrator was unfamiliar with the grievance policy and believed addressing concerns was sufficient, leading to a lack of documented grievances.
A facility failed to conduct a required Level II PASRR evaluation for a resident with schizophrenia and bipolar disorder, following a positive Level I PASRR screen. Despite the resident's significant psychiatric history and an eight-month stay at a psychiatric hospital, the facility did not perform the necessary assessment, as staff misunderstood the criteria for triggering a Level II evaluation.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical and psychosocial needs. One resident developed a pressure injury due to the lack of a care plan for skin integrity, while another resident's psychiatric diagnoses were not addressed in their care plan. Staff interviews revealed inconsistencies in care planning responsibilities.
A resident experienced significant weight loss, but the facility failed to notify the Physician or follow the RD's recommendations for weekly weights. Despite the RD's communication to the ADON and DON, there was no documentation of the Physician being informed or orders being obtained. Interviews with staff revealed a lack of communication and documentation, leading to the deficiency.
A CMA at a LTC facility administered ophthalmic eye drops to a resident without wearing gloves, violating the facility's infection control policy. The resident, who was cognitively intact and had multiple diagnoses, received eye drops without the required hand hygiene and glove use, posing a risk of cross-contamination and infection. Interviews with staff confirmed awareness of the policy, but the Administrator did not perceive a risk to residents.
A resident with severe cognitive impairment developed a suspected deep tissue injury (SDTI) to the right heel due to the facility's failure to implement necessary interventions. Despite being at risk for pressure ulcers, the care plan lacked specific measures to address the resident's behavior of removing shoes and manipulating the wheelchair footrest. Interviews with staff revealed a lack of awareness and documentation of preventive interventions, and the resident's family observed inconsistent use of heel boots.
Unsafe and Unhomelike Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in multiple rooms. Survey observations identified stained ceiling tiles with apparent moisture damage in rooms 100, 107, 109, and 119, including several tiles that were yellowish-brown, bowed, or stained in areas near windows, corners, and above resident areas. A small supply closet near the nurse's station also had stained and bowed ceiling tiles while storing disposable cups, spoons, isolation gowns, N95 respirator masks, aerosol masks with tubing, oxygen tubing, nasal cannulas, and other oxygen supplies. The Maintenance Director stated the building had experienced heavy rain about 6-8 weeks earlier due to clogged gutters and roof leakage, and that the gutters had since been cleaned and the stained ceiling tiles replaced. Additional observations showed peeling paint and holes in resident rooms affecting R11, R12, R19, and R20. In one room, surveyors observed a 20-inch by 12-inch hole in drywall above R11's bed, along with peeling paint and a hole in the ceiling tile. In another room, there were multiple areas of peeling paint, a hole in the wall near the floor, a scrape behind one bed, and a round spot of missing paint below a clock, with R12's clothes and shoes covered in white dust and particles from crumbling paint. Another room had a 21-inch by 4-inch hole in the wall near the air conditioner. Residents stated the room conditions bothered them, did not feel homelike, and in one case made the resident feel unsafe. The Administrator stated residents were comfortable reporting repairs to the Maintenance Director and that issues would usually be fixed promptly if he knew about them.
Delayed Incontinence Care and Brief Changes
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for four sampled residents who were unable to manage their own activities of daily living. Facility policies stated that residents were entitled to reasonable accommodation of their needs and that incontinent residents were to receive perineal care as needed to maintain cleanliness, comfort, and prevent skin breakdown. The Director of Nursing stated the expectation was for a soiled brief to be changed within 10 minutes, and no longer than 15 minutes after an episode of incontinence. One resident reported using the call light for bowel incontinence and waiting approximately 15 minutes before speaking with staff, then waiting until a CNA entered the room about 26 minutes after the initial request to change the brief. The room smelled of feces when observed, and two staff members were sitting at the nurses' station at the time. Another resident stated she was changed only once per night shift and had waited over 3 hours in a wet brief after asking to be changed. She said this made her miserable because she was always incontinent. A third resident reported sitting in feces for 2 hours because two people were needed for her incontinence care and only two CNAs were working on the floor at the time. A fourth resident stated she waited about 40 minutes in a wet brief the night before the interview, after pressing the call light twice while staff were at the nurses' station. She became tearful and said waiting that long made her feel terrible because she got raw in her perineal area if she sat in a soiled brief too long.
Incomplete PRN Narcotic Pain Documentation
Penalty
Summary
The facility failed to ensure pain assessments were completed before and after the administration of PRN narcotic pain medications for four sampled residents: R4, R8, R16, and R18. Facility policies for Pain Management and PRN Medication required use of a pain assessment tool appropriate to the resident’s cognitive status, documentation of the reason for PRN use, the time of administration, and evaluation of effectiveness. The policies also stated that pain management would be reassessed at established intervals for effectiveness and adverse consequences. R18 was admitted with diagnoses including cerebral infarction, neuralgia, and unspecified pain, and her care plan included pain-related interventions and opioid-related goals. Her MAR showed documented administrations of Hydrocodone-Acetaminophen with pain assessments before and after administration, but the Medication Monitoring/Control Record showed additional tablets removed that were not documented on the MAR. For March 2026, 17 tablets were removed and 13 PRN doses were missing from the MAR, including pain assessment and reevaluation. For April 2026, 10 tablets were removed and 8 PRN doses were missing from the MAR, also without the required pain assessment and reevaluation. R4 was admitted with diagnoses including diastolic heart failure, wedge compression fracture of T11-T12 vertebra, and unspecified pain. Her care plan identified pain related to age, decreased mobility, restless leg syndrome, muscle spasms, and opioid use. Her MAR showed one documented Tramadol administration in March 2026, one in April 2026, and none in May 2026, while the Medication Monitoring/Control Record showed 9 tablets removed in March, 6 in April, and 7 in May. In each month, multiple PRN doses were missing from the MAR, including pain assessments and reevaluations before and after administration. R16 was admitted with cerebrovascular disease, Alzheimer’s disease with late onset, and idiopathic neuropathy. Her care plan addressed pain related to hip fracture history, decreased range of motion, arthritis, weakness, CVA, and muscle weakness. Her MAR showed no documented Hydrocodone-Acetaminophen administrations in April 2026 and one documented administration in May 2026, while the Medication Monitoring/Control Record showed 5 tablets removed in April and 9 in May. In both months, PRN doses were missing from the MAR, including pain assessment and reevaluation. R8 was admitted with Type 2 diabetes mellitus with hyperglycemia, unspecified myalgia, and acquired absence of the left foot and right great toe. Her care plan addressed acute pain related to toe amputation and opioid use. Her MAR showed no documented Hydrocodone-Acetaminophen administrations in March 2026, four documented administrations in April 2026, and none in May 2026, while the Medication Monitoring/Control Record showed 5 tablets removed in March, 16 in April, and 7 in May. In each month, PRN doses were missing from the MAR, including pain assessments and reevaluations before and after administration.
Expired IV Antibiotic Left Available for Resident Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications with expired or post-discard dates were not available for resident use. Surveyors observed a full, unadministered IV antibiotic bag of Meropenem 1 g/100 mL normal saline hanging on an IV pole in Resident 1’s room with a label directing that it be discarded after 03/03/2026, yet it remained available on 04/08/2026. Review of the facility’s Medication Storage policy showed it addressed expiration dates and beyond-use dates determined by the pharmacist and manufacturer’s expiration dates, but did not include directions for staff on how to appropriately address medications past their discard date. Resident 1 had been admitted with acute osteomyelitis, renal abscess, and perinephric abscess and had an active physician order for Meropenem 1 g in 100 mL normal saline every 8 hours. Progress notes documented that the resident’s PICC line would not flush and staff were unable to administer the scheduled antibiotic during the night shift. An LPN reported that during that night shift she set up the Meropenem prior to attempting to flush the PICC, did not notice the discard date of 03/03/2026 on the label, and left the antibiotic hanging on the IV pole after being unable to administer it. She stated she usually worked on another unit and believed the expired medication should not have been in the medication room, noting that unit managers and charge nurses were supposed to remove expired products. The DON stated that a licensed nurse should check medication rooms daily for expired medications, and the Administrator stated that staff were expected to be mindful of expiration dates and that nurses or unit managers were responsible for ensuring medications in medication rooms were not expired.
Failure to Follow Enhanced Barrier Precautions and PPE Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff adhered to its infection prevention and control program and PPE requirements for a resident on enhanced barrier precautions. The facility’s policy, revised in January 2026, required an infection prevention and control program and staff education with demonstrated competence in infection control practices and resident care procedures. The resident was admitted with acute osteomyelitis, renal abscess, and perinephric abscess requiring IV antibiotics, and the care plan documented enhanced barrier precautions related to IV access, including isolation per physician order. Physician orders also included twice-daily wound care to the spine area and routine observation of the IV site every shift. On the survey date, observation showed there was no signage outside the resident’s doorway indicating enhanced barrier precautions, and during wound care performed by the ADON, a PPE gown was not donned prior to providing direct care. The ADON later stated she had forgotten to put on a gown before performing the wound care. The DON stated that precaution signs are hung with tape and that the resident’s sign must have fallen off, and further stated her expectation that staff follow infection control signage and policy for enhanced barrier protection. The Administrator stated her expectation that staff follow infection control signage and adhere to precautions prior to entering a resident’s room and noted that not following precautions could lead to a resident developing a possible infection.
Improper Food Storage, Hair Restraint, and Kitchen Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observation of the kitchen, a Dietary Manager was seen wearing a hairnet that sat approximately three inches above the hairline, leaving hair exposed on both sides of the head and in the front above the forehead. The same observation identified a container of strawberries with mold in refrigerator 1, two heads of lettuce in an opened, uncovered, and undated plastic bag, and food items in freezer 1 that were not properly covered or sealed, including French toast sticks and chicken patties in original containers with uncovered flaps and a freezer storage bag containing three sausages that was not sealed and had ice crystals. The kitchen area also had heavy grease buildup and debris. An area beside the stove and fryer was observed with a thick film of splattered grease on the floor, walls, appliance sides, and pipes extending from the wall into the floor and back into the wall. An area between the stove and fryer was also covered with splattered grease and debris on the floor and wall. On a later observation, the Dietary Manager was still wearing the hairnet in the same manner, and the previously observed grease-splattered areas remained soiled. In interviews, a Dietary Aide stated food stored in the refrigerator or freezer should be dated, sealed, and covered, and said she did not know why that had not been done for the items observed. A cook stated food should be labeled, dated, and secured when stored, and that kitchen staff should follow the facility's policy and procedures. The Dietary Manager stated staff should use FIFO and follow storage procedures, that all hair should be pulled back and secured with a hairnet at all times, and that grease buildup near the stove and fryer could be a fire hazard. The Administrator stated she had not previously believed freezer-burnt food would make residents sick, expected dietary staff to follow food storage policy, and acknowledged that grease splattered throughout the kitchen could create a potential grease fire.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for wound care for 2 of 3 residents sampled for wound care, including a resident with unspecified dementia, neuromuscular dysfunction of bladder, chronic kidney disease, and essential hypertension, and another resident with unspecified dementia, metabolic encephalopathy, pressure ulcer of the left hip, unstageable, and other obstructive and reflux uropathy. The first resident had a BIMS score of 6 out of 15, indicating moderate cognitive impairment, and the second resident had a BIMS score of 0 out of 15, indicating severe cognitive impairment. During observation of wound care, the wound care nurse failed to clean or disinfect the bedside table before placing clean dressing supplies on it for both residents. For the first resident, the nurse also failed to clean or disinfect her hands after removing the dirty dressing and did not change gloves or sanitize hands before applying the clean dressing. For the second resident, the nurse again failed to clean or disinfect the bedside table before placing supplies on it and failed to change gloves or sanitize hands after removing the dirty dressing and before applying the new dressing. During interview, the wound care nurse stated she knew she had done wrong during both dressing changes and acknowledged she should have removed gloves, washed hands, and put on new gloves before applying clean dressings, and should have cleaned and sanitized the bedside tables before placing supplies on them. The DON, who was also the Infection Preventionist, stated she expected staff to follow wound care procedures, including using a clean barrier, performing hand hygiene, and changing gloves at the appropriate times.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting the majority of its residents. During an initial kitchen tour, surveyors observed several food items in the reach-in cooler that were not labeled or dated, including bowls of fruit, sandwiches, and chicken soup. Additionally, a large container of leftover chili was found with an outdated label. The facility's policy required all leftovers to be labeled, dated, and stored properly, but these practices were not followed. Furthermore, a box of bacon was found opened and uncovered, which is against the facility's food storage policy. The report also highlighted issues with food handling and hygiene practices. A male cook was observed without a beard covering, contrary to the facility's policy requiring facial hair to be covered. The same cook was seen using gloved hands instead of utensils to serve food, failing to change gloves between tasks, which could lead to cross-contamination. Despite reminders from the Dietary Manager, the cook continued to use improper food handling techniques. Interviews with facility staff, including the Regional Certified Dietary Manager and the Director of Nursing, confirmed that these practices were not in line with the facility's policies and expectations.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and had been admitted with conditions including chronic obstructive pulmonary disease, anxiety disorder, and morbid obesity, was able to exercise their right to choose their bathing preferences. The resident expressed a desire to take showers instead of bed baths, but due to their size, they were informed they could not fit on the shower bed. Despite the resident's expressed preference for showers, the facility continued to provide only bed baths, with no documented evidence of showers being given over a four-month period. Interviews with staff, including a CNA, the ADON, the DON, and the Administrator, revealed a lack of awareness and communication regarding the resident's preferences. The CNA and ADON believed the resident preferred bed baths, while the DON and Administrator were unaware of the resident's desire for showers. The facility had bariatric shower equipment available, but it was not utilized for the resident. The Administrator acknowledged the absence of a formal process to assess residents' bathing preferences, indicating a systemic issue in honoring resident choices.
Failure to Follow Grievance Policy for Resident Complaints
Penalty
Summary
The facility failed to adhere to its grievance policy, resulting in unresolved grievances for two residents. Resident R73, who was cognitively intact, reported missing clothing items that had not been returned or replaced despite assurances from the facility. The grievance form related to this issue was incomplete, lacking details about the investigation and signatures from the grievance official. The Social Services Director, responsible for overseeing grievances, acknowledged that not all grievances were documented, especially if resolved in real-time, but confirmed that unresolved issues should be documented. Resident R6, also cognitively intact, and a family member reported missing clothing items to the Administrator, who had been in her position for seven months. The Administrator handled complaints in real-time via her personal cell phone but did not document these interactions or the resolutions. She was unfamiliar with the facility's grievance policy and believed her method of addressing concerns was adequate. The Social Services Director confirmed that R6 had no documented grievances and that the Administrator had not communicated any issues to her. The Administrator admitted to not having read the grievance policy and was unable to confirm if she was following it. She believed that addressing concerns was sufficient, regardless of documentation. This lack of adherence to the grievance policy resulted in unresolved grievances and a failure to document and track resident concerns as required by the facility's policy.
Failure to Conduct Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to ensure a resident received a Level II Preadmission Screening and Resident Review (PASRR) referral following a positive Level I PASRR screening. The resident, identified as having schizophrenia, bipolar disorder, anxiety, and depression, was admitted to the facility after an eight-month stay at a psychiatric hospital. Despite the positive Level I PASRR screen, which necessitated a Level II evaluation, the facility did not conduct the required assessment. The facility's policy mandates that a positive Level I screen should trigger a Level II evaluation by the state-designated authority before admission, but this was not adhered to in the case of the resident. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Administrator, revealed a lack of understanding and execution of the PASRR process. The Social Services Director and Director of Nursing both stated that the resident did not meet all criteria for a Level II evaluation, despite the resident's significant psychiatric history. The Administrator admitted uncertainty about what would trigger a Level II PASRR assessment, indicating a gap in knowledge and compliance with the PASRR requirements. This oversight resulted in the resident not receiving the necessary evaluation and potentially appropriate care and services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, R99 and R23, which resulted in deficiencies in meeting their medical, nursing, and psychosocial needs. For R99, the facility did not create a care plan addressing the resident's risk for developing pressure injuries, despite being assessed as at risk shortly after admission. This oversight led to R99 developing a suspected deep tissue injury (SDTI) to the right heel, which was identified after the injury had occurred. Interviews with facility staff, including the MDS nurses and the Director of Nursing (DON), revealed a lack of clarity and responsibility in ensuring that care plans were initiated and updated appropriately. R23 was admitted with psychiatric diagnoses including schizophrenia, bipolar disorder, depression, and anxiety. However, the facility did not develop or implement a care plan to address these psychiatric needs. Although there were care plans related to psychotropic drug use and behavioral symptoms, they did not specifically address the resident's psychiatric diagnoses. Interviews with the Licensed Clinical Social Worker (LCSW) and the Administrator indicated uncertainty about the necessity of a care plan for R23's psychiatric conditions, despite the resident's history and ongoing treatment needs. The facility's policies on comprehensive care plans and pressure injury prevention were not adhered to, as evidenced by the lack of timely and appropriate care plans for both residents. The facility's failure to document and implement care plans based on the residents' assessments and needs contributed to the deficiencies identified during the survey. Staff interviews highlighted inconsistencies in the understanding and execution of care planning responsibilities, which further exacerbated the issues observed in the care of R99 and R23.
Failure to Monitor and Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R83, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. R83 experienced significant weight loss, but the facility did not notify the Physician of this weight loss nor did they follow the recommendations from the Registered Dietician (RD). The RD had recommended that R83 be weighed weekly for four weeks due to the significant weight loss, but there was no documented evidence that the Physician was notified or that an order for weekly weights was obtained. The resident's weight was recorded as 163.8 pounds on one date and 154 pounds on another, indicating a 5.98% weight loss over 24 days. Despite the RD's recommendation, the resident was not weighed again until over a month later, showing further weight loss. Interviews with facility staff, including the RD, Physician, Central Supply/CNA, ADON, DON, and Administrator, revealed a breakdown in communication and documentation. The RD communicated her recommendations via email to the ADON and DON, expecting the Physician to be notified. The Physician stated that weekly weights were a standing order and expected to be informed of the RD's recommendations. The Central Supply/CNA was responsible for weighing residents but was not aware of the recent weight loss. The ADON and DON acknowledged the lack of documentation and failure to notify the Physician or obtain orders. The Administrator expected staff to follow the RD's recommendations and notify the Physician, which was not done in this case.
Infection Control Breach in Eye Drop Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by a Certified Medication Aide (CMA) administering ophthalmic eye drops to a resident without wearing gloves. The facility's policy, dated May 2022, required staff to perform hand hygiene and wear examination gloves when administering eye drops. During an observation, CMA 2 was seen administering eye drops to Resident 41 without gloves, using her thumb and forefinger to open the resident's eyelids. This action was contrary to the facility's policy, which was designed to prevent cross-contamination and infection. Resident 41, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, had been admitted to the facility with diagnoses including hemiplegia, hemiparesis, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. Interviews with CMA 2, another CMA, the Unit Manager, the Director of Nursing, and the Administrator revealed awareness of the policy and the potential for harm if gloves were not used. However, the Administrator did not believe residents were at risk if eye drops were administered without gloves.
Failure to Prevent Pressure Injury in Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a pressure injury in a resident, identified as R99, who was admitted with severe cognitive impairment and at risk for developing pressure ulcers. Thirteen days after admission, R99 developed a suspected deep tissue injury (SDTI) to the right heel. The facility's policy required the interdisciplinary team to develop a care plan with measurable goals and appropriate interventions based on the resident's risk assessment. However, the care plan for R99 lacked documented evidence of interventions addressing the resident's behavior of constantly removing shoes and socks and manipulating the wheelchair footrest. The facility's records indicated that R99's care plan included interventions such as encouraging good nutrition and hydration, using a wheelchair cushion and pressure-reducing mattress, and wound care as ordered. Despite these measures, the resident developed a large SDTI on the right heel, which was attributed to resting the heels over the edge of the wheelchair. Recommendations from the wound care provider included pressure reduction, offloading, and ensuring compliance with the turning protocol, but these were not effectively implemented or documented in the care plan. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), revealed a lack of awareness and documentation of specific interventions prior to the development of the SDTI. The ADON and DON could not recall any interventions in place before the injury, and the Administrator was unfamiliar with the care planning process. The resident's family member, who visited daily, observed that heel boots were seldom used, and there was a lack of consistent intervention to prevent the injury. This deficiency highlights the facility's failure to adhere to its policy and ensure appropriate preventive measures were in place for at-risk residents.
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Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hopkinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Health Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Western State Nursing Facility | 3.7 mi | ★★★★★ | 3 | 0 |
| Christian Heights Nursing And Rehabilitation Cente | 11.5 mi | ★★★★★ | 7 | 0 |
| Shady Lawn Nursing And Rehabilitation Center | 16 mi | ★★★★★ | 0 | 0 |
| Elkton Nursing And Rehabilitation Center | 20.9 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.