Bradford Village Healthcare Center

Based on observation, record review and interview, the facility failed to: a. ensure expired medications were removed from circulation for three (#8, 46, and #56) of 10 sampled residents reviewed with controlled medications; and b. medications were administered as ordered for one (#24) of five sampled residents reviewed for unnecessary medications. The administrator identified 81 residents resided in the facility. Findings: The MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy, dated 01/2022, read in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 1. Resident #8 had diagnoses which included chronic obstructive pulmonary disease. A Physician Order, dated 05/18/24, documented hydrocodone-acetaminophen (an opioid) tablet 5-325 mg give one tablet by mouth every four hours as needed for pain. An Individual Resident's Narcotics Record, dated 05/18/24, documented the last dose of hydrocodone-acetaminophen 5-325 mg was administered to Resident #8 on January 25th. The remaining count…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to notify the physician when a resident's blood pressure was abnormal for one (#24) of five sampled residents reviewed for unnecessary medication. The administrator identified 81 residents resided in the facility. Findings: Resident #24 had a diagnosis of hypertension. A physician's order, dated 12/01/22, documented valsartan (an antihypertensive) 160 mg, give one tablet by mouth one time a day for hypertension. A physician's order, dated 05/10/23, documented amlodipine besylate (an antihypertensive) 5 mg, give one tablet by mouth one time a day for hypertension. A physician's order, dated 07/24/24, documented to obtain blood pressure and heart rate one time a day for monitoring if systolic blood pressure 170 or greater refer to as needed hydralazine (vasodilator) order. The January 2025 Medication Admin Audit Report documented amlodipine besylate was initialed as given on: a. 01/28/25 at 8:01 a.m., b. 01/30/25 at 7:52 a.m., and c. 01/31/25 at 8:10 a.m. The January 2025 Medication Admin Audit Report documented the valsartan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed within the required timeframe for one (#170) of 18 sampled residents reviewed for care plans. The administrator identified 81 residents resided in the facility. Findings: Resident #170 admitted to the facility on [DATE]. Resident #170's admission Resident Assessment was dated 01/22/25. There was no comprehensive care plan located in Resident #170's clinical record. On 02/11/25 at 9:45 a.m., the case manager stated they were responsible for MDS resident assessments and care plans for the skilled residents. On 02/11/25 at 9:48 a.m., the case manager stated they put in basic care plans when residents initially admitted to the facility. They stated they would then complete the admission assessment. They stated the comprehensive care plan should be completed no more than 21 days after admission. On 02/11/25 at 9:50 a.m., the case manager stated Resident #170 admitted on [DATE]. They stated the care plan was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure food items were properly sealed, dated, and labeled during one of one kitchen observations. The DON identified 96 residents resided in the facility and received services from the kitchen. Findings: The facility's Dining Services Policies and Procedures - Food Storage policy, revised 04/30/09, read in part, .Food items will be stored, thawed, and prepared in accordance with approved sanitary practices .Fresh Fruits .Rotate so that oldest produce is used first .Fresh vegetables are to be checked and sorted for ripeness . On 11/27/23 at 1:24 p.m., the following items were observed in the walk in the freezer during the initial kitchen tour: a. an opened clear bag of mixed frozen vegetables in a carton not labeled or dated, b. frozen broccoli in a clear bag not properly sealed, and c. cheese pizza in a clear bag not properly sealed. On 11/27/23 at 1:36 p.m., a white bulk storage bin with a clear transparent lid containing a white powder had no label or date. On 11/27/23 at 1:42 p.m., the CDM stated the white…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to report a communicable disease to the OSDH for four (#19, 47, 48, and #146) of four residents reviewed for COVID-19. The DON identified 96 residents resided in the facility. Four residents were positive for COVID-19 in the facility. Findings: 1. Resident #146 had diagnoses which included cerebral palsy and diabetes. A nursing note, dated 11/18/23, documented Resident #146 tested positive for COVID-19. 2. Resident #47 had diagnoses which included depression and transient ischemic attack. A nursing note, dated 11/23/23, documented Resident #47 tested positive for COVID-19. 3. Resident #19 had diagnoses which included acute kidney failure and COPD. A nursing note, dated 11/24/23, documented Resident #19 tested positive for COVID-19. 4. Resident #48 had diagnoses which included asthma and diabetes. A nursing note, dated 11/24/23, documented Resident #48 tested positive for COVID-19. On 11/30/23 at 9:53 a.m., state reportable incidents were reviewed and there was no documentation Resident #19, 47, 48, and #146's positive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for one (#94) of 20 sampled residents reviewed for resident assessments. The DON identified 96 residents resided in the facility. Findings: Resident #94 had diagnoses which included COPD and hypertension. A Discharge Summary, dated 10/18/23, documented Resident #94 was discharged home with their spouse. It documented Resident #94 was able to walk using a walker and put themselves in a car. Resident #94's discharge resident assessment, dated 10/18/23, documented Resident #94 had a planned discharge to a short-term general hospital (acute hospital). On 11/29/23 at 2:34 p.m., the CM stated Resident #94's discharge resident assessment documented the resident was discharged to an acute hospital. They stated Resident #94's discharge summary documented the resident was discharged home. The CM stated it could have been an error.

Based on observation, record review, and interview, the facility failed to ensure the menu was followed for one of one meal service observed. The Resident Census and Conditions of Residents report, dated 08/21/23, documented 93 residents resided in the facility. The DON identified 93 residents received services from the kitchen. Findings: A Dietary Spreadsheet, dated 03/14/23, documented the lunch service was to contain Dsrt of Day. On 08/21/23 at 12:05 p.m., Resident #14 was observed in the dining room eating a salad. There was no observation a dessert had been provided. On 08/21/23 at 12:07 p.m., Resident #5 was observed in the dining room eating a salad. There was no observation a dessert had been provided. On 08/21/23 at 12:22 p.m., Resident #14 was asked how their lunch was. They stated it was good but they did not get any dessert. They stated it was normal not to be served any dessert. On 08/21/23 at 12:29 p.m., Resident #11 stated they weren't offered a dessert at the lunch meal. On 08/21/23 at 12:30 p.m., Resident #5 stated they didn't receive a dessert at the lunch meal.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure allegations related to verbal and physical abuse was reported accurately and thoroughly investigated for two (#12 and #184) of three sampled residents reviewed for abuse. The Residents Census and Conditions, report, dated 11/27/22, documented 85 residents resided in the facility. Findings: The facility's Abuse, policy, revised 09/16/16, read in part, .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident . Resident #12 had diagnosis of diabetes mellitus type two, chronic kidney disease, and gout. Resident #12's quarterly assessment, documented the resident's cognition was intact, and they required extensive to total assistance with bed mobility, transfers, hygiene, and toileting. It documented the resident had impaired range of motion to bilateral lower extremities and was always incontinent of bowel and bladder. On 11/27/22 at 11:32 a.m., Resident #12 stated CNA #2 was terrible. Resident #12 stated the CNA screamed at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were administrated as ordered for two (#26 and #134) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 11/27/22, documented 85 residents resided in the facility. Findings: The facility's Preparation For Medication Administration policy, read in part, .The resident is always observed after administration to ensure that the dose was completely ingested . 1. Resident #26 had diagnosis which included chronic pain syndrome, hypertension, and chronic combined systolic and diastolic heart failure. A Resident Assessment, dated 10/03/22, documented the resident's cognition was intact. On 11/28/22 at 8:22 a.m., Resident #26 was observed laying in bed with a blanket covering them. A large white pill was observed on the resident's upper abdomen area. Five pills were observed on the floor. Resident #26 was observed to sit up on the side of the bed and the large white pill was still in the blanket. On 11/28/22 at 8:30 a.m., LPN #1 was asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure the kitchen was maintained clean and in good repair, and food was stored in accordance with professional standards for food service safety. The DON identified 85 residents who received food from the kitchen. Findings: A Food Storage policy, revised 04/30/09, read in part, .Label and date all storage containers. Rotate stock. Use the first in, first out method . On 11/27/22 at 9:41 a.m., a tour of the kitchen was conducted. The following observations were made: a. filters on the back of four ovens, and on one oven motor had visible debris, b. undated and expired bread was observed on a rack in the kitchen, and c. the steam cart's splash guard was soiled and cracked. On 11/27/22 at 10:29 a.m., the DM was asked how long they kept bread after it had been opened. They stated for three days. They were asked when the bread had been received. They stated last week. The DM was asked how was the bread dated. They stated, the bread was not dated. They stated the bakery would replace the supply of bread weekly.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to provide a clean homelike environment for one (hall 50 shower) of five shower rooms observed for homelike environment. The Resident Census and Conditions of Residents report, dated 11/27/22, documented 85 residents resided in the facility. The Administrator identified five shower rooms. Findings: Completed Work Orders list, dated 11/01/22 through 11/29/22, contained no documentation regarding the hall 500 shower room. On 11/28/22 at 7:37 a.m., the hall 500 shower room was observed to have brown/black substance covered in a cloudy coating along edge of floor/wall near the whirlpool tub. There were two hoses observed behind the whirlpool tub that are connected to the tub from the wall valve for water source. The hose on the left side was white in color with areas of a black substance covering parts of it. The hose on the right with the yellow handle at the valve was also white in color with the majority of it covered in a black substance. The hose with the yellow handle was observed dripping at the water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to have an adequate system in place to ensure physician order to receive therapy services were followed for one (#60) of 24 sampled residents reviewed for physician orders. The Resident Census and Conditions report, dated 11/27/22, documented 85 residents resided in the facility. Findings: Resident #60 had diagnosis which included COPD, unilateral osteoarthritis right knee, fibromyalgia, scoliosis, bilateral artificial hips, chronic pain, and bed confinement status. Resident #60's quarterly assessment, dated 10/01/22, documented the resident's cognition was intact, and they required extensive to total assistance of one to two persons for mobility ADLs. It documented the resident had no ROM impairment. On 11/27/22 at 2:21 p.m., Resident #60 stated they want to be able to get therapy and walk. Resident #60's Physician Progress Note, dated 09/07/22, read in part, .Orders .po/Ot [sic] evaluation and treatment for generalized weakness and debility, pt requires strengthening, back exercises . Resident #60's Physician's Order,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.