Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Place Care Center during CMS and state inspections, most recent first.
The facility failed to properly manage resident trust funds by making multiple unauthorized online retailer purchases from the accounts of several residents with conditions such as CHF, Alzheimer’s disease, aphasia, epilepsy, ESRD, anxiety disorder, and type 2 DM, including both cognitively intact and cognitively impaired individuals who required staff assistance with ADLs. For each affected resident, fund statements showed specific debits that were not signed or authorized by the resident or a representative, despite a facility policy requiring signed vouchers or check request forms and invoices for withdrawals. In addition, the facility did not document that quarterly resident fund statements were provided to residents or their representatives for two consecutive quarters, and the Administrator confirmed both the unauthorized transactions and the absence of quarterly statements during interviews.
Surveyors found that the facility did not notify multiple Medicaid residents or their representatives when resident trust fund balances approached the SSI resource limit, as required. Review of medical records and quarterly fund statements showed that several residents with conditions such as CHF, Alzheimer’s disease, diabetes, epilepsy, ESRD, anxiety disorder, and prior CVA, ranging from cognitively intact to severely impaired and all needing ADL assistance, had account balances between roughly $1,600 and $7,400 over several quarters. Despite these balances reaching the point at which notification is mandated, there was no documentation that any notifications were provided, and the Administrator confirmed that such notifications had not been made.
Multiple residents with cognitive impairment and complex medical conditions had their trust fund accounts used by former administrative and activities staff to make unauthorized online purchases of clothing, electronics, snacks, personal care items, and activity supplies. Required documentation and signatures authorizing withdrawals were absent, and some residents reported not requesting or receiving the items, while searches showed that certain items were missing or located in the activities department instead of with the residents. Former staff reported that they were informed when Medicaid residents’ balances exceeded allowable limits and then ordered items from an online retailer based on lists or general discussions, but without proper consent from residents or their representatives, resulting in misappropriation of resident funds and belongings.
The facility failed to timely report multiple instances of misappropriation of resident trust funds, where several cognitively impaired and cognitively intact residents had unauthorized online purchases made from their accounts by former business office, activities, and social services staff. Items such as clothing, electronics, personal care products, snack foods, and dementia activity supplies were ordered without resident or representative consent, often without required documentation or signatures, and some items were never received by the residents and were instead found in the activities department. An activities staff member observed large quantities of goods ordered under resident accounts being stored and used in the activities area, suspected misappropriation, but did not report these concerns to the Administrator, DON, or corporate office, contributing to delayed reporting of these abuse allegations to the state agency as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of misappropriation of resident funds involving several cognitively impaired and cognitively intact residents. Unauthorized online purchases were made for clothing, electronics, snacks, personal care items, and activity supplies using resident trust accounts without resident or representative consent, and documentation of these purchases was absent from medical records. Some items bought with resident funds were not received by the residents and were instead found in the activities department or could not be located. Former business office, activities, and social services staff, as well as facility leadership, had access to and approved these orders, yet not all potential perpetrators were investigated, and suspicions raised by a staff member were not promptly reported to administration or corporate leadership, contrary to facility policies requiring resident authorization and thorough investigation of misappropriation.
A resident with multiple chronic conditions had a physician order indicating DNRCC status, but no signed DNR/DNRCC form was present in the chart for more than a month after admission. When the resident was sent to the hospital by EMS, an RN informed EMS of the DNRCC status and provided a face sheet reflecting this, but could not supply the required state DNR form signed by a physician. EMS staff confirmed they did not receive the necessary documentation and therefore treated the resident as full code during transport, contrary to the facility’s own advanced directives policy that requires providing EMS with a copy of the resident’s advance directive.
A resident with severe cognitive impairment, dementia, DM II, and epilepsy had persistent dental pain with screaming, finger chewing, drooling, spitting out meds, and markedly decreased PO intake. Staff documented presumed tooth infection and weight loss, and the resident was started on Augmentin, but the dental consult was delayed for months while the resident continued to lose weight and show signs of severe decay and pain. Interviews confirmed multiple staff had reported the issue, and the NP stated the behaviors were indicative of dental pain.
A resident’s request for milk at mealtime was not honored when a CNA said none was available, did not check further, and did not contact the kitchen. The resident stated he requested milk daily and usually did not receive it as requested, despite the facility policy requiring alternate beverage selections to be provided in a timely manner.
Improper food handling and unsafe storage of resident eggs. A food service employee handled food with bare hands while preparing trays, including repositioning cooked vegetables and placing sliced bread by hand, despite staff confirming bare-hand contact was not allowed. A resident with paraplegia and protein malnutrition received boiled eggs on breakfast and lunch trays, but the eggs and meal trays were left unrefrigerated for extended periods and multiple bowls of eggs were observed stored on a dresser and hallway railing over several days. Staff and the RD stated the eggs and meals should not remain unrefrigerated for that long.
Food was not served in an appetizing manner when tacos on a test tray and resident trays were wrapped in foil with liquid pooled inside and under the plate, leaving the tortillas wet, soggy, greasy, and difficult to eat. Two residents reported the tacos were unpalatable, and a DM verified the liquid altered the texture of the tortillas.
Resident Council Concerns Not Addressed: A facility failed to document or discuss resolutions to repeated concerns raised in Resident Council meetings about food, nursing care, housekeeping, and maintenance. An AD stated there was no evidence the concerns were acted on by department staff, and five residents reported the same issues were brought up across multiple meetings without resolution feedback.
Quarterly care conferences were not held for several residents, and care plans were not updated when residents had significant changes in condition. Residents with diagnoses including COPD, ESRD, DM II, Alzheimer’s disease, dementia, and other chronic conditions had missed care conferences across multiple quarters, and two residents had significant weight loss without timely nutrition care plan updates. An RD and SSD verified the missed conferences and the lack of care plan updates.
An LPN administered oral meds in an unsanitary manner by touching pills with contaminated gloves and handling a water cup in a way that could contaminate it. Staff also failed to follow ordered transmission-based precautions for residents on EBP, neutropenic precautions, and contact precautions, including not wearing gowns and not performing hand hygiene. In addition, CNAs delivered meal trays, assisted with setup, and answered call lights without performing hand hygiene between residents.
Failure to Notify Ombudsman of Hospital Discharges: The facility did not notify the Ombudsman's Office after three residents were discharged to the hospital. The affected residents included one with intact cognition, one with impaired cognition and extensive ADL assistance needs, and one with severe cognitive impairment and multiple chronic conditions. Staff and the Administrator confirmed there were no records of the required notifications.
Failure to provide ordered tube feedings for a resident with severe cognitive impairment, DM2, and a G-tube. The resident had a physician order for supplemental Jevity 1.5 Cal when meal intake was below 75%, but the MAR showed missed tube feedings on multiple dates, and the RD verified the omissions.
Failure to document offering a pneumococcal vaccine to a resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and DM2. The medical record lacked evidence that the resident or the resident's representative was contacted for consent, and the DON confirmed the missing documentation. The facility policy stated residents were to be assessed for pneumococcal vaccine eligibility and offered the vaccine series when indicated.
The facility failed to notify the physician and responsible parties of significant weight loss for two residents and failed to notify a POA of a new shingles diagnosis and change in condition for another resident. One resident with dementia and multiple chronic conditions had repeated documented weight loss triggers, another resident with severe cognitive impairment and a feeding tube had a significant weight loss, and a third resident with intact cognition had shingles without documented POA notification. The RD and NP acknowledged the missed notifications, and the facility policy required prompt notification of the attending physician and resident representative.
Failure to provide needed personal care and ADL assistance: two residents had excessively long fingernails with unknown brown material underneath, and both indicated they wanted nail care; CNA verification confirmed the need. A third resident, dependent for hygiene and personal care with COPD and DM2, had multiple missed shower entries on the shower record, and the Administrator verified the missing documentation.
A resident with multiple chronic diagnoses and intact cognition did not receive ordered Ambien at bedtime on several nights. Review of the med record, controlled drug record, resident interview, and LPN/RN verification showed the medication was not signed out as administered and tablets remained in the blister pack, despite the physician order and facility policy requiring meds to be given as ordered.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital without her DNRCC-Arrest paperwork due to a malfunctioning printer. Despite notifying the hospital of her code status, the EMS run report indicated no documentation was provided, leading to the resident being intubated against her pre-existing code status.
Unauthorized Use and Poor Accounting of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to properly manage resident personal funds, including making unauthorized purchases from resident trust accounts and failing to provide required quarterly account statements. For multiple residents, surveyors identified debits to online retailers that were not signed or authorized by the residents or their representatives, despite facility policy requiring such authorization via vouchers or check request forms. The facility also did not document that quarterly resident fund statements were sent to the residents or their representatives for the fourth quarter of 2025 and the first quarter of 2026. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs. This resident’s fund statement showed debits for online retailer purchases in specific amounts on two dates, and the resident’s representative had not authorized these transactions. The Administrator verified that these purchases were made from the resident’s funds without authorization and confirmed that quarterly statements for the relevant quarters had not been provided to the resident or representative. Another resident, cognitively intact with type 2 diabetes mellitus, PTSD, and osteoarthritis, had a substantial increase in account balance over a quarter, yet there was no documentation that quarterly statements were sent, which the Administrator also confirmed. Additional residents with varying levels of cognitive impairment and medical conditions, including type 2 diabetes mellitus, pulmonary hypertension, generalized anxiety disorder, epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, and Alzheimer’s disease, were similarly affected. Their quarterly fund statements showed multiple debits to an online retailer on various dates and in specific amounts, none of which were signed or authorized by the residents or their representatives. For each of these residents, record review showed no documentation that quarterly statements for the fourth quarter of 2025 or the first quarter of 2026 were sent, and in interviews, the Administrator consistently verified both the unauthorized nature of the purchases and the failure to provide the required quarterly statements. Review of the facility’s undated Resident Trust Funds policy showed that resident fund withdrawals were supposed to be supported by signed vouchers or check request forms and invoices, which was not followed in these cases. Across all six residents reviewed for this issue, the survey findings demonstrated that the facility did not maintain resident fund accounts using basic accounting principles as required by its own policy. Unauthorized online purchases were repeatedly charged to resident accounts without the required signatures or documented consent, and there was a systemic lack of documentation that quarterly fund statements were provided to residents or their representatives for two consecutive quarters. These actions and omissions formed the basis of the cited deficiency related to the management and safeguarding of resident personal funds.
Failure to Notify Medicaid Residents of Trust Fund Balances Near SSI Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify Medicaid residents or their representatives when resident trust fund balances approached the Supplemental Security Income (SSI) resource limit. Surveyors reviewed medical records, resident fund account statements, and conducted staff interviews, and determined that six of seven sampled residents with Medicaid payor sources did not receive required notifications when their account balances reached $200 less than the SSI resource limit. There was no documentation of such notifications in the records for these residents, despite quarterly fund statements showing balances at or above the threshold. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs; this resident’s account balance during one quarter ranged from $2270.97 to $1888.16 without any documented notification. Another resident with type 2 diabetes mellitus, PTSD, and osteoarthritis, who was cognitively intact but required ADL assistance, had a quarterly account balance that increased from $1750.26 to $7395.49, again with no documentation of notification when the balance reached the required threshold. A third resident with type 2 diabetes mellitus, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and needed ADL assistance, had a quarterly balance that decreased from $2193.82 to $1618.38, with no evidence of notification at the appropriate point. Additional residents with epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, type 2 diabetes mellitus, Alzheimer’s disease, and congestive heart failure were also affected. These residents ranged from cognitively intact to severely cognitively impaired and all required assistance with ADLs. Their quarterly resident fund statements showed balances between approximately $1600 and nearly $5000 over multiple quarters, yet there was no documentation that they or their representatives were notified when their balances reached $200 less than the SSI resource limit. In an interview, the Administrator confirmed that the facility had not provided the required notifications for these residents when their resident fund accounts reached the specified threshold.
Misappropriation and Unauthorized Use of Resident Trust Funds for Online Purchases
Penalty
Summary
The deficiency involves the misappropriation and unauthorized use of resident trust funds and belongings by former facility staff, including the former Business Office Manager (BOM), former Activities Director (AD), and former Social Services (SS) staff. Facility records showed that multiple residents had debits from their resident fund accounts for online retailer purchases that were not authorized by the residents or their representatives, and required documentation such as signed vouchers or check request forms was absent. The facility’s own abuse policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the documented actions of staff met this definition. One resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, had several online purchases charged to her resident funds account, including clothing and snack items, without authorization from her representative. Progress notes contained no documentation of these purchases by the former BOM, AD, or SS. The resident later confirmed that items had been purchased using his account and that he believed a television had been ordered but never received. The Administrator confirmed that the former AD made unauthorized online purchases from this resident’s account and that the facility could not verify that all items, including a cowboy outfit and other clothing, were provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional supplements. These purchases were not documented in progress notes and were not authorized by the resident or her representative. The resident reported that a cart of items was brought to her, including a new tablet and clothing she had not requested, and that she sent the items back. The Administrator verified that the former SS placed a substantial order under this resident’s name with the intent that the cost be withdrawn from her account, despite the lack of authorization. A resident with type 2 diabetes, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and required ADL assistance, had debits from his funds account for hearing aids and a television purchased through an online retailer. His representative had not authorized these purchases, and there was no documentation in progress notes of such purchases by the former BOM, AD, or SS. The Administrator confirmed that the former BOM and former AD used this resident’s funds to buy hearing aids and a television without authorization and that the television purchased for the resident was not in his possession and was suspected to be elsewhere in the facility. Another resident with epilepsy, end-stage renal disease, and aphasia following cerebral infarction, who was severely cognitively impaired and dependent for ADLs, had multiple online retailer debits from his resident funds account that were not authorized by his representative. Items purchased included a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks. There was no documentation in progress notes of these purchases by the former BOM, AD, or SS. The Administrator confirmed that these items were purchased without authorization, and a search of the resident’s room with his permission revealed that some of the items ordered were not present. A further resident with Alzheimer’s disease, congestive heart failure, and type 2 diabetes, who was severely cognitively impaired and required ADL assistance, had multiple unauthorized debits from his resident funds account for online purchases. Items included cologne, boys’ pajamas, slippers, socks, various snack foods, soda, a record player, dementia activity items, televisions, a fidget blanket, and a music set. The resident’s representative had not authorized these purchases, and there was no progress note documentation by the former BOM, AD, or SS. A search of the resident’s room showed that some items were missing and some were found in the activities department. The Administrator verified that the former BOM and former AD used this resident’s funds to purchase these items without authorization. Interviews with former staff clarified how these actions occurred. The former BOM stated that she informed the former AD and former SS when Medicaid residents’ account balances exceeded $2000 and needed to be spent down, and that some items purchased were used by the activities department. She reported that the former AD and former SS would talk with residents about their needs and interests and then order items from the facility’s online retailer account. The former AD stated that he placed online orders as directed by the Administrator and former BOM, based on lists of items they provided that were said to be derived from conversations with residents. Across the affected residents, required authorization from residents or their representatives was not obtained, documentation in the medical record was lacking, and some purchased items were not in the residents’ possession, constituting misappropriation of resident funds and belongings. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that residents be free from misappropriation of property. Despite these policies, the documented practice involved staff initiating and completing purchases using resident funds without the necessary signatures or clear consent, and in some cases items were used by the activities department or not located with the resident. These actions and omissions led to substantiated findings of misappropriation of resident funds for several residents, as documented in the facility’s self-reported incidents and confirmed by the Administrator.
Failure to Timely Report Misappropriation of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of misappropriation of resident funds to the proper authorities, despite multiple instances where resident trust accounts were used without authorization. For one resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed debits for online purchases that were not authorized by the resident’s representative. Items such as a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit, and a sweatshirt were charged to this resident’s account, and documentation of these purchases by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff was absent from the medical record. The resident later confirmed that items had been purchased using his funds and that he believed a television had been ordered but never received. Another resident, cognitively intact but requiring assistance with ADLs and diagnosed with type 2 diabetes mellitus, PTSD, and osteoarthritis, had large online purchases made in her name, including a tablet, tablet keyboard, clothing, personal care items, and other supplies totaling thousands of dollars. These purchases were made by former SS staff without authorization from the resident or her representative, and there was no documentation of these purchases in the progress notes. The resident reported that a cart of items was brought to her, including a tablet and clothing she had not requested, and that she sent the items back. The Administrator later verified that the purchase was made with the intent to withdraw the full amount from the resident’s account, even though the account had not yet been charged at the time of the initial internal review. Additional residents with varying levels of cognitive impairment and dependence for ADLs also had unauthorized online purchases made from their trust accounts. One moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had hearing aids and a television purchased without representative authorization, and the television could not be located. Another severely cognitively impaired resident with epilepsy, end-stage renal disease, and aphasia had multiple clothing and personal items ordered without authorization, with some items not found in his room. A further severely cognitively impaired resident with Alzheimer’s disease, congestive heart failure, and diabetes had numerous items such as cologne, boys’ pajamas, slippers, socks, snack foods, televisions, a record player, dementia activity items, and other products purchased without authorization, with some items missing and some found in the activities department. Interviews with former BOM and AD staff revealed that they used resident funds, including for Medicaid residents over the $2000 resource limit, to order items via an online retailer, and that some items purchased under resident accounts were kept and used in the activities department rather than being provided to the residents. An activities staff member reported she suspected misappropriation when large quantities of items ordered under resident accounts were stored in the activities room and not delivered, but she did not report these suspicions to the Administrator, DON, or corporate office, contributing to the facility’s failure to timely report the misappropriation allegations as required by its abuse policy. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that misappropriation of resident property be reported to the state agency within required timeframes. Despite these policies, multiple residents’ accounts showed unauthorized debits for online purchases without the required signatures or documentation, and staff interviews confirmed that items were ordered and sometimes used for general activities rather than for the specific residents whose funds were charged. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because an activities staff member did not escalate her suspicions of misappropriation to facility leadership, resulting in delayed recognition and reporting of the misappropriation of resident funds.
Failure to Thoroughly Investigate Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of misappropriation of resident funds, including failure to investigate all alleged perpetrators. For one resident with CHF, Alzheimer’s disease, and aphasia who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed unauthorized debits to an online retailer, including purchases of clothing and snack items. The resident’s representative did not authorize these purchases, and there was no progress note documentation by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff regarding these transactions. Online retailer receipts showed that the former AD made several purchases under the resident’s name, and the Administrator later confirmed that items such as a cowboy outfit and other clothing could not all be verified as having been provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional products. The quarterly fund statement reflected significant activity, and receipts showed that the former SS used the resident’s funds for these items without authorization from the resident or her representative. The resident reported that a cart of items was brought to her, that she had not requested them, and that she sent them back, including a tablet when she already had one. The Administrator confirmed that the former SS placed a large order under this resident’s name without authorization and that the purchase was made with the intent that the cost be withdrawn from the resident’s account. A moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had unauthorized online retailer debits for hearing aids and a television, with no documentation in progress notes by the former BOM, former AD, or former SS. Receipts showed the former AD purchased hearing aids and the former BOM purchased a television using the resident’s funds, and the Administrator confirmed these purchases were unauthorized and that the television’s location was unknown. Another severely cognitively impaired resident with epilepsy, ESRD, and aphasia had unauthorized debits for clothing and personal items, with no documentation of purchases in the medical record. Receipts showed the former BOM and former AD purchased multiple clothing items and labels using the resident’s funds without authorization, and some items could not be found in the resident’s room. A further severely cognitively impaired resident with Alzheimer’s disease, CHF, and diabetes had multiple unauthorized online purchases for televisions, snacks, clothing, activity items, and other goods, with no documentation by the former BOM, former AD, or former SS. Receipts showed the former BOM and former AD used this resident’s funds for numerous items, some of which were later found stored in the activities department rather than with the resident. Interviews with former and current staff revealed that the former BOM, former AD, and former SS were involved in directing and placing orders using resident funds, including for residents on Medicaid who were over the $2000 resource limit, and that some items purchased with resident funds were used by the activities department. The former BOM stated that the Administrator was aware of and approved all online orders, and the former AD stated he ordered items as directed by the Administrator and former BOM. The current AD reported that the former AD told her he would order items for one resident using another resident’s funds and that numerous snack and activity items ordered under resident fund accounts were kept in the activities room and never delivered to residents; she discussed her suspicions with other staff but did not report them to the Administrator, DON, or corporate office. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because the AD did not report her suspicions, and leadership interviews confirmed that the Administrator and a corporate clinical operations leader had access to and approved online orders but were not fully investigated as potential perpetrators. The facility’s own policies required resident or designee signatures for fund disbursements and mandated thorough investigation and timely reporting of misappropriation, which did not occur in these cases.
Failure to Provide Required DNRCC Documentation to EMS During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to properly implement and document a resident’s do not resuscitate comfort care (DNRCC) status and provide the required documentation to EMS during transfer. The resident was admitted with multiple diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, type 2 diabetes mellitus, and encephalopathy, and was documented as cognitively intact and needing assistance with ADLs. A physician’s order dated 03/02/26 indicated the resident’s code status as DNRCC, but review of the medical record from admission through 04/03/26 showed there was no DNR or DNRCC form signed by a physician in the chart. The medical record also did not contain a DNRCC form, despite the code status order. On 04/03/26, a nurse received an order to send the resident to the hospital via EMS and called 911; EMS transported the resident. The EMS run report documented that facility staff stated the resident’s code status was DNRCC, but they were unable to provide a DNRCC form to accompany the resident. Interviews with the RN who arranged the transfer and with two paramedics confirmed that the facility did not have a signed DNRCC form on file to give to EMS, and that only a face sheet indicating DNRCC status was provided. EMS personnel reported that, without the required state DNR form signed by a physician, they were required to treat the resident as full code during transport and upon hospital admission. Review of the facility’s Advanced Directives policy showed that the nurse supervisor was required to inform EMS of a resident’s advanced directive and provide a copy of the directive, which did not occur in this case.
Delayed Dental Care and Pain Management
Penalty
Summary
The facility failed to ensure prompt dental services for a resident with vascular dementia, DM II, major depressive disorder, epilepsy, and severe cognitive impairment. The resident was nonverbal and required assistance with ADLs, had a feeding tube and mechanically altered diet, and had been ordered PRN Tylenol for pain. On 06/19/25, the resident spent most of the shift screaming loudly in the common area and could not be redirected. The next day, oral intake decreased, and over the following days meal intake dropped further from prior 100 percent intake to 26 to 50 percent, then 0 to 25 percent, with continued poor intake thereafter. On 06/25/25, nursing documented continued behaviors including not eating, biting her fingers, and spitting out medications, and the resident was started on Augmentin for a presumed tooth infection. The June MAR showed no Tylenol administered for dental pain, and the July MAR showed Tylenol given only once. By 07/07/25, staff reported the resident had not been eating for three weeks due to tooth pain, had lost weight from 142.4 pounds to 134 pounds, and continued to show behaviors such as holding her cheek, biting her thumb, and drooling. On 07/15/25, the resident had lost 10.4 pounds, a 7.3 percent loss in one month, was only eating chocolate chip cookies and taking sips of supplement, and a dental consultation was ordered for oral surgery to extract teeth with severe decay and infection. The dental appointment process was delayed, with an outside dental provider not contacted until 07/15/25 and the consult not scheduled until 10/03/25. In September, the guardian canceled one appointment because the resident would not cooperate without sedation, and later declined to complete consent paperwork at the facility. During observation on 09/23/25, the resident was seen chewing on her fingers and eating less than 50 percent of lunch, and on 09/24/25 her teeth appeared rotten with decay and receding gums. Staff interviews confirmed that CNA, ST, and RD had reported the resident's dental pain and decreased intake, and the NP stated she had not been notified of ongoing dental pain but verified the resident's behaviors were indicative of dental pain.
Failure to Honor Resident Beverage Preferences
Penalty
Summary
The facility failed to ensure beverage preferences and requests were honored for Resident #16, who repeatedly requested milk with meals. During lunch tray delivery, a CNA brought the tray to the resident’s room, and when the resident asked for milk, the CNA stated there was no milk in the refrigerator and did not look for it or call the kitchen. The CNA confirmed that if the resident was supposed to have milk, it would have been on the tray. The resident later stated he did not receive the milk he requested at lunch the prior day and said he requested milk daily but usually did not receive it as requested. Review of the facility policy titled Dining and Food Preferences stated that during meal service, residents who requested an alternate beverage selection would be provided with the selection in a timely manner.
Improper Food Handling and Unsafe Storage of Resident Eggs
Penalty
Summary
Food was prepared and handled in a manner that did not follow professional standards when a food service employee used bare fingers to handle food on the tray line. During lunch tray preparation, the employee placed cooked peppers and onions on a plate and then used bare fingers to pick up a piece of onion hanging over the edge and repositioned it back onto the plate. The employee later placed sliced bread on a pan using bare hands. The Food Service Manager and District Manager both verified that staff should not handle food with bare hands, and the facility policy required proper glove use and serving utensils to prevent cross contamination. Resident #10 had diagnoses including paraplegia, osteomyelitis of vertebra, protein malnutrition, neuromuscular dysfunction of bladder, and injury of the lumbar spinal cord. The resident’s MDS showed intact cognition and that he required set up with ADLs. The meal ticket showed he received two boiled eggs on each breakfast and lunch tray. The resident stated he did not eat breakfast because he slept until noon, and that aides placed his bowls of boiled eggs on his dresser so he could eat them later. He also stated he did not eat lunch until around 4:00 P.M. and that the lunch tray was not removed until after that time. Surveyors observed multiple insulated bowls containing boiled eggs stored on the resident’s dresser and on a hallway railing, with dates spanning several days. The resident stated the eggs were from one to two days earlier and that he might eat them throughout the night. A CNA verified the bowls were not refrigerated and did not know how long boiled eggs could safely remain unrefrigerated. The DM stated boiled eggs could only be stored unrefrigerated in insulated bowls for no longer than two hours and could be refrigerated up to five days, and the RD stated that when the resident did not eat a meal when delivered, the meal should be refrigerated and reheated later. The facility policy stated eggs would be cooled to 70 degrees Fahrenheit within two hours of cooking.
Food Not Served in an Appetizing Manner
Penalty
Summary
Food was not served in an appetizing manner when a test tray and resident lunch trays contained tacos with liquid pooled under the plate and inside the foil wrapping. During observation, the tacos were wrapped in foil with a significant amount of liquid inside the foil, and the tortilla was saturated with liquid. The District Manager verified that the liquid in the foil altered the texture of the tortillas. Resident #86 was observed attempting to eat the tacos and had difficulty because the tortillas were wet and soggy, and the resident confirmed he could not eat them. Resident #16 later stated the tacos he received were greasy, there was liquid inside the foil pouch, he had to dry the taco with a napkin because it was soaked, and another part of the tortilla was too hard for him to chew. The facility policy stated food should be prepared to conserve nutritive value, flavor, and appearance and should be palatable and attractive.
Resident Council Concerns Not Addressed
Penalty
Summary
The facility failed to respond to and address resident concerns raised during Resident Council meetings. Review of the Resident Council meeting minutes for 03/19/25, 04/29/25, 05/28/25, 06/25/25, 07/30/25, and 08/28/25 showed repeated concerns involving food services for five of the six months reviewed, nursing care for four of the six months, housekeeping services for four of the six months, and maintenance services for two of the six months. The minutes did not contain documented notes showing the prior month’s concerns had been resolved or addressed. Interviews confirmed the lack of resolution feedback. The Activity Director stated he led the monthly Resident Council meetings but had no documented evidence that prior concerns were discussed as resolved or that the food service, nursing, housekeeping, or maintenance departments had acted on them. Five residents who regularly attended the meetings stated that concerns voiced in earlier meetings were not discussed as resolved in later meetings and that the same concerns were brought up during several meetings. The residents involved included one with anemia and intact cognition, one with Alzheimer’s disease and moderately impaired cognition, one with heart failure and moderately impaired cognition, one with COPD and moderately impaired cognition, and one with interstitial pulmonary disease and intact cognition.
Quarterly care conferences not held and care plans not updated for changes in condition
Penalty
Summary
The facility failed to ensure care conferences were held on a quarterly basis with the resident and/or representative, and failed to ensure care plans were updated in a timely manner. Review of medical records, care conference summaries, care plans, staff interviews, and policy showed this affected five residents reviewed for care plans: Residents #30, #07, #06, #03, and #55. The facility census was 75. Resident #30 was admitted with chronic respiratory failure with hypoxia, COPD, CHF, HTN, sleep apnea, and morbid obesity, and had intact cognition on the MDS. Care conference summary review showed no care conference was conducted in the first quarter of 2025, and the SSD verified this. Resident #07 was admitted with ESRD on hemodialysis, DM II, and a cerebral infarction with aphasia and left-sided hemiplegia, and had intact cognition on the MDS. Care conference review showed no conference was conducted in the second quarter of 2025, which the SSD also verified. Resident #06 was admitted with COPD, DM II, and major depressive disorder, had moderate cognitive impairment on the MDS, and had no care conference in the first quarter of 2025. Resident #03 was admitted with Alzheimer’s disease, obstructive hydrocephalus, DM II, morbid obesity, HTN, and CKD stage IV, and had no care conference in the second quarter of 2025. Resident #55, admitted with COPD, acute respiratory failure with hypoxia, and DM II, had intact cognition with a BIMS of 13 and had not had a care conference since 06/09/23. The facility also failed to update care plans when residents had changes in condition. Resident #19 had vascular dementia, DM II, major depressive disorder, and epilepsy, with severe cognitive impairment and a significant weight loss of 8.2 pounds, or 5.76%, from 06/22/25 to 07/06/25; the nutrition care plan was not updated after the weight loss, and the RD verified this. Resident #45 had DM II, depression, Alzheimer’s disease with behavioral disturbance, anxiety, and HTN, and experienced progressive weight loss from 190.8 pounds on 01/08/25 to 168.2 pounds on 09/08/25. The plan of care dated 04/16/25 identified nutritional risk, but there was no documented update for the recent significant weight loss. Weight notes on 07/03/25, 08/05/25, and 09/09/25 showed triggers for significant weight loss, and the progress notes did not document notification of the responsible party or physician. The RD verified the nutrition care plan had not been updated to reflect the weight loss.
Infection Control Lapses During Medication Pass, Precautions, and Meal Delivery
Penalty
Summary
Medication administration was not performed in a sanitary manner for a resident with chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, diabetes mellitus type 2, and moderate cognitive impairment who required staff supervision with ADLs. During observation, an LPN wearing gloves touched the medication cart and computer, opened a sealed pouch of individually packaged medications, and placed each pill into the palm of her gloved hand before putting it into a medication cup. The LPN then handled a water cup with the same gloved hand and passed it to the resident by pinching the cup with her thumb and index finger near the water inside. The LPN later confirmed her gloves were contaminated when she placed the oral medications in her hand and that she did not handle the water cup in a way that prevented contamination. Transmission-based precautions were not followed for three residents with physician-ordered precautions. One resident with vascular dementia, type 2 diabetes, major depressive disorder, epilepsy, severe cognitive impairment, weight loss, and a feeding tube had an order for Enhanced Barrier Precautions related to a g-tube and a history of MDRO infection, but there was no signage on the door and no PPE outside the room. A CNA provided hands-on care without donning a gown, and the CNA confirmed she had not worn a gown and had not seen the sign. Another resident with chronic pulmonary edema, hypertension, breast cancer, cerebral infarction, acute respiratory failure, and bone cancer had neutropenic precautions ordered, and although a sign was posted, a CNA exited the room wearing gloves and carrying soiled linen after providing peri care without washing hands or wearing a gown. A third resident with metabolic encephalopathy, open wounds, congestive heart failure, and type 2 diabetes had contact precautions ordered for VRE in the urine, with a sign and PPE bin outside the room, but two CNAs assisted the resident in the bathroom without wearing gowns. Hand hygiene was also not performed during meal tray delivery to three residents. Two CNAs delivered lunch trays, entered and exited the residents’ rooms, physically assisted with tray setup, and answered call lights without performing hand hygiene between residents or during that period. Both CNAs confirmed they did not perform hand hygiene while passing trays and assisting the residents. The facility policy stated hand hygiene should be used before and after contact with a resident and after contact with items in a resident’s room.
Failure to Notify Ombudsman of Hospital Discharges
Penalty
Summary
The facility failed to notify the Ombudsman's Office after residents were discharged to the hospital. This deficiency affected three of four residents reviewed for hospital discharge, including Resident #02, Resident #64, and Resident #19, in a facility with a census of 75. Record review showed Resident #02 was admitted to the facility and later discharged to the hospital twice, with diagnoses including surgical after care, dementia, diabetes, osteoarthritis of the left hip, peripheral vascular disease, and heart failure. The MDS comprehensive assessment dated 08/08/25 showed the resident had intact cognition. Record review showed Resident #64 was admitted to the facility and discharged to the hospital twice, with diagnoses including metabolic encephalopathy, arthritis, morbid obesity, urinary tract infection, chronic kidney disease, depressive disorder, heart disease, overactive bladder, diabetes, dysuria, and calculus of kidney. The MDS assessment dated 07/31/25 showed impaired cognition, partial assistance with hygiene, dependence on staff for toileting, and maximum assistance with mobility. Resident #19, admitted on 03/14/24, had diagnoses including vascular dementia, type II diabetes mellitus, major depressive disorder, and epilepsy, and was hospitalized through 08/11/25. The significant change MDS dated 07/23/25 showed severe cognitive impairment with a BIMS score of 2 and need for partial assistance with eating, transfers, and dressing, and substantial assistance with toileting and bathing. The SSD stated there was no evidence the Ombudsman's Office was notified for Resident #02 or Resident #64, and the Administrator verified there were no records of notification for Resident #19.
Failure to Provide Ordered Tube Feedings
Penalty
Summary
The facility failed to provide tube feedings as ordered for Resident #19, who had an admission date of 03/14/24 and diagnoses including vascular dementia, type 2 diabetes mellitus, major depressive disorder, and epilepsy. The resident's MDS assessment dated 07/23/25 showed severe cognitive impairment, partial assistance needed with eating, five percent or greater weight loss during the review period, and use of a mechanically altered diet supplemented with tube feedings. A physician order dated 08/28/25 directed that the resident receive a supplemental feeding via gastrostomy tube of Jevity 1.5 Cal, 237 milliliters if meal consumption was less than 75 percent. Review of the September 2025 MAR showed the resident did not receive the ordered tube feeding on 09/07/25, 09/10/25, and 09/12/25. During interview on 09/25/25 at 12:34 P.M., the RD verified that the resident did not receive the supplemental tube feeding as ordered on those dates.
Failure to Document Offering Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure residents were offered pneumococcal vaccines as required. For Resident #19, who was admitted on 03/14/24 with diagnoses including vascular dementia, type two diabetes mellitus, major depressive disorder, and epilepsy, the medical record and MDS assessment dated 07/23/25 showed severe cognitive impairment and a need for staff assistance with ADLs. Review of the medical record did not include documentation that the facility offered the resident, or contacted the resident's representative, for consent regarding a pneumococcal vaccination. During interview on 09/29/25 at 11:23 A.M., the DON confirmed the record lacked documentation of the facility offering the resident and/or reaching out to the resident's representative regarding consent for a pneumococcal vaccine. The facility policy titled Pneumococcal Vaccine dated October 2023 stated that all residents were to be offered pneumococcal vaccines and, when indicated, were to be offered the vaccine series within 30 days of admission.
Failure to Notify Physicians and Representatives of Significant Weight Loss and Condition Changes
Penalty
Summary
The facility failed to ensure that responsible parties and/or physicians were notified of significant weight loss for three residents reviewed for nutrition. Resident #45, who had diagnoses including type 2 diabetes mellitus, depression, Alzheimer's disease with behavioral disturbance, anxiety, and hypertension, had a series of documented weights showing a decline from 190.8 pounds to 168.2 pounds over several months. Progress notes documented triggers for greater than 5% weight loss in one month, 9% loss in three months, and greater than 10% loss in six months, but there was no documented evidence that the resident's responsible party or physician was notified. The resident's responsible party stated she had not been notified, and the RD stated she did not notify the responsible party and was not aware of anyone else doing so. The NP stated she had not been made aware of the weight loss and expected to be notified of residents with significant weight loss. Resident #61 had diagnoses including diabetes, depression, and unspecified diarrhea, and had a sister who was the POA and emergency contact. The record showed the resident was diagnosed with shingles and prescribed Benadryl for itching, but there was no documented evidence that the POA was notified of the new diagnosis or the change in condition. Nursing progress notes and an IDT meeting note also did not show that the POA had been notified. The resident stated she wanted her sister to be contacted if her condition changed, and the Regional Nurse verified there was no documentation of POA notification. The NP confirmed the new diagnosis and medication but stated she did not inform the family representative because nurses were to notify family representatives of condition changes and new diagnoses. Resident #19 had diagnoses including vascular dementia, type II diabetes mellitus, major depressive disorder, and epilepsy, and had severe cognitive impairment with a BIMS score of two. The resident required assistance with eating, transfers, dressing, toileting, and bathing, and the MDS indicated a 5% weight loss or more in the last month along with a feeding tube and mechanically altered diet. Weights showed a loss from 142.4 pounds to 134.2 pounds, equal to an 8.2-pound or 5.76% loss. The RD verified she did not notify the resident's guardian of the significant weight loss because she was not aware she was responsible for notifying families. The facility policy stated that the attending physician and resident representative would promptly be notified of a change in a resident's medical condition or status.
Failure to Provide Needed Personal Care and ADL Assistance
Penalty
Summary
The facility failed to provide needed personal care and assistance with activities of daily living for three residents reviewed for personal care. Resident #07, who had diagnoses including end stage renal disease with hemodialysis dependence, diabetes mellitus type II, and cerebral infarction with aphasia and left hemiplegia, was documented as dependent on staff for personal care and hygiene and had a care plan intervention for nail care as needed. During observation, the resident’s fingernails were excessively long, extended about one inch past the fingertips, and had an unknown brown material underneath them; the resident indicated a desire for the nails to be cut and cleaned. Resident #41, who had diagnoses including myocardial infarction, pulmonary edema, spinal stenosis, history of lumbar wedge fracture, and atherosclerosis of both legs, was also documented as dependent on staff for personal care and hygiene with nail care as needed in the care plan. Observation showed the resident’s fingernails were excessively long with an unknown brown material underneath and extended about one inch past the fingertips; the resident stated a desire for nail care. CNA #527 verified the condition of Residents #07 and #41 and the need for nail care. Resident #55, who had COPD, acute and respiratory failure with hypoxia, and type II diabetes mellitus, was documented as dependent on staff for hygiene and personal care, with care plan interventions for assistance with showers, personal hygiene, and ADLs. Review of shower sheets showed no documented showers on multiple dates, and the Administrator verified the missing documentation.
Failure to Administer Ordered Ambien
Penalty
Summary
The facility failed to administer Ambien as ordered for one resident. The resident was admitted with diagnoses including thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, acute and chronic respiratory failure with hypoxia, COPD, and hypertension. The MDS dated 08/20/25 showed intact cognition and need for staff assistance with ADLs. A physician order dated 09/02/25 directed Ambien 5 mg, one-half tablet by mouth at bedtime. Review of the controlled drug receipt/record disposition form showed Ambien was not signed out and documented as administered on 09/19/25, 09/22/25, and 09/23/25, and five tablets remained in the blister pack. The resident confirmed she had not received Ambien for three nights in the past week. An LPN observed that five tablets were still available in the blister pack and verified the medication had not been signed out on those dates. The RN/VPCO also verified the medication was not signed out and confirmed the resident had not been administered Ambien as ordered on those dates. The facility policy stated medications should be administered as ordered.
Failure to Provide DNR Documentation During Resident Transfer
Penalty
Summary
The facility failed to ensure a resident was adequately prepared for a transfer by not providing EMS and the hospital with the resident's code status and other pertinent information. The resident, who had severe cognitive impairment and multiple diagnoses including spinal stenosis, type 2 diabetes mellitus, Alzheimer disease, and hypertension, was found unresponsive in her room. Despite the facility staff calling 911 and notifying the hospital of the resident's DNRCC-Arrest status, the EMS run report indicated that no documentation or further information was provided. Consequently, the resident was transported to the hospital without her DNRCC-Arrest paperwork, leading to her being intubated against her pre-existing code status due to the lack of available information upon arrival at the hospital. Interviews with facility staff revealed that the failure to provide the necessary documentation was due to a malfunctioning printer, which prevented the staff from printing the resident's DNRCC-Arrest form and other pertinent information. The facility's policy required a transfer summary to be completed when a resident is transferred to the hospital, but this was not adhered to in this case. The hospital records confirmed that the resident was intubated and later had life support withdrawn once the appropriate paperwork was obtained and the family was contacted. This deficiency was investigated under Complaint Number OH00153365.
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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 Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkeley Square Retirement Cen | 0.8 mi | ★★★★★ | 6 | 0 |
| Westover Retirement Community | 1.1 mi | ★★★★★ | 6 | 0 |
| Jamestowne Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Golden Years Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Residence At Huntington Court | 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 July 2026) and official state health department websites.