Bradford Heights Nursing & Rehabilitation

Inspectors wroteObservation, interview, and facility policy review revealed the facility failed to maintain a homelike environment for residents related to peeling paint on the walls in room [ROOM NUMBER], holes in the wall in rooms [ROOM NUMBER], and stained ceiling tiles in rooms 100, 107, 109, and 119. This affected four (4) out of 20 sampled residents, R11, R12, R19, and R20.

Inspectors wroteObservation, interview, and review of facility policies revealed the facility failed to provide assistance with incontinence care in a timely manner for four (4) of 10 sampled residents (R1, R6, R7, and R14).

Inspectors wroteBased on interview, record review, and review of the facility policies, the facility failed to ensure pain assessments were completed prior to and after the administration of as needed (PRN) narcotic pain medications for four (4) out of four (4) sampled residents, Resident (R)4, R8, R16, and R18.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that medications with expired or post discard dates were not available for resident use for one of four sampled residents (Resident (R) 1). Observation on 04/08/2026 revealed an intravenous (IV) antibiotic (Meropenem) container hanging on an IV pole in R1's room labeled with directions to discard the medication after 03/03/2026.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure all staff properly adhered to infection control and personal protective equipment (PPE) regulations in accordance with professional standards for one of four sampled residents (Resident (R) 1) for enhanced barrier isolation. Observation on 04/08/2026 revealed a staff member entered a R1's room, who was on enhanced barrier precautions and performed direct resident care without donning the appropriate PPE.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 93 of the facility's 93 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents sampled for wound care out of the total sample of 20, (Resident (R)2 and R6).

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 90 of the facility's 94 residents who consumed food from the kitchen. Observation during the initial kitchen tour revealed numerous food items in the reach-in cooler not labeled or dated. In addition, continued observation of the kitchen revealed [NAME] 2 failed to have a beard covering in place. Further observation revealed [NAME] 2 failed to utilize utensils when serving food, using his gloved hands and not changing gloves.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure each resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and the resident had a right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 30 sampled residents (Resident #6 (R6)).

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure its grievance policy was followed to ensure prompt resolution of all residents' grievances and completion of such grievances for 2 of 30 sampled residents (Residents (R6 and R73)).

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents received a Level II Preadmission Screening and Resident Review (PASRR) referral based on the positive Level 1 PASRR screening results for 1 of 2 residents sampled for Level II PASRR out of the total sample of 30 residents (Resident #23 (R23)). The facility assessed R23 to have a positive Level I PASRR screen on admission on [DATE], related to her diagnoses and psychiatric (psych) stay. Based on the positive Level I PASRR, R23 required a Level II Screening related to diagnoses of schizophrenia and bipolar disorder. However, the facility failed to ensure R23 received a Level II PASRR evaluation as required.

Inspectors wroteBased on observation, interview, record review and review of facility polity, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 2 of 30 sampled residents (Resident (R)23 and R99). 1. The facility admitted R99 on 04/28/2022, and on 05/04/2024 assessed R99 as being at risk for developing pressure injuries. However the facility failed to develop a care plan for at risk for impaired skin integrity or risk for developing pressure injuries. On 05/11/2024, R99 developed a suspected deep tissue injury (SDTI) to the right heel. 2. The facility admitted R23 with diagnoses of schizophrenia, bipolar disorder, depression, and anxiety. [...]

Inspectors wroteBased on interview, record review and review of the facility's policy, it was determined the facility failed to ensure interventions were in place to prevent a resident from developing a pressure injury for 1 of 30 sampled residents, (Resident (R)99). On 05/11/2022, 13 days following admission to the facility, Resident 99 developed a facility acquired suspected deep tissue injury (SDTI) to the right heel.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 30 sampled residents, (Resident (R)83). R83 experienced significant weight loss; however, the facility failed to notify the Physician of the resident's significant weight loss and failed to follow recommendations from the Registered Dietician (RD).

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections, for 1 of 30 sampled residents, (Resident (R)41). Observation revealed Certified Medication Aide (CMA) 2 administered R41's ophthalmic eye drops without wearing gloves.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation of the kitchen on 11/25/19 revealed a bag of waffles and green peppers stored in the freezer and were not dated. Review of the Census and Condition, dated 11/25/19 revealed ninety-two (92) of ninety-two (92) residents received their meals from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan with services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being related to Activities of Daily Living (ADL's) and Catheter Care for two (2) of eighteen (18) sampled residents, (Resident #74 and #189).

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to provide activities of daily living (ADL's) to one (1) of eighteen (18) sampled resident who wast unable to carry out own ADL's (Resident #74). Observations of Resident #74 during a three day time frame revealed the resident facial hair was unshaven and fingernails on both hands and feet were long, jagged, and not trimmed. In addition, there was a black colored substance underneath fingernails on both hands. The findnigs include: Review of the facility's policies titled, Care of Fingernails/Toenails and Shaving The Resident, dated October 2010, revealed the purposes of the procedure is to promote cleanliness, to provide skin care, and to clean the nail bed, to keep nails trimmed, and to prevent infections. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for three (3) of eighteen (18) sampled residents, (Resident #37, #74, and #189).

Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents' nebulizer treatments were provided in accordance with professional standards of practice (Resident #46). Observation on 11/26/19 at 3:20 PM revealed Resident #46 was lying in bed yelling out and there was a nebulizer (breathing treatment) mask, empty and running, lying on the resident's chest with the resident pointing at the nebulizer mask, attempting to talk by yelling out. There was no nurse in the room.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents was not administered a Psychotropic medication without an appropriate diagnosis (Resident #87). Resident #87 was being administered Seroquel (anti-psychotic medication), for the diagnosis of anxiety.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. On [DATE], observation of two (2) of two (2) medication carts on the 100 and 200 Hall, revealed medication not dated when opened.