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 The Bradford Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Care plans were not developed or implemented for two residents. One resident with severe functional dependence and a contracted hand had physician orders and a care plan for a palm roll, but observations and staff interviews showed the palm roll was not in use as ordered. Another resident with COPD had an order for albuterol nebulizer treatments, but the comprehensive care plan did not address nebulizer care or use, and the nebulizer was observed sitting at the bedside.
Failure to provide needed fingernail care for two dependent residents. One resident with muscle wasting, lack of coordination, and legal blindness was dependent for ADLs and had long, jagged fingernails with brown debris underneath; the resident said the nails scratched him and he could not care for them himself. Another resident with hemiplegia/hemiparesis was dependent for personal hygiene and had long, jagged fingernails with dark brown substance underneath; staff confirmed the nails were dirty and needed trimming.
A resident with hemiplegia, dysphagia, and gastrostomy status had ordered enteral feeding and water flushes. During observation, the tube feeding bag and water flush bag were both dated two days earlier, and the ADON acknowledged they should have been changed daily.
Respiratory care was not provided according to policy and orders for four residents with oxygen needs or COPD. Staff observed oxygen tubing without a date and nebulizer masks and tubing left uncovered or not stored in a covered bag, and an S3 Corporate Nurse and an LPN confirmed the supplies should have been dated, changed weekly, and kept in covered storage between uses.
A resident with depression received antidepressant medications via PEG tube, including trazodone and Prozac, but the MAR did not show behavior monitoring while the medications were being given. The care plan called for monitoring for changes in mood, cognition, hallucinations, delusions, social isolation, suicidal thoughts, and withdrawal. The ADON stated the resident had not been monitored for behaviors because he had not received a psychotropic, despite the resident currently taking an antidepressant.
A resident with multiple chronic conditions was using bilateral hand assist rails without documented quarterly assessment for entrapment risk or informed consent, as required by facility policy. The DON confirmed that the necessary Side Rail Utilization Assessment and consent process had not been completed.
A facility failed to report an alleged abuse incident involving a resident to the State Agency, despite conducting an internal investigation. The resident, with severe cognitive impairment and other mental health conditions, was allegedly kicked and cursed at by a CNA. The facility's policy requires timely reporting of such incidents, but this was not done, resulting in a deficiency.
A resident with severe cognitive impairment and frequent bowel incontinence was not checked every two hours as required by their care plan. Video footage showed a CNA entered the resident's room at night and did not return until the next morning, which was confirmed by the facility's administrator and DON.
A resident with multiple diagnoses and a self-care performance deficit was found with long and dirty fingernails, despite having a care plan requiring assistance with personal hygiene. The resident, who was cognitively intact, had requested nail trimming a week prior, but the facility failed to provide this care. The DON confirmed the need for nail trimming.
A resident, who was cognitively intact and receiving hospice care, felt threatened and unsafe after an administrator threatened to notify APS over a payment issue. The resident expressed a desire to leave the facility due to the administrator's rude behavior, which was confirmed by multiple staff members.
A resident with severe cognitive impairment and high fall risk was found with side rails in use without a physician's order, assessment, or consent, effectively acting as a restraint. Facility staff confirmed the lack of necessary documentation and acknowledged the inappropriate use of side rails as a restraint.
The facility failed to ensure proper use and maintenance of bed rails for several residents, lacking assessments, consents, and physician orders. Residents with various medical conditions had side rails raised without necessary documentation, as confirmed by observations and interviews with the corporate nurse. This indicates a systemic issue in adhering to protocols for safe bed rail use.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. An LPN administered incorrect medications to two residents: one received the wrong inhalation medication, and another received half the prescribed dose of Metoprolol Succinate ER. Both errors were confirmed by the LPN, a Nurse Practitioner, and the DON.
The facility failed to submit accurate payroll information for direct care staffing to CMS. A review of the PBJ report indicated low weekend staffing. Interviews revealed that the corporate office handles report submissions, and late agency staffing hours can result in inaccurate staffing levels being reported, suggesting inadequate staffing.
A resident with severe cognitive impairment and multiple diagnoses was unable to reach their call light, which was placed on a bedside table. Despite requiring extensive assistance, the resident's call light was observed out of reach on multiple occasions, and a CNA confirmed it should not have been placed there.
A facility failed to investigate an incident of resident-to-staff violence, where a resident with a history of violent behavior pushed an LPN and used profanity. Despite the facility's policy requiring such incidents to be reported and investigated, the DON did not complete an incident report, and the Administrator did not review available camera footage. The incident was not reported to the Corporate Compliance Officer, as it was deemed a behavior rather than an incident, indicating non-compliance with regulatory requirements.
The facility failed to ensure that a resident with multiple diagnoses, including mobility issues, was free from accidents and hazards. The resident was repeatedly observed with their bed in a high position and the call bell out of reach, contrary to physician orders and the care plan. A Restorative Aide confirmed these deficiencies.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Care Plans Not Developed or Implemented for Contracture Management and Nebulizer Use
Penalty
Summary
The facility failed to ensure Resident #5’s plan of care was developed and implemented for contracture management. Resident #5 was admitted with diagnoses including muscle wasting and atrophy, lack of coordination, contractures, encephalopathy, atrial fibrillation, essential hypertension, cerebral infarct, and idiopathic progressive neuropathy. The annual MDS showed a BIMS score of 00, indicating the resident was rarely understood, and that the resident was totally dependent on staff for all ADLs. The comprehensive care plan included applying a palm roll to the left hand daily in the morning and removing it in the evening, and physician orders also directed use of a palm roll for 8 hours for contracture management. However, observations on 09/22/2025 and 09/23/2025 did not reveal a palm roll in the resident’s left contracted hand, and an OT and an LPN confirmed the left hand was contracted and the palm roll was not in use as ordered. The facility also failed to develop a care plan for Resident #44’s nebulizer treatments. Resident #44 had diagnoses including COPD and chronic sinusitis, and the physician ordered albuterol sulfate nebulization three times daily for bronchospasms related to COPD. The quarterly MDS identified asthma/COPD and chronic lung disease with shortness of breath at rest, with exertion, or lying flat. Review of the comprehensive care plan did not show any plan for nebulizer treatments, and observations showed the nebulizer machine sitting on the resident’s bedside table. A corporate nurse observed the machine at the bedside, and the MDS nurse confirmed the resident had not been care planned for the care and use of the nebulizer and should have been.
Failure to Provide Needed Fingernail Care
Penalty
Summary
The facility failed to ensure dependent residents received the necessary services to maintain nail care for 2 of 3 residents reviewed for ADLs. The facility’s policy stated that nail care includes daily cleaning and regular trimming to clean the nail bed, keep nails trimmed, and prevent infections. Resident #35 was admitted with diagnoses including muscle wasting and atrophy, lack of coordination, and legal blindness, and the MDS showed the resident was dependent for bathing, toileting, dressing, and personal hygiene. During observation, Resident #35’s fingernails were long, past the fingertips, some were jagged, and there was a brown substance underneath. The resident stated the nails scratched him, that he could not see to care for them himself, and that he did not have anything to clean or clip them. Resident #86 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and the MDS showed impairment on one side of the upper extremity and dependence for personal hygiene and shower/bath. During observation, Resident #86’s fingernails on both hands were long and jagged with a dark brown substance underneath. A CNA stated fingernails are trimmed as needed and confirmed Resident #86’s fingernails were long, jagged, dirty, and needed trimming. The corporate nurse also confirmed Resident #35’s fingernails were long and jagged with brown substance underneath and should have been cut and cleaned but were not.
Tube Feeding and Flush Bags Not Changed Daily
Penalty
Summary
Resident #1, admitted on 07/30/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia following cerebral infarction, and gastrostomy status, had physician orders for enteral feeding at 40 ml per hour for 12 hours via pump starting at 2000 and a water flush of 100 ml every 6 hours. During observation on 09/22/2025 at 8:40 a.m., Resident #1 was observed receiving continuous tube feeding of Isosource 1.5 at 40 ml/hr and a water flush at 100 ml/hr. The tube feeding bag and water flush bag were both observed dated 09/20/2025. During interview at 8:50 a.m., the ADON acknowledged that the tube feeding bag and water flush bag were dated 09/20/2025 and should have been changed daily.
Respiratory Supplies Not Changed or Stored Properly
Penalty
Summary
The facility failed to provide respiratory care in accordance with its policy and physician orders for four residents who received oxygen or nebulizer treatments. The facility’s Oxygen Administration policy stated oxygen cannula and tubing were to be changed within 7-10 days or if visibly soiled and stored in a covered device between uses. Resident #18, who had chronic respiratory failure with hypoxia and other chronic conditions, had an order for oxygen equipment changes every Sunday, but observations on 09/22/2025 showed oxygen in use via nasal cannula with no date on the tubing, and S3 Corporate Nurse confirmed the tubing should have been dated and was not. Resident #19, who had chronic respiratory failure with hypoxia, had an order for PRN ipratropium-albuterol nebulizer treatments, but observations showed the hand held nebulizer mask and tubing dated 09/0/08/2025 lying on a corner shelf and not stored in a covered device. Resident #44, who had COPD and chronic sinusitis, was observed with a nebulizer machine on the bedside table and the mask uncovered, and S3 Corporate Nurse confirmed it should have been bagged. Resident #75, who had COPD and other chronic conditions, had orders for nebulizer tubing and mask changes every Friday and bag changes every 30 days, but the nebulizer mask dated 09/08/2025 was observed lying uncovered on a roommate’s nightstand, and S10 LPN confirmed it should have been in a black bag labeled with the resident’s name.
Failure to Monitor Behaviors While Resident Received Antidepressants
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary drugs by not monitoring behaviors while the resident received antidepressant medications. The resident was admitted with a diagnosis of depression and the care plan identified antidepressant use related to depression, including monitoring for changes in behavior, mood, cognition, hallucinations, delusions, social isolation, suicidal thoughts, and withdrawal. Physician orders included Trazodone 100 mg via PEG tube at bedtime for major depressive disorder and Prozac 20 mg via PEG tube in the morning for major depressive disorder. Review of the resident’s September 2025 MAR did not show that behaviors were monitored while the resident was receiving the antidepressant medication. During interview, the ADON stated the resident had not been monitored for behaviors because he had not received a psychotropic, while acknowledging the resident was currently taking an antidepressant medication.
Failure to Obtain Informed Consent and Complete Quarterly Side Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails and did not conduct quarterly assessments for the risk of entrapment as required by its own policy. Specifically, for one resident with diagnoses including muscle wasting, chronic pain, osteoarthritis, and morbid obesity, the medical record did not contain evidence that a Side Rail Utilization Assessment had been completed quarterly. The facility's policy mandates that such assessments be performed upon admission, readmission, quarterly, or with significant changes, and that informed consent be obtained after discussing the risks and benefits with the resident or their representative. Observations confirmed that the resident was using bilateral hand assist rails during multiple surveyor visits, and interviews with the resident and the DON verified that the required assessment and consent process had not been completed as per policy. The resident, who was cognitively intact, reported using the rails for bed mobility, but documentation of the necessary assessment and consent was missing from the medical record.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the State Survey and Certification Agency. The facility's policy mandates timely reporting of suspected abuse to appropriate agencies, but this was not adhered to in the case of a resident who was allegedly kicked and cursed at by a CNA. The incident was reported internally on December 25, 2024, and an investigation was conducted, including interviews with the involved staff and witness statements. However, the facility did not notify the State Agency as required. The resident involved in the incident had a complex medical history, including severe cognitive impairment, neurocognitive disorder with Lewy Bodies, and other mental health conditions. The resident's MDS assessment indicated severely impaired cognition, which underscores the vulnerability of the resident. Despite the internal investigation and acknowledgment of the incident by the Director of Nursing, the failure to report the alleged abuse to the State Agency constitutes a deficiency in the facility's adherence to regulatory requirements.
Failure to Implement Incontinence Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and frequent bowel incontinence. The resident, who had a BIMS score of 2 indicating severely impaired cognition, was admitted with diagnoses including schizoaffective disorder bipolar type, Alzheimer's disease, history of falls, and osteoarthritis. The care plan required staff to check the resident every two hours for incontinence. However, a review of the facility's video footage revealed that a CNA entered the resident's room at 11:08 p.m. and did not return until 6:25 a.m. the following morning, indicating that the resident was not checked every two hours as required. Interviews with the facility's administrator and DON confirmed the lapse in care, acknowledging that no staff entered the resident's room during the specified time frame, thus failing to adhere to the care plan's intervention for incontinence management.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care for a resident who was unable to perform self-care due to a self-care performance deficit related to decreased vision and impaired balance. The resident, who was admitted with multiple diagnoses including muscle wasting, COPD, and anxiety, was cognitively intact with a BIMS score of 15. Despite having a care plan that required assistance with personal hygiene, the resident's fingernails were observed to be long and dirty. The resident expressed that he did not want long fingernails and had requested them to be trimmed a week prior. The Director of Nursing confirmed the observation that the resident's fingernails were dirty and needed trimming.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically in the case of one resident. The facility's Resident Rights Policy mandates that all residents be treated with kindness, respect, and dignity. However, the administrator's interaction with a resident did not adhere to this policy. The resident, who was cognitively intact and receiving oxygen therapy and hospice care, reported feeling fearful and threatened after an encounter with the administrator. The resident expressed a desire to leave the facility due to the administrator's rude behavior. The incident involved a discussion about the resident's payment process, during which the administrator threatened to notify Adult Protective Services (APS) if the resident's funds were not used to pay his bill. This threat left the resident visibly shaken and adamant about leaving the facility, as confirmed by multiple staff members. The administrator acknowledged making the statement about contacting APS if the payment was not made, which contributed to the resident's distress and feeling of unsafety.
Failure to Ensure Resident's Right to Be Free from Unnecessary Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. Specifically, the facility did not complete a side rail utilization assessment, obtain consent for the use of side rails, or secure a physician's order for the use of bedrails for Resident #360. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully and must be based on a physician's order with consent from the resident or their representative. Resident #360, who was admitted with severe cognitive impairment and a high risk for falls, was observed with bilateral upper side rails in use without the necessary assessments or orders. Despite the resident's dependency on staff for mobility and the absence of an indication for side rails for mobility assistance, the side rails were used, effectively acting as a restraint. Interviews with facility staff confirmed the lack of a physician's order, side rail assessment, and consent for the use of side rails, acknowledging that the side rails were used as a restraint.
Failure to Ensure Proper Use and Maintenance of Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for several residents, as evidenced by the lack of assessments, informed consents, and physician orders. The facility's policy requires a thorough assessment of residents for the use of side rails, obtaining informed consent, and ensuring physician orders are in place. However, for 11 out of 17 residents investigated, these steps were not followed, leading to deficiencies in compliance with the facility's guidelines and regulatory requirements. For instance, Resident #3, who has multiple diagnoses including hemiplegia and schizophrenia, had side rails raised without a documented assessment or consent. Similarly, Resident #17, diagnosed with Alzheimer's disease and a history of falls, had side rails raised without consent or documented checks for placement and functioning. These oversights were confirmed through observations and interviews with the facility's corporate nurse, who acknowledged the absence of necessary documentation and assessments. Other residents, such as Resident #23 and Resident #41, also had side rails raised without prior assessments or consents, and in some cases, without physician orders. The facility's failure to conduct quarterly assessments and obtain necessary consents and orders for the use of side rails was a recurring issue across multiple residents, indicating a systemic problem in adhering to the established protocols for the safe use of bed rails.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate during a medication pass observation. Two specific errors were identified. The first involved Resident #19, who was administered Fluticasone Propionate and Salmeterol 250mcg/50mcg by oral inhalation instead of the prescribed Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act. This discrepancy was confirmed by the LPN during an interview, who acknowledged that the medication administered did not match the physician's order. The second error involved Resident #93, who received one-half tablet of Metoprolol Succinate ER 25mg instead of the full tablet as prescribed for essential hypertension. The LPN and a Nurse Practitioner confirmed the error upon reviewing the medication card and physician's order. The Director of Nursing also verified that the medications administered to both residents did not align with the physician orders, contributing to the facility's medication error rate exceeding the acceptable threshold.
Inaccurate Payroll Submission for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. A review of the Payroll Based Journal (PBJ) report for the fiscal year 2024, 2nd quarter, revealed that excessively low weekend staffing was triggered. During interviews, the administrator and human resources personnel indicated that the corporate office is responsible for submitting the PBJ report. The administrator suggested that an agency invoice might have been missed or not available at the time of reporting. The human resources representative explained that when staffing agencies send staffing hours late, the reported staffing hours to the corporate office do not reflect the actual staffing levels, leading to an appearance of inadequate staffing.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring the call light was within reach. The resident, who was admitted with diagnoses including parkinsonism, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus, pain unspecified, restlessness and agitation, and insomnia, had a severe cognitive impairment as indicated by a BIMS score of 03. The resident required extensive assistance with bed mobility, transfer, and toilet use. On the morning of August 19, 2024, observations revealed that the resident's call light was placed on the bedside table, out of reach. During an interview, the resident confirmed the inability to reach the call light. Later, the resident was heard calling for help, and the call light was still observed to be out of reach. A CNA confirmed that the call light should not have been out of the resident's reach.
Failure to Investigate Resident-to-Staff Violence Incident
Penalty
Summary
The facility failed to comply with applicable Federal, State, and local laws, regulations, and codes by not investigating an incident involving resident-to-staff violence. The incident involved a resident who was cognitively intact and had a history of violent behavior, including bipolar disorder and anxiety disorder. On the night of the incident, the resident was observed yelling and using profanity in the hallway. When approached by an LPN, the resident pushed the LPN and slammed the door. Despite this, the facility did not complete an incident report or conduct an investigation as required by their Workplace Aggression/Violence Policy. The facility's policy mandates that all employees report any threats or violent acts, which include verbal or physical harassment and threats, to the appropriate supervisor or HR Director. However, the Director of Nursing (DON) did not consider it necessary to write an incident report after seeing the progress note in the resident's medical record. Additionally, the facility's Administrator did not review the camera recording of the incident, and the recording was no longer available. This lack of action and documentation indicates a failure to adhere to the facility's policy and ensure a safe environment for both staff and residents. Interviews with staff revealed that the incident was not reported to the facility's Corporate Compliance Officer, as it was not considered an incident but rather a behavior. The resident's behavior was notably above baseline, and the resident was later transferred to a Behavioral hospital with police assistance. The facility's failure to investigate and report the incident demonstrates non-compliance with their own policies and regulatory requirements, compromising the safety and well-being of both staff and residents.
Failure to Ensure Resident Safety and Accessibility
Penalty
Summary
The facility failed to ensure that Resident #3 was free from accidents and hazards. Resident #3, who has multiple diagnoses including muscle wasting, gait and mobility issues, anxiety disorder, and heart failure, was observed multiple times with their bed in a high position and the call bell out of reach, despite physician orders and a comprehensive care plan specifying the use of a low bed and fall mats. On several occasions, the call bell was found hanging off the side of the bed, wrapped around the assist rail, or on the floor, making it inaccessible to the resident. These observations were confirmed by a Restorative Aide who acknowledged that the bed should be lowered and the call bell should not be on the floor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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How nearby facilities compare on the same public inspection record.
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| Southern Hills Healthcare And Rehabilitation | 0.1 mi | ★★★★★ | 3 | 0 |
| The Guest House Skilled Nursing Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Heritage Manor South | 1.9 mi | ★★★★★ | 4 | 0 |
| Garden Park Nursing & Rehab Ctr, Llc | 2 mi | ★★★★★ | 9 | 0 |
| Spring Lake Skilled Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 5 | 0 |
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