Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 At Brookside during CMS and state inspections, most recent first.
A cognitively intact male resident with chronic pain and multiple comorbidities, including IBD and a tracheostomy, had orders for scheduled Hydrocodone-Acetaminophen for pain and Atorvastatin at bedtime. During a medication pass, an LVN administered two Hydrocodone-Acetaminophen tablets instead of one Hydrocodone-Acetaminophen and one Atorvastatin, resulting in a duplicate opioid dose. The resident later reported that the two medications looked similar in color, shape, and size, and he did not realize he had received two Hydrocodone tablets. This error occurred despite care plan interventions for pain management and a facility policy requiring monitoring of drug regimens to prevent unnecessary drugs and duplicate therapy.
A resident with severe cognitive impairment and multiple comorbidities, including a Stage 3 pressure ulcer, had an active order and care plan interventions for Enhanced Barrier Precautions (EBP). EBP signage and a PPE cart were present outside the room. During observed wound assessment and dressing change to the buttock pressure injury, a consulting wound care NP and an LVN provided direct wound care without donning gowns, contrary to the facility’s EBP policy requiring gowns and gloves for high-contact care activities such as wound care. Both clinicians later acknowledged they forgot to wear gowns, while the ICP, DON, RDCS, and Administrator all stated that staff and consultants are expected to follow EBP orders, signage, and policy for residents with chronic wounds, indwelling devices, or MDROs.
A full-time social worker was employed without a Texas license, despite state requirements and facility policy. The social worker had a bachelor's degree in social work and had completed some, but not all, steps toward licensure. The administrator confirmed the social worker was not licensed and was only supervised by a PRN licensed social worker who was not assigned oversight duties.
A resident with hypertension and coronary artery disease had blood pressure medication held on multiple occasions due to low blood pressure readings, but the physician was not notified as required by facility policy. Staff interviews confirmed that physician notification was expected each time such medication was held, but this step was missed and not documented.
A resident with moderate cognitive impairment and high care needs was not provided with a privacy curtain that closed completely during personal care. Staff were aware of the issue but did not report it, resulting in the resident experiencing embarrassment and a lack of privacy, contrary to facility policy.
A resident with COPD who smoked daily was not accurately identified as a tobacco user on the MDS assessment, despite staff supervision and documentation of her smoking in other records. Interviews and observations confirmed the resident's daily tobacco use, but the MDS nurse overlooked marking this on the assessment, resulting in an inaccurate record.
A resident with a tracheostomy and complex respiratory conditions did not receive oxygen therapy at the physician-ordered rate, as staff administered oxygen at a higher flow and incorrect air compressor setting. LVNs confirmed the error and adjusted the settings after review, but the deficiency occurred due to failure to follow the care plan and physician's orders.
A resident with hypertension did not receive PRN clonidine as ordered when blood pressure readings exceeded prescribed parameters. Multiple elevated BP readings were documented without administration of the medication, and staff interviews revealed gaps in communication and awareness of the order. Facility policy required medications to be given as prescribed, but this was not followed.
A resident with hypertension did not receive prescribed PRN clonidine on multiple occasions when blood pressure readings exceeded the physician-ordered threshold. Staff interviews revealed a lack of communication between MAs and nurses regarding elevated BP readings, resulting in missed medication administration as required by facility policy.
A resident was not provided with the dignity, self-determination, and communication rights required, as staff actions or inactions failed to support the resident's ability to exercise these rights.
A deficiency was identified when a CNA repeatedly put her fingers in the face of a resident with dementia and other medical conditions during care, causing visible agitation. Video evidence provided by a family member confirmed the incident, and multiple staff interviews acknowledged the behavior as inappropriate and undignified, in violation of facility policy on resident rights.
A CNA repeatedly placed her fingers in the face of a cognitively impaired female resident during care, causing visible agitation and prompting the resident to attempt to bite the CNA. The incident, captured on video by a family member, was confirmed by staff interviews and found to be inconsistent with facility policies on abuse prevention and resident dignity.
A resident with significant cognitive and physical impairments developed a pressure ulcer that was not properly measured or documented in the EMR when first identified. Although treatment orders were initiated, the required wound assessment and documentation were not completed by the Treatment Nurse, and staff interviews revealed confusion about responsibility and timelines. This failure to follow facility policy prevented proper monitoring of the wound's progression.
A resident's advance directive indicating a DNR status was not honored by the facility, leading to life-saving procedures being performed against his wishes. The resident, with multiple medical conditions, was listed as Full Code despite providing an advance directive upon admission. Facility staff were unaware of the directive, and it was not communicated to emergency personnel, resulting in the resident receiving unwanted treatments.
A resident with severe cognitive impairment and limited range of motion did not receive appropriate care to prevent further contractures, as palm guards were not consistently applied to her hands. Despite being assessed and referred to restorative care, staff interviews revealed a lack of adherence to the care plan, with the Restorative Aide citing workload issues and the absence of a palm guard for the right hand. The interim DON confirmed the expectation for palm guards to be in place, highlighting the deficiency in care.
A facility failed to assess and discontinue an unnecessary urinary catheter for a resident without a medical condition requiring it. The resident, with severe cognitive impairment, was admitted with a catheter from a previous hospitalization. Staff interviews revealed a lack of policy addressing catheter necessity, leading to delayed bladder retraining and catheter removal.
A resident with chronic respiratory failure and a tracheostomy was not provided the correct oxygen dose as per physician orders, receiving 4.5 L/min instead of the prescribed 2-4 L/min. An LVN admitted to not verifying the oxygen setting, and the interim DON confirmed the care plan was not followed, potentially leading to increased oxygen dependency.
A facility failed to provide appropriate pharmaceutical services for a resident receiving IV antibiotics by not ensuring the administration of saline and heparin flushes as per the SASH protocol without a physician's order. The necessary SASH documentation was missing from the MAR, and the oversight was identified during a medication pass observation. Interviews revealed that the omission was due to an oversight, and the MAR did not include the required SASH documentation.
A dietary staff member worked with an expired Food Handlers Certificate, risking foodborne illness for residents. Interviews confirmed the importance of maintaining current certifications, but the staff member was unaware of the renewal requirement.
Duplicate Administration of Hydrocodone Resulting in Significant Medication Error
Penalty
Summary
Surveyors identified a deficiency related to medication administration when a resident received a duplicate dose of a routine pain medication. The resident, a cognitively intact male with chronic pain, ulcerative colitis, Crohn's disease, a tracheostomy, and a recent acute respiratory infection, had physician orders for Hydrocodone-Acetaminophen 10-325 mg one tablet by mouth four times a day for chronic pain and Atorvastatin 80 mg by mouth at bedtime. Facility policy on unnecessary drugs required that each resident's drug regimen be managed and monitored to remain free from unnecessary medications, including duplicate therapy, and that the attending physician and facility staff ensure appropriate dosing and monitoring. On the evening in question, the resident's routine pain medication was duplicated by an LVN during medication administration. Instead of receiving one Hydrocodone-Acetaminophen tablet and one Atorvastatin tablet, the resident was given two Hydrocodone-Acetaminophen tablets at the same medication pass. The resident later reported that he knew his medications but that the Hydrocodone-Acetaminophen and Atorvastatin tablets looked similar in color, shape, and size, and he did not realize at the time of administration that he had received two Hydrocodone tablets instead of the ordered combination of one Hydrocodone and one Atorvastatin. Record review showed that the resident’s care plan included pain management with scheduled pain medications and interventions such as assessing for pain at routine intervals and monitoring for changes in bowel habits, appetite, and sleep. Another care plan entry documented a history of alleged misappropriation related to pain medications for this resident. Despite these documented needs and the facility’s written policy on avoiding unnecessary drugs and duplicate therapy, the LVN’s administration of an extra Hydrocodone-Acetaminophen tablet resulted in a significant medication error and a failure to ensure the resident’s drug regimen was free from excessive dose and duplicate drug therapy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident with a chronic wound. The resident was an elderly female with multiple diagnoses including Alzheimer’s disease, cerebral infarction, major depression, protein-calorie malnutrition, dysphagia, schizophrenia, and a pressure ulcer of the buttocks. Her quarterly MDS showed she was severely cognitively impaired, rarely or never made herself understood, sometimes understood others, and was dependent on staff for self-care and mobility. Her care plan documented a pressure ulcer with interventions for infection control precautions, and physician’s orders directed the use of EBP every shift for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. On the survey date, EBP signage was posted outside the resident’s room, and a PPE cart with gowns and gloves was located at the entrance. The resident was observed lying in bed and unable to respond appropriately to interview questions. During a wound care observation, a consulting wound care NP and an LVN performed an assessment and dressing change on the resident’s right buttock Stage 3 pressure injury. During this direct contact wound care, neither the NP nor the LVN wore a gown, despite the EBP order, posted signage, and facility policy requiring PPE, including gowns and gloves, for high-contact care activities such as wound care. In subsequent interviews, the LVN and NP each acknowledged they failed to follow EBP because they forgot to wear gowns during the wound assessment and dressing change, and both stated they should have applied gowns prior to providing care. The Infection Control Preventionist, DON, RDCS, and Administrator each stated their expectation that staff and consultants follow the EBP policy, orders, and signage for residents with chronic wounds, indwelling devices, or MDROs, and confirmed that this resident was on EBP due to a Stage 3 pressure ulcer. The facility’s written EBP policy required initiation of EBP for residents with wounds and specified that gowns and gloves be made available and used for high-contact resident care activities, including any wound care requiring a dressing, which was not followed during the observed wound care procedure.
Unlicensed Social Worker Employed Full-Time
Penalty
Summary
The facility failed to ensure that the full-time social worker hired for a facility with more than 120 beds met the required qualifications as outlined by state regulations. The social worker, hired in December 2024, held a bachelor's degree in social work but was not licensed by the Texas State Board of Social Worker Examiners at the time of employment. Review of the employee file confirmed the absence of a license, and the facility's job description required licensure per state requirements. The administrator acknowledged that the social worker was not licensed and was preparing to take the licensure exam, while a licensed social worker was only employed on a PRN basis and was not assigned to oversee the unlicensed social worker. During interviews, the social worker stated she had passed the ASWB examination and completed the fingerprint background check but had not yet taken the required Texas jurisprudence exam. Her duties included participating in care plan meetings, promoting resident rights, and providing support to residents and families. The lack of licensure was only addressed after surveyor intervention, as evidenced by the completion of the jurisprudence exam on the day of the survey.
Failure to Notify Physician of Held Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a physician was consulted regarding the need to alter treatment for a resident with a history of hypertension and coronary artery disease. The resident, who had moderately impaired cognition, was prescribed metoprolol tartrate 100 mg twice daily with specific parameters to hold the medication if systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) less than 50, or heart rate less than 50. Over the course of August 2025, the medication was held on five occasions due to blood pressure readings outside the prescribed parameters. However, there was no documentation or indication that the physician was notified about the medication being held on these occasions. Interviews with facility staff revealed that the expectation was for the physician to be notified each time a medication with parameters was held, and that such notifications should be documented in the resident's electronic record. The Director of Nursing and the Registered Dietitian Consultant both acknowledged that physician notification was overlooked in this case. The facility's policy required nursing staff to observe changes, make assessments, and notify the physician as indicated, but this process was not followed for the resident in question.
Failure to Provide Adequate Privacy During Personal Care
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs) and frequent turning and repositioning due to a terminal illness was not provided with adequate privacy during personal care. The resident, who had moderate cognitive impairment and was dependent for personal hygiene and toileting, had a privacy curtain in her room that did not close completely, leaving an approximate three-foot gap. Both the resident and a hospice CNA reported that the curtain was too short and did not provide sufficient privacy, especially during bed baths and personal care. The resident expressed embarrassment and discomfort due to the lack of privacy, fearing exposure when people entered the room. Facility staff, including a CNA who regularly cared for the resident, were aware that the privacy curtain did not close fully but had not reported the issue to facility management. The Director of Nursing (DON) and the Administrator confirmed upon observation that the curtain was too short and had not been reported to them previously. The facility's policy required the protection of resident privacy during personal care, but this was not upheld in this instance, resulting in a failure to maintain the resident's dignity and privacy.
Failure to Accurately Document Tobacco Use on MDS Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of a resident with a history of chronic obstructive pulmonary disease (COPD) and daily tobacco use. Review of the resident's face sheet, care plan, and smoking safety screen confirmed that the resident smoked cigarettes daily, with staff storing and distributing smoking materials, lighting cigarettes, and supervising smoking breaks. Multiple interviews with the resident and staff, as well as direct observation, further confirmed the resident's ongoing tobacco use and the facility's supervision of her smoking activities. Despite this, the resident's admission Minimum Data Set (MDS) assessment did not indicate current tobacco use during the assessment period. The MDS nurse, responsible for completing all MDS assessments, acknowledged that the resident's tobacco use should have been marked but was overlooked. The Director of Nursing and Administrator also confirmed the oversight, stating that the MDS was not accurate in this instance. The facility's policy and the Resident Assessment Instrument (RAI) manual require accurate documentation of tobacco use, which was not followed in this case.
Failure to Administer Oxygen Therapy per Physician Orders for Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and heart failure did not receive oxygen therapy as ordered by the physician. The resident's care plan and physician's orders specified oxygen administration at 4-6 liters per minute (LPM) via an oxygen concentrator through the tracheostomy, and the air compressor was to be set at 60 PSI. However, during an observation, the resident was found receiving oxygen at 8 LPM and the air compressor was set at 40 PSI, both of which were inconsistent with the physician's orders. Licensed vocational nurses (LVNs) involved in the resident's care confirmed upon review that the oxygen and air compressor settings were incorrect and subsequently adjusted them to the ordered levels. The resident's oxygen saturation was checked and found to be 94% at the time of correction. The facility's policy on oxygen administration required verification and adherence to physician orders, which was not followed in this instance, resulting in the deficiency.
Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident with a diagnosis of hypertension and anxiety disorder. The resident had a physician's order for clonidine HCl 0.2 mg to be administered orally every 8 hours as needed if the systolic blood pressure (SBP) exceeded 160. Record review showed multiple instances where the resident's SBP was above the prescribed threshold, but the medication was not administered as ordered. The medication administration record (MAR) documented several dates and times when the resident's blood pressure was elevated, yet the PRN clonidine was not given. Interviews with staff revealed a lack of awareness and communication regarding the resident's elevated blood pressure readings and the corresponding PRN medication order. Medication aides (MAs) reported that they do not administer PRN medications and that such orders would not appear on their MARs, while licensed vocational nurses (LVNs) indicated they were unaware of the elevated blood pressure readings and relied on MAs to report abnormal values. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in the case of this resident.
Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
A deficiency occurred when a male resident with diagnoses of hypertension and anxiety disorder did not receive clonidine 0.2 mg as ordered by his physician on nine separate occasions over a period of several weeks. The physician's order specified that clonidine should be administered by mouth every eight hours as needed if the resident's systolic blood pressure (SBP) exceeded 160. Review of the medication administration record (MAR) showed that on multiple dates and times, the resident's SBP was above the prescribed threshold, but the medication was not given as required. Interviews with staff revealed that medication aides (MAs) did not administer PRN medications and that nurses were responsible for this task. One MA stated she was unaware of the clonidine order because it was not listed on her MAR, while a nurse reported she had not been informed of the elevated blood pressures and would begin asking MAs about out-of-range readings. The resident did not report any adverse effects and was unaware of his elevated blood pressure readings. Facility policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. This deficiency was identified based on surveyor findings that indicated the resident's rights in these areas were not upheld. Specific actions or omissions by facility staff led to the resident not being treated with the dignity and respect required, and their ability to make choices or communicate needs was not fully supported.
Failure to Honor Resident Dignity During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) repeatedly put her fingers in the face of a female resident with Alzheimer's disease, cerebral infarction, anxiety disorder, dysphagia, and schizophrenia. The resident was rarely understood, usually understood others, and required moderate to total assistance with daily care. The incident was captured on video by a family member, who later reported feeling disturbed after viewing the footage. The video showed the CNA placing her fingers in the resident's face multiple times while preparing to provide incontinent care, which visibly agitated the resident and led her to attempt to bite the CNA's fingers. Interviews with facility staff, including the Interim Director of Nursing (DON), the Regional Director of Clinical Services, and other nursing staff, confirmed that the CNA's actions were inappropriate and could affect the resident's dignity. The CNA herself admitted to being playful with the resident at the time, but later recognized her behavior as inappropriate, especially after learning of the resident's dementia diagnosis. Staff members interviewed agreed that putting fingers in a resident's face was not acceptable and could impact a resident's sense of dignity. The facility's policy on resident rights, revised in December 2016, requires all employees to treat residents with kindness, respect, and dignity, in accordance with federal and state laws. The actions of the CNA were found to be inconsistent with this policy, as confirmed by both facility leadership and direct care staff after reviewing the video evidence and discussing the incident.
Failure to Protect Resident from Abuse and Maintain Dignity
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) placed her fingers in the face of a female resident with significant cognitive impairment, including Alzheimer's disease, cerebral infarction, anxiety disorder, dysphagia, and schizophrenia. The resident was rarely understood, usually understood others, and required moderate to total assistance with daily activities. The incident was captured on video by a family member, who later reported feeling disturbed after viewing the footage. The video showed the CNA repeatedly putting her fingers in the resident's face while preparing to provide incontinent care, which visibly agitated the resident and led her to attempt to bite the CNA's fingers. Interviews with facility staff, including the Interim Director of Nursing (DON), Regional Director of Clinical Services, and other nursing staff, confirmed that the CNA's actions were inappropriate and could affect the resident's dignity. The CNA herself admitted to being playful with the resident and acknowledged that her behavior was not appropriate, especially after learning of the resident's dementia diagnosis. Staff members interviewed agreed that placing fingers in a resident's face was not acceptable and could impact the resident's dignity. Facility policy reviews indicated that residents have the right to be free from abuse, neglect, and to be treated with respect and dignity. The actions of the CNA were inconsistent with these policies, as confirmed by both the video evidence and staff interviews. The incident demonstrated a failure to protect the resident from actions that could cause mental anguish or emotional distress, as required by facility policy and resident rights.
Failure to Document and Assess New Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice. Specifically, when a new wound was identified on the resident, the Treatment Nurse did not measure or adequately document the wound in the electronic medical record (EMR) at the time it was first found. Although the wound was discovered and treatment orders were entered, the required initial wound assessment and documentation, including measurements, were not completed as per facility policy. The resident involved was a female with significant medical and cognitive impairments, including major depressive disorder, Down syndrome, and a history of urinary tract infections. She was always incontinent of bowel and bladder and required moderate assistance with activities of daily living. The wound, located on the back of her right thigh near the gluteal fold, was described as a shallow, pink/red, moist area consistent with a stage 2 pressure injury. Staff interviews revealed that the wound had been present for at least two weeks, and there was confusion among staff regarding the exact timeline and responsibility for documentation. Multiple staff members, including CNAs and nurses, acknowledged awareness of the wound but failed to ensure timely and complete documentation in the EMR. The Treatment Nurse admitted to not completing the wound assessment form and stated that she had the measurements but did not enter them into the system. The facility's policy required that any newly identified wounds be assessed and documented by the Treatment Nurse or charge nurse, with measurements recorded and care plans updated accordingly. The lack of documentation meant that the wound's progression could not be properly monitored, as confirmed by interviews with the Interim DON and Regional Director of Clinical Services.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored. Upon admission, the resident provided a copy of his advance directive, which indicated his preference for a Do-Not-Resuscitate (DNR) status under certain medical conditions. However, the facility did not have a DNR order in place and instead had the resident listed as Full Code. This discrepancy was not communicated to emergency medical technicians or hospital personnel, leading to the resident receiving life-saving procedures against his wishes. The resident, an elderly male with multiple medical conditions including hypertension, cerebral infarction, hemiplegia, vascular dementia, and respiratory failure, was admitted to the facility with an advance directive. Despite this, the facility's records showed him as Full Code, and his advance directive was not uploaded into the electronic medical record (EMR). When the resident experienced respiratory distress, he was sent to the hospital without the facility providing information about his advance directive, resulting in him being intubated and receiving treatments he had wished to avoid. Interviews with facility staff revealed a lack of awareness and understanding of the resident's advance directive. One nurse believed the resident was Full Code with a DNR pending, while another stated that the advance directive was not a DNR because the resident did not have a terminal illness. The facility's policy required that advance directives be maintained in the resident's medical record and communicated to staff, but this was not followed, leading to the failure to honor the resident's documented treatment preferences.
Failure to Provide Appropriate ROM Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, specifically in ensuring the use of palm guards to prevent further contractures. The resident, a female with severe cognitive impairment and functional limitations in both upper and lower extremities, was observed multiple times without palm guards in her hands as required by her care plan. Despite being assessed for the need for palm guards and referred to restorative care, the resident did not consistently have the devices applied, particularly in her right hand, which was noted to be tightly contracted. Interviews with staff revealed a lack of adherence to the resident's restorative plan of care. The LVN acknowledged that the resident needed palm guards in both hands but had never seen one for the right hand. The Restorative Aide admitted to not following the plan of care, citing being overburdened with responsibilities and not having a palm guard for the resident's right hand. The Director of Rehabilitation confirmed the resident's need for bilateral palm guards and range of motion exercises, which were not being consistently provided. The deficiency was further highlighted by the interim DON, who stated that the expectation was for the resident to have palm guards in place as specified in the restorative plan of care. Observations confirmed that the resident's hands were at risk of becoming more contracted due to the lack of proper intervention. The facility's policy on resident mobility and range of motion emphasized the need for treatment to prevent a decrease in range of motion, which was not adhered to in this case.
Failure to Assess and Discontinue Unnecessary Urinary Catheter
Penalty
Summary
The facility failed to assess and attempt the removal of an indwelling urinary catheter for a resident who did not have a medical condition necessitating its use. The resident, a female with severe cognitive impairment and dependent on all activities of daily living, was admitted with a catheter from a previous hospitalization. Despite the absence of a genitourinary diagnosis, the facility did not initiate bladder retraining or seek to discontinue the catheter until prompted by surveyor intervention. Interviews with facility staff revealed that there was no policy in place to address the necessity of catheter use based on medical diagnosis. The Unit Manager and interim DON acknowledged that the resident's catheterization was not justified by her medical condition, and the Administrator confirmed that bladder retraining should have been attempted. The Corporate Nurse admitted that existing policies only covered catheter insertion and care, not the criteria for catheter use.
Failure to Administer Correct Oxygen Dose
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident, specifically by not administering the correct dose of oxygen as per the physician's orders. The resident, a female with chronic respiratory failure and a tracheostomy, was prescribed oxygen at 2-4 L/min via nasal cannula. However, observations revealed that the resident was receiving oxygen at 4.5 L/min on multiple occasions. This discrepancy was noted during observations on two consecutive days. An LVN acknowledged that the oxygen was set incorrectly and admitted it was her responsibility to ensure the correct setting at the beginning of each shift. Despite checking the resident's oxygen saturation levels, which were within normal limits, the LVN did not verify the oxygen dosage setting. The interim DON confirmed that the staff did not follow the care plan, which could lead to the resident becoming dependent on a higher oxygen dose. The facility's Oxygen Administration policy requires verification of physician orders for safe oxygen administration, which was not adhered to in this case.
Failure to Document and Administer IV Flushes as per SASH Protocol
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident who was receiving IV antibiotics. Specifically, the facility did not ensure that the resident was administered a saline IV flush before the administration of an IV antibiotic and a saline and heparin flush after the medication administration, as per the SASH protocol, without a physician's order. This oversight was identified during a medication pass observation, where it was noted that the necessary SASH documentation was missing from the Medication Administration Record (MAR). The resident involved was a female admitted with a diagnosis of a urinary tract infection and was prescribed Piperacillin/Tazobactam via a midline IV catheter. Despite the facility's policy requiring physician orders to be recorded and signed, the electronic medical record lacked orders for the necessary IV flushes. Interviews with nursing staff and management revealed that the omission was due to an oversight, and the MAR did not include the required SASH documentation, which was supposed to be ensured by the Unit Manager and ultimately the Director of Nursing.
Expired Food Handlers Certificate in Dietary Staff
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service, specifically for one of the nine dietary staff members reviewed. Dietary Staff B was found to have an expired Food Handlers Certificate while working in the facility's kitchen, which could place residents at risk of foodborne illness due to being served by improperly trained staff. The deficiency was identified through interviews and record reviews, which revealed that Dietary Staff B's certificate had expired, and she had worked several days with the expired certification. Interviews with the Dietary Manager, HR staff, and the Administrator confirmed the importance of maintaining current food handler certifications to ensure proper food handling and prevent foodborne illnesses. Dietary Staff B admitted to being unaware of the requirement to renew the certificate every two years. The facility's policy mandates that employees present recertifications to the human resource director before the expiration of current certifications, but this was not adhered to in the case of Dietary Staff B.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Livingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberwood Nursing And Rehabilitation Center | 5.4 mi | ★★★★★ | 7 | 0 |
| Woodland Park Nursing & Rehab | 17.7 mi | ★★★★★ | 0 | 0 |
| Pine Ridge Health Care Llp | 18.7 mi | ★★★★★ | 0 | 0 |
| Corrigan Ltc Nursing & Rehabilitation | 19.7 mi | ★★★★★ | 12 | 0 |
| Groveton Nursing Home | 25.5 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Bradford At Brookside.
100% money-back within 48 hours.
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.