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Deficiency Records for Bradford Hills Nursing and Rehabilitation Center
A list of the most recent deficiencies for Bradford Hills Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Bradford Hills Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-11-22 | 2024-12-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-11-22 | 2024-12-23 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-11-22 | 2024-12-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-11-22 | 2024-12-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-11-22 | 2024-12-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-11-22 | 2024-12-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-11-22 | 2024-12-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-11-22 | 2024-12-23 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-11-22 | 2024-12-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-11-22 | 2024-12-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-11-22 | 2024-12-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-11-22 | 2024-12-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-11-22 | 2024-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-11-22 | 2024-12-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-11-22 | 2024-12-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-11-22 | 2024-12-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-22 | 2024-12-23 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-11-22 | 2024-12-23 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-11-22 | 2024-12-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-22 | 2024-12-23 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-11-14 | 2024-12-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-11-14 | 2024-12-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-11-14 | 2024-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-11-14 | 2024-12-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-11-14 | 2024-12-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-11-14 | 2024-12-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-10-31 | 2024-11-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-03 | 2024-06-27 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-06-03 | 2024-06-27 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-12-20 | 2024-02-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-20 | 2024-02-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-20 | 2024-02-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-20 | 2024-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-20 | 2024-02-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-20 | 2024-02-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-08 | 2024-01-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-08 | 2024-01-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-08 | 2024-01-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-08 | 2024-01-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-08 | 2024-01-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-08 | 2024-01-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-08 | 2024-01-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-27 | 2023-03-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-27 | 2023-03-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-27 | 2023-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-27 | 2023-03-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-27 | 2023-03-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-27 | 2023-03-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-27 | 2023-03-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-27 | 2023-03-10 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-27 | 2023-03-10 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-01-27 | 2023-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-27 | 2023-03-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-27 | 2023-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-17 | 2023-02-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-01-17 | 2023-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-30 | 2022-04-18 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-30 | 2022-04-18 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-10-31 | Not Fixed | Y |
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