The Bradford Skilled Nursing and Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to report a resident's elopement to the State Survey Agency in accordance with State law, for 1 (#4) of 5(#1, #2, #3, #4, #5) sampled residents. Based on record review and interview, the facility failed to report a resident's elopement to the State Survey Agency in accordance with State law, for 1 (#4) of 5(#1, #2, #3, #4, #5) sampled residents.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents plan of care was revised after a change in condition for 1 (#4) of 5 residents whose plan of care was reviewed. The facility failed to revise Resident #4's plan of care after an elopement and after the development of a diabetic ulcer. Based on record review and interviews the facility failed to ensure residents plan of care was revised after a change in condition for 1 (#4) of 5 residents whose plan of care was reviewed. The facility failed to revise Resident #4's plan of care after an elopement and after the development of a diabetic ulcer.

Inspectors wroteBased on record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive plan of care for 1 (#4) of 5 sampled residents. The facility failed to develop and implement approaches addressing Resident #4's risk of developing a diabetic foot ulcer.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure residents' plans of care were developed and implemented for 2 (#5, #44) of 2 (#5, #44) residents out of a total sample of 37 residents. The facility failed to provide a palm roll for Resident #5 and failed to develop a plan of care for nebulizer treatments for Resident #44.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain nail care for 2 (#35, #86) of 3 (#5, #35, #86) residents reviewed for ADLs.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide appropriate treatment and services for 1(#1) of 1(#1) resident reviewed for tube feedings. The facility failed to ensure Resident #1's tube feeding bag and water flush bag were changed daily.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for 4 (#18, #19, #44, #75) of 4 (#18, #19, #44, #75) residents reviewed for respiratory therapy. The facility failed to ensure respiratory supplies were changed weekly and stored in a covered device.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of unnecessary medications for 1 (#1) of 5 (#1, #2, #3, #4, #11) residents reviewed for unnecessary medications. The facility failed to monitor behaviors for Resident #1 while receiving an antidepressant.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to obtain informed consent for side rail use and failed to assess resident for the risk of entrapment from side rails quarterly for 1(#3) of 3(#1, #2, and #3) sampled residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an alleged violation involving abuse was reported to the State Survey and Certification Agency for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse.

Inspectors wroteBased on record review, facility's video footage review, and interviews the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure, Resident #4 was checked every two hours for incontinence.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure a resident received ADL (Activities of Daily Living) care for 1 (Resident #3) out 4 (Residents #1, #2, #3, #4) residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were treated with dignity and respect. The facility failed to address 1 resident (#1) out of 3 (#1, #2, #3) residents in a dignified and respectful manner.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure residents have a right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 (Resident #360) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. The facility failed to ensure: 1.) a side rail utilization assessment was completed, 2.) a consent for the use of side rails was obtained, and 3.) a physician's order was in place for the use of bedrails for Resident #360. Review of facility's Use of Restraints policy with a revision date of April 2017 revealed in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. [...]

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails. The facility failed to assess residents for use of bed rails (side rails), obtain an informed consent from resident or resident representative prior to installation of bed rails, and/or obtain physician order for bed rails for 11 (#3, #17, #23, #41, #66, #68, #72, #78, #80, #88, #96) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints.

Inspectors wroteBased on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of 5% or greater by committing 2 errors (#19, #93) out of 29 opportunities for an error rate of 6.9%.

Inspectors wroteBased on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required.

Inspectors wroteBased on observations and interview the facility failed to accommodate the needs of 1 (#78) of 26 sampled residents. The facility failed to ensure Resident #78's call light was within reach.

Inspectors wroteBased on record review and interviews the facility failed to ensure provision of services in compliance with all applicable Federal, State, and local laws, regulations and codes by failing to investigate an incident involving resident to staff violence for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to follow the facility's policy by failing to investigate a resident to staff verbal exchange that progressed to a physical exchange between Resident #1 and S6 LPN (Licensed Practical Nurse).

Inspectors wroteBased on observations, record reviews and interview, the facility failed to ensure 1 (Resident #3) of 3 (Resident #1, #2, #3) sampled residents was free of accidents and hazards.

Inspectors wroteBased on record review and interview the facility failed to ensure a physician's order was entered correctly for one resident (#2) of four residents (#1, #2, #3, #4) that were sampled.

Inspectors wroteBased on record reviews and interviews the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 4 (#2, #7, #18, #71) of 32 residents reviewed for advance directives.

Inspectors wroteBased on record review and an interview the facility failed to ensure resident's plan of care was reviewed and revised for 1 (#13) out of a total of 25 sampled residents reviewed for plan of care. The facility failed to revise the plan of care for Resident #13 to include refusal of house supplements.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who required assist with activities of daily living (adl) received the necessary services to maintain grooming and hygiene for 1 (#86) of 3 residents reviewed for activities of daily living. The facility failed to ensure Resident #86 received a shower in a timely manner.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure there was sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure that resident calls for help were answered timely and resident needs were met.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe, functional environment. The facility failed to ensure: 1. Toilets were securely attached to the floor in resident #209's, and resident #7's bathrooms. 2. Resident #24's faucet was attached securely to the bathroom sink 3. Clean out receptacle on 200 hall was warped, uneven and unleveled.

Inspectors wroteBased on observations and interviews, the facility failed to accommodate the needs of 2 (#73, #101) of 25 sampled residents observed for accommodation of needs. The facility failed to ensure the call light devices were in a position where they could be activated.

Inspectors wroteBased on record review and interviews the provider failed to complete an investigation for 1(Resident #68) of 1(Resident #68) residents after Resident #68 had an injury from an unknown origin.

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#92) out of 3 (#34, #209, #92) sampled residents reviewed for food. The facility served Resident #92's dislikes. Review of Resident #92's Medical Record revealed admit date [DATE]. Review of Resident #92's MDS (Minimum Data Set) assessment dated [DATE] revealed: Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) 15 - intact cognition. During an interview on 07/24/2023 at 8:30 a.m. Resident #92 reported he filled out his dislikes and likes for the kitchen but they keep sending him squash and beets. Resident #92 further reported his dislikes, squash and beets, are on his dietary ticket but the kitchen doesn't pay attention and sends it anyway. Observation on 07/24/2023 at 12:15 p.m. revealed Resident #92's lunch tray contained squash in a bowl. [...]