Inspection·June 20, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the main kitchen area. Residents Affected - Some Findings include: Observation of the facility's main kitchen on June 20, 2025, at 10:28 AM with Employee 1 (dietary clerk) and Employee 2 (dietitian) revealed the following: The dishwashing area had multiple smaller winged insects flying around. Two dead cockroach appearing insects were observed in the overhead wooden cupboards in the dishwashing area. These cupboards contained several loose unused trash bags and multiple boxes of surgical masks. An opening between the wall splash guard and the underlying wall was observed. This opening was located under the stainless-steel counter in the dishwashing area. Further observation of this area revealed the plastic splash guard was not securely affixed to the wall as noted while pushing in the center of the splash guard. While tapping on the splash guard, there was obvious insect activity noted as evidenced by a cockroach appearing insect being observed just inside the opening to the area between the splash guard and wall. Further observation revealed a thick, black colored, greasy, and sticky substance that coated the bottom of the stainless-steel table in the dishwashing area. Observation of the cook area located on the opposite side of the kitchen from the dishwashing area revealed three dead cockroach appearing insects on the floor behind various cooking appliances. There was unidentified debris on the floor. An interview with Employee 3, cook, on June 20, 2025, at 10:37 AM revealed sightings of cockroaches under the floor mats in the cook area in the morning. Further observation of this area revealed four live cockroach appearing insects coming from underneath a wheeled cart against the wall (adjacent to the floor mats) that was used for storing clean pots and pans. There was also a dead cockroach appearing insect on the floor and an extensive build-up of dirt and debris along the perimeter of the wall. Multiple air vents above a double set of egress doors to the kitchen contained a significant (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395586 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bradford Hills Nursing & Rehabilitation Center 15900 Route 6 Troy, PA 16947 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)