Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Pavilion At Brmc, The during CMS and state inspections, most recent first.
The facility failed to ensure the attending physician documented required monthly visits with signed and dated progress notes for four residents. Records for residents with diagnoses including dementia, bipolar disorder, functional quadriplegia, conversion disorder, GERD, anxiety, and HTN showed extended gaps with no physician progress notes, and the NHA confirmed the missing documentation during interview.
Improper Storage of Treatment Ice Packs with Food: A CNA was observed confirming that two ice packs used for resident treatments were stored in the Third Floor freezer next to frozen microwave meals. The CNA stated that treatment ice packs should not be stored in the same unit with food.
MDS assessments were inaccurately coded for three residents regarding wander/elopement alarm use. Each resident had a physician order for a wanderguard bracelet to be worn at all times, and TARs showed staff checked bracelet placement every shift, but the MDS P0200E item was coded as Not Used instead of Used Daily. The RN Assessment Coordinator confirmed the coding error.
A resident with Alzheimer's and other health issues was left unattended in the bathroom during a shift change, despite requiring substantial assistance for toileting. The resident was later found on the floor with injuries, including a neck fracture. Staff interviews confirmed that leaving residents unattended in the bathroom was against facility practice.
A resident with Alzheimer's and other health issues was left unattended in the bathroom by a nurse aide during a shift change, despite requiring substantial assistance for toileting. The resident was later found on the floor with a neck fracture. Staff interviews confirmed the resident was left unattended, contrary to facility policy.
Missing Physician Progress Notes for Required Visits
Penalty
Summary
The facility failed to ensure that the attending physician documented required monthly visits by writing, signing, and dating a progress note for each visit for four of 14 residents reviewed. Facility policy stated that attending physicians were to visit residents once monthly and document a progress note related to the visit. Review of clinical records showed that Resident R1, who had diagnoses including dementia, Wernicke encephalopathy, and high blood pressure, had physician progress notes dated and signed on several dates, but the record lacked evidence of any physician progress notes between 10/23/24 and 7/16/25, a nine-month period. Resident R2, with diagnoses including bipolar disorder, obstructive and reflux uropathy, and functional quadriplegia, had a last physician progress note dated and signed on 9/28/25, with no evidence of any physician progress notes between that date and 4/23/26. Resident R6, diagnosed with conversion disorder, GERD, and high blood pressure, also had no physician progress notes between 9/18/25 and 4/23/26. Resident R30, with diagnoses including dementia, anxiety, and high blood pressure, had no physician progress notes between 6/17/25 and 4/23/26. During interview, the Nursing Home Administrator confirmed that the records for these residents lacked the required physician progress notes at the time of review.
Improper Storage of Treatment Ice Packs with Food
Penalty
Summary
The facility failed to maintain sanitary operations and food safety standards in one of two resident unit freezers reviewed on the Third Floor. During observation, two ice packs used for resident treatments were found stored in the freezer next to frozen microwave meals. During interview, a CNA confirmed that the ice packs used as treatments for residents were in the freezer with food and stated that ice packs used as treatments should not be stored in the same unit with food.
MDS Assessments Incorrectly Coded for Wander/Elopement Alarm Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the use of wander/elopement alarms for three of 14 residents reviewed. MDS instructions for section P0200E required all alarms used during the seven-day look-back period to be coded by frequency of use, including devices such as wanderguard bracelets worn by the resident. For Resident R1, who had diagnoses including dementia, Wernicke encephalopathy, and high blood pressure, the clinical record showed a physician’s order for a wanderguard bracelet to be worn at all times, and TARs for February 2025, August 2025, and March 2026 showed staff checked the bracelet placement every shift, yet quarterly MDS assessments for those periods coded P0200E as Not Used. Resident R6, who had diagnoses including conversion disorder, GERD, and high blood pressure, also had a physician’s order for a wanderguard bracelet to be worn at all times. TARs showed the bracelet placement was checked every shift during February 2025, portions of August 2025, and February 2026, but the quarterly, significant change, and quarterly MDS assessments for those periods coded P0200E as Not Used. Resident R10, who had diagnoses including dementia, diabetes, and high blood pressure, had a physician’s order for a wanderguard bracelet to be worn at all times, and TARs showed the bracelet placement was checked every shift during September 2025 and March 2026, but the quarterly MDS assessments for those periods also coded P0200E as Not Used. During interview, the RN Assessment Coordinator confirmed the MDSs for these residents were coded incorrectly and should have been coded as Used Daily.
Resident Neglect Due to Unattended Bathroom Incident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R5, was free from neglect during care. Resident R5, who had a history of Alzheimer's Disease, major depressive disorder, seizures, muscle weakness, hearing loss, chronic pain, history of falling, age-related physical debility, and macular degeneration, required substantial assistance for toileting. The resident's care plan indicated a need for extensive assistance from one to two staff members for toilet use and transfers. On the day of the incident, a Nurse Aide (NA) assisted Resident R5 to the restroom and left the resident unattended on the toilet during a shift change. The NA informed the incoming staff that Resident R5 was in the bathroom and needed assistance but then left the facility. The incoming staff acknowledged the information but did not immediately assist the resident. As a result, Resident R5 was found on the bathroom floor with bruising and a swollen knee, and was later diagnosed with a type 2 dens fracture. Interviews with staff confirmed that it was not the practice to leave residents unattended in the bathroom, and that staff should monitor residents for safety. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the resident was left unattended, leading to the fall and subsequent injury. The facility's policies on resident care and fall prevention were not adhered to, resulting in neglect of Resident R5's needs.
Plan Of Correction
What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? On 9/27/24, The DON (Director of Nursing) met with Employee 1, Employee 2 and the staff on 2nd floor and educated them not to leave Resident R5 on the toilet unattended. The residents care plan was reviewed and updated to reflect new toileting status. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents with a BIMS (Brief Interview for Mental Status) of less than eight (8) have the potential to be impacted. On 10/16/2024 the facility completed staff training regarding the safety risks associated with leaving residents unattended while on the toilet. A whole house resident BIMS audit was completed by the DON on 12/17/2024 to identify residents considered to have severe impairment (a BIMS score of 0-7). Any current resident, new admissions, or resident reviewed during the care planning process identified with a BIMS of 0-7 will have their care plans updated to reflect supervision while on the toilet. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The facility will identify those residents with severe impairment and the DON will place a GOLD star on the nameplate outside of the resident room and with a GOLD star above the resident bed. The facility will update the Fall Prevention and Investigation Policy to reflect the addition of the star. Whole house staff education on the change will be completed by the DON. The updated fall policy will be reviewed during our New Employee Orientation. The facility will continue to monitor its fall prevention program during weekly fall prevention meetings to ensure proper fall prevention procedures are in line with the facility fall protocol to include utilizing the stars on the door nameplate and above the headboard. The facility will continue to provide staff education on Abuse, Neglect, Exploitation and Misappropriation of Property through our online education portal while also offering an in-person Abuse education on January 14th, 2025 provided by the Pavilion's Social Service Director and on February 25th, 2025 with the Department of Human Services Area Agency on Aging. How the corrective action will be monitored to ensure that the deficient practice will not recur: i.e., what quality assurance programs will be accomplished? The prior week's resident fall event reports will be audited at the weekly fall prevention meeting to assess for resident care plan compliance and if modifications are needed. Audit results will be reported at the facility Quality Assurance Performance Improvement and Kaleida Health Quality Improvement Patient Safety monthly committees. Weekly audits will continue until 12 consecutive weeks of 90% compliance has been achieved. Modification may be made to the plan of correction to improve compliance. Changes will be reported to the facility QAPI monthly meeting.
Resident Left Unattended in Bathroom Resulting in Fall and Neck Fracture
Penalty
Summary
The facility failed to provide adequate supervision for a resident during toileting, resulting in a fall and a fracture of the neck. The resident, who had a history of Alzheimer's Disease, major depressive disorder, seizures, muscle weakness, hearing loss, chronic pain, history of falling, age-related physical debility, and macular degeneration, required substantial assistance for toileting. Despite these needs, the resident was left unattended in the restroom by a nurse aide during a shift change. The incident occurred when the nurse aide assisted the resident onto the toilet and then left the resident unattended, informing the incoming staff that the resident was in the bathroom and needed assistance. The incoming staff acknowledged this information, but the resident was later found on the floor by another nurse aide, having sustained bruising and a significant neck injury. The resident was subsequently sent to the emergency room for evaluation and treatment. Interviews with staff confirmed that the resident was left unattended, which was against the facility's practice of ensuring residents are monitored in the restroom for safety. The facility's policy on fall prevention was not adhered to, leading to the resident's fall and injury. The deficiency was confirmed through staff interviews and a review of the resident's care plan and clinical records.
Plan Of Correction
- What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? On 9/27/24, The DON (Director of Nursing) met with Employee 1, Employee 2 and the staff on 2nd floor and educated them not to leave Resident R5 on the toilet unattended. The residents care plan was reviewed and updated to reflect new toileting status. - How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents with a BIMS (Brief Interview for Mental Status) of less than eight (8) have the potential to be impacted. On 10/16/2024 the facility completed staff training regarding the safety risks associated with leaving residents unattended while on the toilet. A whole house resident BIMS audit was completed by the DON on 12/17/2024 to identify residents considered to have severe impairment (a BIMS score of 0-7). Any current resident, new admissions, or resident reviewed during the care planning process identified with a BIMS of 0-7 will have their care plans updated to reflect supervision while on the toilet. - What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The facility will identify those residents with severe impairment and the DON will place a GOLD star on the nameplate outside of the resident room and with a GOLD star above the resident bed. The facility will update the Fall Prevention and Investigation Policy to reflect the addition of the star. Whole house staff education on the change will be completed by the DON. The updated fall policy will be reviewed during our New Employee Orientation. The facility will continue to monitor its fall prevention program during weekly fall prevention meetings to ensure proper fall prevention procedures are in line with the facility fall protocol to include utilizing the stars on the door nameplate and above the headboard. The facility will continue to provide staff education on Abuse, Neglect, Exploitation and Misappropriation of Property through our online education portal while also offering an in-person Abuse education on January 14th, 2025 provided by the Pavilion's Social Service Director and on February 25th, 2025 with the Department of Human Services Area Agency on Aging. - How the corrective action will be monitored to ensure that the deficient practice will not recur: i.e., what quality assurance programs will be accomplished? The prior week's resident fall event reports will be audited at the weekly fall prevention meeting to assess for resident care plan compliance and if modifications are needed. Audit results will be reported at the facility Quality Assurance Performance Improvement and Kaleida Health Quality Improvement Patient Safety monthly committees. Weekly audits will continue until 12 consecutive weeks of 90% compliance has been achieved. Modification may be made to the plan of correction to improve compliance. Changes will be reported to the facility QAPI monthly meeting.
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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 Bradford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bradford Manor Nursing And Rehab | 1.8 mi | ★★★★★ | 0 | 0 |
| Bradford Ecumenical Home, Inc | 1.9 mi | ★★★★★ | 0 | 0 |
| Absolut Center For Nursing And Rehabilitation At A | 12.7 mi | ★★★★★ | 0 | 0 |
| The Pines Healthcare & Rehab Centers Olean Campus | 13.1 mi | ★★★★★ | 0 | 0 |
| Salamanca Rehabilitation & Nursing Center | 14.1 mi | ★★★★★ | 9 | 0 |
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