Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 30, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory standards related to medication self-administration, food safety, medical records security, and other facility operations.
Findings
The facility was found deficient in allowing a resident to self-administer nebulization treatment without proper assessment and supervision, improper food storage and handling practices including uncovered and expired foods, inadequate hand hygiene among dietary staff, and failure to securely store archived medical records, exposing resident information to potential unauthorized access.
Deficiencies (3)
Failed to ensure the interdisciplinary team determined clinical appropriateness before allowing a resident to self-administer medications, specifically nebulization treatment.
Failed to ensure foods stored in freezer, refrigerator, and dry storage were covered, expired foods were removed, and dietary staff washed hands between dirty and clean tasks.
Failed to safeguard resident-identifiable information by storing archived medical records in an unsecured garage accessible without supervision.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: Some
Residents affected: Many
Number of nebulization treatments per day: 3
Dates of archived medical records: 2016-2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Observed passing medications and unable to continuously observe resident self-administering nebulization treatment |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and hygiene practices |
| DA #1 | Dietary Aide | Observed handling food and beverages without washing hands |
| DC #2 | Dietary Cook | Observed contaminating hands and improper food handling |
| DA #3 | Dietary Aide | Observed improper hand hygiene during food preparation |
| DC #4 | Dietary Cook | Observed contaminating hands and improper food handling |
| Maintenance Supervisor | Maintenance Supervisor | Reported garage door left open during workday and medical records stored in garage |
| Medical Records Director | Medical Records Director | Interviewed about medical records storage practices |
| Business Office Manager | Business Office Manager | Interviewed about medical records storage and HIPAA compliance |
| Administrator | Facility Administrator | Confirmed medical records stored unsecured in garage and discussed security measures |
| LPN #8 | Licensed Practical Nurse | Stated residents were not allowed to self-administer nebulization treatments |
| Medical Director | Medical Director | Expressed concerns about resident self-administration of nebulization treatments |
| Director of Nursing | Director of Nursing | Stated facility policy requires nurse supervision during nebulization treatments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was conducted due to complaints regarding improper transfer assistance for residents requiring two-person assistance, resulting in falls and injuries to residents #36 and #178.
Complaint Details
The complaint investigation substantiated that CNA #18 and CNA #12 failed to follow care plans requiring two-person assistance during resident transfers, resulting in falls and injuries to residents #178 and #36. Both CNAs were terminated. The facility confirmed the allegations and took corrective actions.
Findings
The facility failed to ensure residents requiring two-person assistance for transfers were transferred by the appropriate number of staff, leading to falls and injuries. Two CNAs (#18 and #12) transferred residents alone despite care plans requiring two-person assistance, resulting in falls with head injuries and bruises. Both CNAs were terminated for not following care plans and facility policies.
Deficiencies (1)
Failure to ensure residents requiring two-person assistance for transfers were transferred by the appropriate number of staff, resulting in falls and injuries.
Report Facts
Residents affected: 2
Fall dates: Falls occurred on 11/06/2024 and 03/31/2025
Morse Fall Scale score: 35
CNA #18 hire date: 11/28/2023
Termination dates: CNA #18 terminated on 11/06/2024; CNA #12 termination date not specified
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #18 | Certified Nursing Assistant | Failed to follow two-person assist care plan, transferred Resident #178 alone resulting in fall; terminated |
| CNA #12 | Certified Nursing Assistant | Failed to follow two-person assist care plan, transferred Resident #36 alone resulting in fall; terminated |
| Director of Nursing | Director of Nursing (DON) | Assessed Resident #178 after fall; confirmed fall and monitoring; interviewed staff |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed Resident #178 after fall |
| Administrator | Facility Administrator | Interviewed regarding incidents, confirmed policy violations and staff terminations |
| Medical Director | Medical Director (MD) | Provided expectations on fall assessments and transfer assistance |
| LPN #10 | Licensed Practical Nurse | Described protocol for resident found on floor |
| CNA #11 | Certified Nursing Assistant | Stated staff should check closet care plan and never lift two-person assist resident alone |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was conducted due to complaints regarding improper transfer assistance leading to falls involving two residents who required two-person assistance for transfers.
Complaint Details
The complaint investigation substantiated that CNA #18 and CNA #12 failed to follow the care plans requiring two-person assistance for transfers, resulting in falls for Resident #178 and Resident #36 respectively. Both CNAs were terminated. The facility confirmed the incidents and the failure to follow protocols.
Findings
The facility failed to ensure residents requiring two-person assistance for transfers were transferred by the appropriate number of staff, resulting in falls and injuries to two residents. Two CNAs were terminated for not following care plans and facility policies regarding resident transfers.
Deficiencies (1)
Failure to ensure residents requiring two-person assistance for transfers were transferred by the appropriate number of staff, resulting in falls and injuries to residents #36 and #178.
Report Facts
Residents reviewed for falls: 4
Falls on specific dates: 2
Morse Fall Scale score: 35
Pain rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #18 | Certified Nursing Assistant | Terminated for transferring Resident #178 alone despite two-person assist requirement, resulting in a fall and injury. |
| CNA #12 | Certified Nursing Assistant | Terminated for transferring Resident #36 alone despite two-person assist requirement, resulting in a fall and injury. |
| Director of Nursing | Director of Nursing (DON) | Provided interviews confirming the incidents and facility policies. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed Resident #178 after fall incident. |
| Administrator | Facility Administrator | Interviewed staff and confirmed policy violations and injuries. |
| Medical Director | Medical Director (MD) | Provided expectations regarding fall assessments and transfer protocols. |
| LPN #10 | Licensed Practical Nurse | Described procedures following resident falls. |
| CNA #11 | Certified Nursing Assistant | Stated staff should check care plans and never lift two-person assist residents alone. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 30, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure proper clinical assessment for residents self-administering medications, food safety violations, secure storage of medical records, and adherence to infection control and medication administration protocols.
Complaint Details
The complaint investigation revealed substantiated issues including improper medication self-administration without assessment, food safety violations, and unsecured storage of medical records.
Findings
The facility failed to ensure that a resident was clinically assessed before self-administering nebulization medication, resulting in minimal harm potential. Food safety violations were observed including uncovered and expired food items and improper hand hygiene by dietary staff. Archived medical records were stored insecurely in an open garage accessible to unauthorized personnel, risking confidentiality breaches.
Deficiencies (3)
Failure to ensure interdisciplinary team assessment before allowing resident to self-administer nebulization medication.
Failure to ensure foods stored were covered, expired items removed, and dietary staff washed hands properly.
Failure to safeguard resident-identifiable information by storing archived medical records in an unsecured garage.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: Some
Residents affected: Many
Date of medication order: Mar 14, 2025
BIMS score: 11
Training date: Feb 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Observed leaving Resident #9 unattended during nebulization treatment and interviewed about medication administration protocol |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety violations and cleaning practices |
| DA #1 | Dietary Aide | Observed handling food and beverages without proper hand hygiene |
| DC #2 | Dietary Cook | Observed contaminating hands and improper food handling |
| DA #3 | Dietary Aide | Observed improper hand hygiene during food preparation |
| DC #4 | Dietary Cook | Observed contaminating hands and improper food handling |
| Medical Director | Medical Director | Interviewed regarding concerns about resident self-administration of nebulization medication |
| Director of Nursing | Director of Nursing | Interviewed about facility policy on medication self-administration and nurse supervision |
| Medical Records Director | Medical Records Director | Interviewed about medical records storage practices |
| Business Office Manager | Business Office Manager | Interviewed about medical records storage and HIPAA compliance |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about storage of medical records in maintenance garage |
| LPN #8 | Licensed Practical Nurse | Interviewed about medication self-administration policies |
| Administrator | Facility Administrator | Interviewed about medication self-administration, medical records storage, and facility security |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 3, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the use of unnecessary psychotropic medications and inaccurate assessments at Bradford House Nursing and Rehab, LLC.
Complaint Details
The complaint investigation focused on the inappropriate use of antianxiety medication as a chemical restraint for Resident #3 and inaccurate reporting of restraint use on the Quarterly MDS. The complaint was substantiated with findings of medication used for staff convenience and failure to document chair/bed alarm restraint use accurately.
Findings
The facility failed to ensure that Resident #3's antianxiety medication was not used as a chemical restraint for exit seeking behaviors and failed to accurately assess the use of a chair/bed alarm restraint on the resident's Quarterly Minimum Data Set (MDS). The facility lacked policies for chemical restraints and MDS assessments, and non-medication interventions were not consistently used prior to medication administration.
Deficiencies (2)
Failure to prevent use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function for Resident #3.
Failure to accurately assess the use of a chair/bed alarm restraint on Resident #3's Quarterly Minimum Data Set (MDS).
Report Facts
Medication dosage: 1
Medication dosage: 0.5
Assessment Reference Date: Oct 30, 2024
Brief Interview of Mental Status score: 14
Falls: 9
Medication administration dates: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated Resident #3 was given antianxiety medication for exit seeking behaviors |
| Director of Nursing | Director of Nursing | Stated antianxiety medication should not be given for exit seeking behaviors and non-medication interventions should be used first |
| Former Assistant Director of Nursing | Assistant Director of Nursing | Signed the MDS with discrepancies and was terminated partially related to these issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 3, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the improper use of psychotropic medications as chemical restraints and inaccurate assessment of restraint use on Resident #3.
Complaint Details
The complaint investigation focused on Resident #3's use of psychotropic medication as a chemical restraint and the accuracy of restraint documentation on the MDS. The complaint was substantiated with findings of improper medication use and inaccurate MDS reporting.
Findings
The facility failed to ensure Resident #3's antianxiety medication was not used as a chemical restraint for exit seeking/wandering behaviors and failed to accurately document the use of a chair/bed alarm restraint on the resident's Quarterly Minimum Data Set (MDS). The facility lacked a policy for chemical restraints and MDS assessments, and non-medication interventions were not consistently used prior to medication administration.
Deficiencies (2)
Failure to prevent use of unnecessary psychotropic medications as chemical restraints for Resident #3.
Failure to accurately assess and document the use of chair/bed alarm restraint on Resident #3's Quarterly MDS.
Report Facts
Medication dosage: 1
Medication dosage: 0.5
Falls: 9
MDS Assessment Reference Date: Oct 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Stated Resident #3 was given antianxiety medication for exit seeking behaviors |
| Director of Nursing | DON | Stated antianxiety medication should not be given for exit seeking behaviors and expected use of non-medication interventions |
| Former Assistant Director of Nursing | Signed the MDS with discrepancies and was terminated partially related to MDS issues |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory standards related to resident safety, medication and food storage, and quality assurance processes.
Findings
The facility was found to have multiple deficiencies including unsafe wheelchair conditions for a resident, a loose threshold posing a safety hazard, expired nutritional supplements not discarded, improper food storage risking cross-contamination, and failure of the Quality Assurance and Performance Improvement (QAPI) Committee to prevent repeated deficiencies.
Deficiencies (5)
Resident #30's wheelchair arms were cracked, torn, and ripped with foam exposed, and maintenance logs showed no documentation of repair.
Loose threshold between Resident #69's room and hallway remained unfixed, posing a safety risk.
Expired fiber-fortified therapeutic malnutrition feedings and liquid supplements were not discarded.
Food items stored improperly with milk cartons placed on top of raw meat, risking cross-contamination.
Quality Assurance and Performance Improvement (QAPI) Committee failed to develop and implement effective plans to prevent repeated deficiencies in food and medication storage.
Report Facts
Expiration date: 2024
Weight: 10
Quantity: 8
Plan of Correction monitoring frequency: 5
Plan of Correction monitoring duration: 4
Recertification survey date: Nov 17, 2022
Recertification survey date: Feb 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about reporting torn wheelchair arms |
| Physical Therapist #1 | Physical Therapist | Interviewed about wheelchair ownership for Resident #30 |
| Physical Therapist #2 | Physical Therapist | Interviewed via telephone about wheelchair responsibility |
| Maintenance #1 | Maintenance Staff | Interviewed about reporting and responsibility for wheelchair repairs |
| Director of Nursing | Director of Nursing | Interviewed about loose threshold and expired nutritional supplements |
| Dietary Manager | Dietary Manager | Interviewed about proper food storage and cross-contamination risks |
| Administrator | Administrator | Interviewed about QAA Committee processes and corrective actions |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, medication and food storage, and quality assurance processes at Bradford House Nursing and Rehab, LLC.
Findings
The facility was found to have multiple deficiencies including unsafe wheelchair conditions, loose thresholds posing safety risks, expired nutritional supplements, improper food storage risking contamination, and failure to implement effective Quality Assurance and Performance Improvement (QAPI) plans to prevent repeated deficiencies.
Deficiencies (5)
Resident's wheelchair arms were cracked, torn, and ripped with foam exposed, posing safety risks.
Loose threshold between Resident #69's room and hallway creating an unsafe environment.
Expired fiber-fortified therapeutic malnutrition feedings and liquid supplements were not discarded by expiration date.
Food items stored improperly with milk cartons placed on top of raw meat risking cross contamination.
Failure of the Quality Assurance and Performance Improvement (QAPI) Committee to develop and implement effective plans to prevent repeated deficiencies in food procurement, drug storage, and medication storage.
Report Facts
Expiration date: 2024
Weight: 10
Quantity: 47
Survey dates: 2
Monitoring frequency: 5
Monitoring duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed about reporting torn wheelchair arms | |
| Physical Therapist (PT) #1 | Interviewed about wheelchair ownership | |
| Physical Therapist (PT) #2 | Interviewed via telephone about wheelchair responsibility | |
| Maintenance #1 | Interviewed about reporting and responsibility for wheelchair arm repairs | |
| Director of Nursing (DON) | Interviewed about awareness of loose threshold and expired nutritional supplements | |
| Dietary Manager | Interviewed about proper food storage and cross contamination risks | |
| Administrator | Interviewed about QAA Committee processes and corrective action monitoring |
Inspection Report
Deficiencies: 5
Date: Nov 17, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies at Bradford House Nursing and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including failure to consistently assist a resident with hearing aids, unsecured medication carts, improper hand hygiene during meal tray distribution, exposure of resident personal health information during medication administration, and failure to consistently wear personal protective equipment (PPE) for a resident on contact isolation precautions. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failed to ensure staff consistently assisted a resident to apply hearing aids.
Failed to ensure medications were securely stored; medication carts left unlocked and one cart in disrepair.
Failed to ensure hands were consistently sanitized to prevent cross contamination during meal tray service.
Failed to ensure residents' personal health information was kept secure during medication administration.
Failed to ensure personal protective equipment (PPE) was consistently worn while providing direct care for a resident on contact isolation.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Medication carts: 3
Medication carts unlocked: 2
Medication cart malfunction: 1
Residents affected: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication storage and resident PHI exposure findings |
| CNA #6 | Certified Nursing Assistant | Named in hearing aid assistance and meal tray hand hygiene findings |
| CNA #5 | Certified Nursing Assistant | Named in hearing aid assistance and meal tray hand hygiene findings |
| CNA #7 | Certified Nursing Assistant | Named in hearing aid assistance and meal tray hand hygiene findings |
| LPN #2 | Licensed Practical Nurse | Named in medication cart security findings |
| LPN #3 | Licensed Practical Nurse | Named in PPE non-compliance finding |
| LPN #4 | Licensed Practical Nurse | Named in medication cart malfunction and meal tray hand hygiene findings |
| Director of Nursing | Director of Nursing | Provided statements on expectations for hearing aid assistance, medication cart security, hand hygiene, resident PHI protection, and PPE use |
| Administrator | Administrator | Provided statements on expectations and policies related to hearing aid assistance, medication cart security, hand hygiene, resident PHI protection |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 17, 2022
Visit Reason
The inspection was conducted based on complaints and observations related to resident care, medication storage, infection control, and staff compliance with facility policies.
Complaint Details
The visit was complaint-related, triggered by concerns about resident care including hearing aid assistance, medication security, infection control practices, and PPE use. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to consistently assist a resident with hearing aids, unsecured medication carts, improper hand hygiene during meal tray distribution, exposure of resident personal health information on medication carts, and failure to consistently use personal protective equipment (PPE) for a resident under contact isolation precautions.
Deficiencies (5)
Failed to ensure staff consistently assisted a resident to apply hearing aids.
Failed to ensure medications were securely stored; medication carts were left unlocked and one cart was in disrepair.
Failed to ensure hands were consistently sanitized to prevent cross contamination during meal tray service.
Failed to ensure residents' personal health information was kept secure during medication administration; computer screens with PHI were left visible.
Failed to ensure personal protective equipment (PPE) was consistently worn while providing direct care for a resident on contact isolation.
Report Facts
Residents affected: 1
Medication carts: 3
Residents affected: 30
Residents affected: 1
Medication administrations: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed leaving medication cart unlocked and computer screen with PHI visible |
| CNA #6 | Certified Nursing Assistant | Stated not assisting Resident #30 with hearing aids due to resident refusal and staff uncertainty |
| Director of Nursing | Director of Nursing | Stated expectation for staff to assist residents with hearing aids and to sanitize hands between meal trays |
| Administrator | Administrator | Stated expectations for staff to assist with hearing aids, lock medication carts, and sanitize hands between meal trays; acknowledged lack of policies |
| LPN #3 | Licensed Practical Nurse | Observed not wearing PPE when providing care to Resident #4 on contact isolation |
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