Health inspection·July 31, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of four residents reviewed (Residents R2, R6, and R84). Findings include: Review of facility policy entitled Admission, Transfer, Discharge and Room Change Policy dated 12/8/24, indicated The Manor is required to provide sufficient Preparation. to ensure safe and orderly transfer. and transfers. are documented in the residents clinical record. Review of Resident R2's clinical record revealed an admission date of 7/23/23, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow). Resident R2's clinical record revealed a progress note dated 4/16/25, at 8:31p.m. indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R6's clinical record revealed an admission date of 10/18/23, with diagnoses that included peripheral vascular disease (a condition in the circulatory system which reduces blood flow to the limbs due to narrowing vessels), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Resident R6's clinical record revealed progress notes dated 6/5/25, at 6:20 a.m. and 6/28/25, at 6:06 p.m. indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R84's clinical record revealed an admission date of 11/10/23, with diagnoses that included COPD, hypertension, and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Resident R84's clinical record revealed a progress note dated 6/24/25, at 1:12p.m. indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 7/30/25, at 1:30 p.m. the Director of Nursing confirmed that the clinical records for Residents R2, R6 and R84 lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when transfers occur clinical information should be provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights Page 1 of 5 395700 395700 07/31/2025 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans for a resident with Post Traumatic Stress Disorder (PTSD), and for a resident requiring oxygen therapy that included measurable objectives and timetables to meet a resident's needs for two of 20 residents reviewed (Residents R8 and R84). Findings include: A facility policy entitled, Care Plan, dated 12/08/24, indicated the facility will develop a comprehensive person centered care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; be developed within seven days after the completion of the comprehensive assessment, prepared by the interdisciplinary team, be periodically reviewed and revised by a team of qualified personal after each assessment, and provide services that meet professional standards of quality. Review of Resident R8's clinical record revealed an admission date of 4/08/25, with diagnoses that included Parkinson’s disease, PTSD, anxiety, and depression. Review of Resident R8's person centered plans of care lacked evidence that a plan of care for PTSD was developed. During an interview on 7/30/25, at 11:45 a.m. the Nursing Home Administrator confirmed that a PTSD care plan was not developed for Resident R8. Review of Resident R84’s clinical record revealed an admission date of 11/10/23, with diagnoses that include chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), hypertension (high blood pressure), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R84’s person centered plans of care lacked evidence that a plan of care for respiratory care with use of oxygen was developed. During an interview on 7/30/25, at 1:30 p.m. the Director of Nursing (DON) confirmed that a plan of care for respiratory care with use of oxygen was not developed for Resident R84. He/she also confirmed that a respiratory plan of care with use of oxygen should have been developed. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395700 Page 2 of 5 395700 07/31/2025 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans by the target date and to reflect the current necessary care and services for four of 20 residents reviewed (Resident R4, R11, R78, and R84).Findings include: Review of facility policy entitled Care Plan Policy dated 12/8/24, indicated The Manor will develop a comprehensive person centered care plan for each resident. and Periodically reviewed and revised. Review of Resident R4's clinical record revealed an admission date of 6/10/25, with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R4's person centered care plans revealed a care plan for catheter with a target date (a date on which the care plan should have been revised) of 6/30/25. Review of Resident R11's clinical record revealed an admission date of 12/17/24, with diagnoses that included hyperlipidemia (high cholesterol) and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R11's person centered care plans revealed all his/her care plans with a target date of 6/26/25. Review of Resident R78's clinical record revealed an admission date of 6/7/24, with diagnoses that included COPD, hyperlipidemia, and type II diabetes (the pancreas does not make enough insulin to control blood sugar levels). Review of Resident R78's person centered care plans revealed all his/her care plans with a target date of 7/17/25. Review of Resident R84's clinical record revealed an admission date of 11/10/23, with diagnoses that included COPD, hypertension (high blood pressure), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R84's person centered care plans revealed all his/her care plans with a target date of 7/10/25. During an interview on 7/30/25, at 1:30 p.m. the Director of Nursing confirmed that Residents R4, R11, R78, and R84's care plans were beyond their target dates and that the care plans should have been updated by the target dates. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395700 Page 3 of 5 395700 07/31/2025 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and change/date oxygen tubing and humidifier bottle according to physician's orders for one of two residents reviewed for respiratory services (Resident R84).Findings include: Review of facility policy entitled Respiratory Services dated 12/8/24, indicated oxygen cannulas [oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery] frequency of change weekly or PRN (as needed), prefilled humidifier bottles frequency of change weekly or PRN when empty. Review of Resident R84's clinical record revealed an admission date of 11/10/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), hypertension (high blood pressure), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R84's physician's orders revealed orders for oxygen at two liters per minute per nasal cannula as needed and oxygen maintenance change O2 [oxygen] tubing and supply bag weekly. change water jug weekly. Review of Resident R84's vital sign records revealed that he/she used his/her oxygen 21 times between 6/23/25, and 7/29/25. Observations on 7/28/25, at 2:00 p.m. revealed a nasal cannula attached to an oxygen tank on the back of Resident R84's wheelchair with no date and a humidifier water bottle attached to an oxygen concentrator that was dated 6/23/25. Further observations on 7/29/25, at 8:30 a.m., 9:28 a.m., and again at 12:25 p.m. revealed the nasal cannula remained attached to the oxygen tank with no date and the humidifier water bottle attached to the concentrator remained dated 6/23/25. During an interview on 7/29/25, at 12:25 p.m. Licensed Practical Nurse Employee E2 confirmed that Resident R84's nasal cannula lacked a date, and the humidifier water bottle was dated 6/23/25. He/she also confirmed that the nasal cannula and the humidifier water bottle should have been changed. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395700 Page 4 of 5 395700 07/31/2025 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during wound care for one of three residents that require EBP's (Resident R9) and failed to provide appropriate infection control measures regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of three residents reviewed with a catheter (Resident R4).Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, dated 12/08/24, are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO). It also indicated that gloves and gown are to be applied prior to performing the high contact resident care activities, which includes wound care. Review of facility policy entitled Infection Control dated 12/8/24, indicated implementation of control measures, the prevention and spread of health care associated infections are accomplished using standard precautions and other barriers, and staff and resident education focuses on risk of infection and practices to decrease this risk. Review of Resident R9's clinical record revealed an admission date of 3/16/23, with diagnoses that included diabetes mellitus (condition where the body doesn't produce enough insulin to control blood sugar levels), diabetic neuropathy, diabetic foot ulcer. and chronic kidney disease. Review of Resident R9's physician's orders dated 6/16/25, included an order to cleanse the right heel diabetic ulcer and apply Dakins solution gauze to the wound and cover with dry dressing. Observation of wound care on 7/29/25, at 12:20 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 entered Resident R9's room without donning (putting on) a gown. Resident R9's room had a sign above the bed indicating EBP's and gloves and gowns were available in the resident's room. During an interview on 7/29/25, at 12:25 p.m. LPN Employee E1 confirmed he/she did not don a gown prior to entering Resident R9's room. Review of Resident R4's clinical record revealed an admission date of 6/10/25, with diagnoses that included Benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to become enlarged and cause difficulty urinating) chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R4's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 7/4/25, revealed that Resident R4 had an indwelling urinary catheter. Observations on 7/29/25, at 8:35 a.m., 9:30 a.m., and again at 12:10 p.m. revealed Resident R4's urinary drainage bag lying flat on the floor with the drainage spout (the part of the urinary bag that opens to empty urine from the bag) facing down and touching the floor. During an interview on 7/29/25, at 12:26 p.m. LPN Employee E2 confirmed that the urinary drainage bag was lying on the floor face down and also confirmed that the urinary drainage bag should not be on the floor. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Residents Affected - Few 395700 Page 5 of 5