Bradford Square Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store food items in accordance with professional standards to prevent the use of outdated products and reduce the risk of foodborne illness.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure resident self-determination by not following its established process for tracking and maintaining scheduled health care appointments, resulting in a missed appointment and the resident's inability to participate in his planned care for 1 of 27 sampled residents, Resident (R) 65.

Inspectors wroteBased on observation, interview, and review of the facility's policies, 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 and control the development and transmission of communicable diseases for 2 of 27 sampled residents, Resident (R) 3 and R28.

Inspectors wroteBased on observation, interview, record review, review of a police report, and facility policy review, the facility failed to follow its policy for the receipt of a Schedule 4 controlled medication (clonazepam) for 1 of 2 sampled residents, Resident (R) 32. On 01/02/2025, Licensed Practical Nurse (LPN) 2 signed the pharmacy's Delivery Receipt for delivery of R32's 15 tablets of clonazepam (a benzodiazepine, used to treat anxiety). However, review of the facility's Narcotic Sheet revealed R32 did not have an entry for the delivery of the clonazepam on 01/02/2025, and review of R32's Medication Administration Record [MAR] revealed R32 missed five doses of clonazepam because the facility did not have that medication.

Inspectors wroteBased on interview, record review, and review of the facility's documents and policies, the facility failed to provide a safe transfer to the appropriate level of care to meet a resident's needs to ensure a safe and orderly discharge from the facility for 1 out of 3 sampled residents (Resident (R) 197). Record review revealed R197 was discharged from the facility to a homeless shelter on 05/01/2023. The resident's diagnoses included type 2 diabetes with ketoacidosis (a serious complication of diabetes when too many ketones build up to dangerous levels in the body) and unspecified lack of normal physiologic development in childhood. The resident had a representative/guardian who was not notified of the discharge details and was only informed of the discharge when the resident called her, on 05/09/2023, from the homeless shelter. [...]

Inspectors wroteBased on interview, record review, review of the facility's local health department inspection, and review of the local health department's website, the facility failed to provide education to food handlers related to safe food handling practice to enable food handlers to effectively carry out the functions of the food and nutrition service department. This deficient practice affected 85 residents receiving meals from the kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's documents and policies, the facility failed to ensure residents had a clean environment for 46 of 46 residents who resided on the 100 and 200 Halls.

Inspectors wroteBased on observation, interview, review of the package insert/product label for tubersol tuberculin (TB) purified protein derivative (PPD), and review of the facility's policy, the facility failed to have an effective system to ensure open TB PPD skin test solution vials were not expired in 1 of 2 medication refrigerators, with the potential to affect 46 of 46 residents on the 100 and 200 Halls. On 04/23/2024, one expired vial of PPD was found in the 100/200 Hall medication refrigerator. The vial of skin test solution had an opened date of 03/19/2024.

Inspectors wroteBased on observation, interview, and review of the facility's document and policies, the facility failed to store food in a safe, clean environment. This affected 85 residents that were provided meals from the kitchen. Observation of the kitchen, on 04/23/2024, revealed ingredient bins were visibly soiled, with a lid left open; utility carts were soiled; and the two spatulas were melted or appeared broken. Observation of the 300 Hall residents' refrigerator, on 04/23/2024, revealed a gelatin salad in a Christmas box and left over salad in a clear container with no resident name, date, or room number.

Inspectors wroteBased on observation, interview, review of the facility's policy, and review of the Plan of Correction (POC) submitted for the 04/26/2024 survey the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective process to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This had the potential to affect all 92 current residents. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights (F550); [...]

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturers' directions for use for the glucometer (blood glucose monitoring device) and disinfectant wipes, review of the facility's policies, the facility failed to identify and correct problems related to infection prevention practices for 7 out of 63 sampled residents, Resident (R) 2, R4, R19, R39, R71, R72, and R44. In addition, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents that received enteral nutrition through tube feedings, R45. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were treated with dignity and respect related to privacy when transporting to a communal bath for 1 of 63 sampled residents (Resident (R) 88) and providing a privacy/dignity bag to cover indwelling urinary catheter bags for 2 out of 6 sampled residents with indwelling urinary catheters (R41 and R62).

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure each resident exercised the right to formulate an advance directive for 1 of 63 sampled residents, Resident (R) 47.

Inspectors wroteBased on observation, interview, record review, review of the facility's investigation reports, review of the local police report, review of the Mapquest website, and review of the facility's policy, it was determined the facility failed to protect 4 out of 10 sampled residents from physical abuse involving resident to resident altercations, Resident (R) 50, 73, 547 and 548. 1. On [DATE], R73 was in his bathroom on the toilet when R296 entered the bathroom and grabbed R73's arm and attempted to hit R73. R73 received scratches to her right chest, and her right arm had bruising. 2. On [DATE], R56 pulled R50's head into her lap using the collar of R50's hooded sweatshirt. The hooded sweatshirt was pulled over R50's head, and R56 was hit R50 in the head with her fists. This resulted in a skin tear on R50's arm. 3. On [DATE], R547 entered R548's room, and R547 smacked R548. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to review and revise the comprehensive care plan (CCP) to include refusals of care for 1 of 63 sampled residents (Resident (R) 45). Per staff interview, R45 had a history of refusals of turning and repositioning, refusals of offers to be transferred out of bed into a Broda chair, refusals of participation in one-to-one activities, and refusals of having her hand splints applied.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a resident received the correct tube feeding rate for 1 of 4 sampled residents, Resident (R) 17. R17 was ordered to be on a tube feeding rate of 70 milliliters (ml)/hour to maintain the resident's nutritional status. However, observation on 04/24/2024 revealed R17's tube feeding rate was 65 ml/hour.

Inspectors wroteBased on observation, interview, record review and review of the facility's policies, the facility failed to ensure the services provided or arranged by the facility, as outlined by the physician orders and the comprehensive care plan met professional standards of quality for 1 of 63 sampled residents, Resident (R) 45. R45 had an active order for oxygen at three liters via tracheostomy mask/collar continuously, and the setting on the oxygen concentrator was observed to be set at between 3.5 liters (3.5L) and 4 liters (4L) on 04/23/2024, 04/24/2024, and 04/25/2024.

Inspectors wroteBased on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) QSO-21-19-NH Memo, and review of the facility's policies, the facility failed to maintain documentation of screening, education, offering, and current Coronavirus Disease 2019 (COVID-19) vaccination status for 1 of 1 sampled staff (State Registered Nurse Aide (SRNA) 2). This failure placed the residents and staff at increased risk for communicable diseases and healthcare-associated infections (HAI).

Inspectors wroteBased on observation, interview, and review of the facility's documents, the facility failed to ensure resident rooms measured 80 square feet per resident in multiple resident rooms. Twenty-three dual occupancy rooms on Unit 1 and Unit 2 were measured at 152 square feet, eight feet short of the 160 square feet required for dual occupancy resident rooms.