Deficiency Records for Bradford Hills Nursing and Rehabilitation Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-01-28 | 2022-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-28 | 2022-02-28 | 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 | 2022-01-28 | 2022-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-28 | 2022-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-28 | 2022-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-28 | 2022-02-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
