Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradford Place Care Center during CMS and state inspections, most recent first.
The facility failed to properly manage resident trust funds by making multiple unauthorized online retailer purchases from the accounts of several residents with conditions such as CHF, Alzheimer’s disease, aphasia, epilepsy, ESRD, anxiety disorder, and type 2 DM, including both cognitively intact and cognitively impaired individuals who required staff assistance with ADLs. For each affected resident, fund statements showed specific debits that were not signed or authorized by the resident or a representative, despite a facility policy requiring signed vouchers or check request forms and invoices for withdrawals. In addition, the facility did not document that quarterly resident fund statements were provided to residents or their representatives for two consecutive quarters, and the Administrator confirmed both the unauthorized transactions and the absence of quarterly statements during interviews.
Surveyors found that the facility did not notify multiple Medicaid residents or their representatives when resident trust fund balances approached the SSI resource limit, as required. Review of medical records and quarterly fund statements showed that several residents with conditions such as CHF, Alzheimer’s disease, diabetes, epilepsy, ESRD, anxiety disorder, and prior CVA, ranging from cognitively intact to severely impaired and all needing ADL assistance, had account balances between roughly $1,600 and $7,400 over several quarters. Despite these balances reaching the point at which notification is mandated, there was no documentation that any notifications were provided, and the Administrator confirmed that such notifications had not been made.
Multiple residents with cognitive impairment and complex medical conditions had their trust fund accounts used by former administrative and activities staff to make unauthorized online purchases of clothing, electronics, snacks, personal care items, and activity supplies. Required documentation and signatures authorizing withdrawals were absent, and some residents reported not requesting or receiving the items, while searches showed that certain items were missing or located in the activities department instead of with the residents. Former staff reported that they were informed when Medicaid residents’ balances exceeded allowable limits and then ordered items from an online retailer based on lists or general discussions, but without proper consent from residents or their representatives, resulting in misappropriation of resident funds and belongings.
The facility failed to timely report multiple instances of misappropriation of resident trust funds, where several cognitively impaired and cognitively intact residents had unauthorized online purchases made from their accounts by former business office, activities, and social services staff. Items such as clothing, electronics, personal care products, snack foods, and dementia activity supplies were ordered without resident or representative consent, often without required documentation or signatures, and some items were never received by the residents and were instead found in the activities department. An activities staff member observed large quantities of goods ordered under resident accounts being stored and used in the activities area, suspected misappropriation, but did not report these concerns to the Administrator, DON, or corporate office, contributing to delayed reporting of these abuse allegations to the state agency as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of misappropriation of resident funds involving several cognitively impaired and cognitively intact residents. Unauthorized online purchases were made for clothing, electronics, snacks, personal care items, and activity supplies using resident trust accounts without resident or representative consent, and documentation of these purchases was absent from medical records. Some items bought with resident funds were not received by the residents and were instead found in the activities department or could not be located. Former business office, activities, and social services staff, as well as facility leadership, had access to and approved these orders, yet not all potential perpetrators were investigated, and suspicions raised by a staff member were not promptly reported to administration or corporate leadership, contrary to facility policies requiring resident authorization and thorough investigation of misappropriation.
A resident with multiple chronic conditions had a physician order indicating DNRCC status, but no signed DNR/DNRCC form was present in the chart for more than a month after admission. When the resident was sent to the hospital by EMS, an RN informed EMS of the DNRCC status and provided a face sheet reflecting this, but could not supply the required state DNR form signed by a physician. EMS staff confirmed they did not receive the necessary documentation and therefore treated the resident as full code during transport, contrary to the facility’s own advanced directives policy that requires providing EMS with a copy of the resident’s advance directive.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital without her DNRCC-Arrest paperwork due to a malfunctioning printer. Despite notifying the hospital of her code status, the EMS run report indicated no documentation was provided, leading to the resident being intubated against her pre-existing code status.
Unauthorized Use and Poor Accounting of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to properly manage resident personal funds, including making unauthorized purchases from resident trust accounts and failing to provide required quarterly account statements. For multiple residents, surveyors identified debits to online retailers that were not signed or authorized by the residents or their representatives, despite facility policy requiring such authorization via vouchers or check request forms. The facility also did not document that quarterly resident fund statements were sent to the residents or their representatives for the fourth quarter of 2025 and the first quarter of 2026. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs. This resident’s fund statement showed debits for online retailer purchases in specific amounts on two dates, and the resident’s representative had not authorized these transactions. The Administrator verified that these purchases were made from the resident’s funds without authorization and confirmed that quarterly statements for the relevant quarters had not been provided to the resident or representative. Another resident, cognitively intact with type 2 diabetes mellitus, PTSD, and osteoarthritis, had a substantial increase in account balance over a quarter, yet there was no documentation that quarterly statements were sent, which the Administrator also confirmed. Additional residents with varying levels of cognitive impairment and medical conditions, including type 2 diabetes mellitus, pulmonary hypertension, generalized anxiety disorder, epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, and Alzheimer’s disease, were similarly affected. Their quarterly fund statements showed multiple debits to an online retailer on various dates and in specific amounts, none of which were signed or authorized by the residents or their representatives. For each of these residents, record review showed no documentation that quarterly statements for the fourth quarter of 2025 or the first quarter of 2026 were sent, and in interviews, the Administrator consistently verified both the unauthorized nature of the purchases and the failure to provide the required quarterly statements. Review of the facility’s undated Resident Trust Funds policy showed that resident fund withdrawals were supposed to be supported by signed vouchers or check request forms and invoices, which was not followed in these cases. Across all six residents reviewed for this issue, the survey findings demonstrated that the facility did not maintain resident fund accounts using basic accounting principles as required by its own policy. Unauthorized online purchases were repeatedly charged to resident accounts without the required signatures or documented consent, and there was a systemic lack of documentation that quarterly fund statements were provided to residents or their representatives for two consecutive quarters. These actions and omissions formed the basis of the cited deficiency related to the management and safeguarding of resident personal funds.
Failure to Notify Medicaid Residents of Trust Fund Balances Near SSI Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify Medicaid residents or their representatives when resident trust fund balances approached the Supplemental Security Income (SSI) resource limit. Surveyors reviewed medical records, resident fund account statements, and conducted staff interviews, and determined that six of seven sampled residents with Medicaid payor sources did not receive required notifications when their account balances reached $200 less than the SSI resource limit. There was no documentation of such notifications in the records for these residents, despite quarterly fund statements showing balances at or above the threshold. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs; this resident’s account balance during one quarter ranged from $2270.97 to $1888.16 without any documented notification. Another resident with type 2 diabetes mellitus, PTSD, and osteoarthritis, who was cognitively intact but required ADL assistance, had a quarterly account balance that increased from $1750.26 to $7395.49, again with no documentation of notification when the balance reached the required threshold. A third resident with type 2 diabetes mellitus, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and needed ADL assistance, had a quarterly balance that decreased from $2193.82 to $1618.38, with no evidence of notification at the appropriate point. Additional residents with epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, type 2 diabetes mellitus, Alzheimer’s disease, and congestive heart failure were also affected. These residents ranged from cognitively intact to severely cognitively impaired and all required assistance with ADLs. Their quarterly resident fund statements showed balances between approximately $1600 and nearly $5000 over multiple quarters, yet there was no documentation that they or their representatives were notified when their balances reached $200 less than the SSI resource limit. In an interview, the Administrator confirmed that the facility had not provided the required notifications for these residents when their resident fund accounts reached the specified threshold.
Misappropriation and Unauthorized Use of Resident Trust Funds for Online Purchases
Penalty
Summary
The deficiency involves the misappropriation and unauthorized use of resident trust funds and belongings by former facility staff, including the former Business Office Manager (BOM), former Activities Director (AD), and former Social Services (SS) staff. Facility records showed that multiple residents had debits from their resident fund accounts for online retailer purchases that were not authorized by the residents or their representatives, and required documentation such as signed vouchers or check request forms was absent. The facility’s own abuse policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the documented actions of staff met this definition. One resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, had several online purchases charged to her resident funds account, including clothing and snack items, without authorization from her representative. Progress notes contained no documentation of these purchases by the former BOM, AD, or SS. The resident later confirmed that items had been purchased using his account and that he believed a television had been ordered but never received. The Administrator confirmed that the former AD made unauthorized online purchases from this resident’s account and that the facility could not verify that all items, including a cowboy outfit and other clothing, were provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional supplements. These purchases were not documented in progress notes and were not authorized by the resident or her representative. The resident reported that a cart of items was brought to her, including a new tablet and clothing she had not requested, and that she sent the items back. The Administrator verified that the former SS placed a substantial order under this resident’s name with the intent that the cost be withdrawn from her account, despite the lack of authorization. A resident with type 2 diabetes, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and required ADL assistance, had debits from his funds account for hearing aids and a television purchased through an online retailer. His representative had not authorized these purchases, and there was no documentation in progress notes of such purchases by the former BOM, AD, or SS. The Administrator confirmed that the former BOM and former AD used this resident’s funds to buy hearing aids and a television without authorization and that the television purchased for the resident was not in his possession and was suspected to be elsewhere in the facility. Another resident with epilepsy, end-stage renal disease, and aphasia following cerebral infarction, who was severely cognitively impaired and dependent for ADLs, had multiple online retailer debits from his resident funds account that were not authorized by his representative. Items purchased included a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks. There was no documentation in progress notes of these purchases by the former BOM, AD, or SS. The Administrator confirmed that these items were purchased without authorization, and a search of the resident’s room with his permission revealed that some of the items ordered were not present. A further resident with Alzheimer’s disease, congestive heart failure, and type 2 diabetes, who was severely cognitively impaired and required ADL assistance, had multiple unauthorized debits from his resident funds account for online purchases. Items included cologne, boys’ pajamas, slippers, socks, various snack foods, soda, a record player, dementia activity items, televisions, a fidget blanket, and a music set. The resident’s representative had not authorized these purchases, and there was no progress note documentation by the former BOM, AD, or SS. A search of the resident’s room showed that some items were missing and some were found in the activities department. The Administrator verified that the former BOM and former AD used this resident’s funds to purchase these items without authorization. Interviews with former staff clarified how these actions occurred. The former BOM stated that she informed the former AD and former SS when Medicaid residents’ account balances exceeded $2000 and needed to be spent down, and that some items purchased were used by the activities department. She reported that the former AD and former SS would talk with residents about their needs and interests and then order items from the facility’s online retailer account. The former AD stated that he placed online orders as directed by the Administrator and former BOM, based on lists of items they provided that were said to be derived from conversations with residents. Across the affected residents, required authorization from residents or their representatives was not obtained, documentation in the medical record was lacking, and some purchased items were not in the residents’ possession, constituting misappropriation of resident funds and belongings. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that residents be free from misappropriation of property. Despite these policies, the documented practice involved staff initiating and completing purchases using resident funds without the necessary signatures or clear consent, and in some cases items were used by the activities department or not located with the resident. These actions and omissions led to substantiated findings of misappropriation of resident funds for several residents, as documented in the facility’s self-reported incidents and confirmed by the Administrator.
Failure to Timely Report Misappropriation of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of misappropriation of resident funds to the proper authorities, despite multiple instances where resident trust accounts were used without authorization. For one resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed debits for online purchases that were not authorized by the resident’s representative. Items such as a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit, and a sweatshirt were charged to this resident’s account, and documentation of these purchases by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff was absent from the medical record. The resident later confirmed that items had been purchased using his funds and that he believed a television had been ordered but never received. Another resident, cognitively intact but requiring assistance with ADLs and diagnosed with type 2 diabetes mellitus, PTSD, and osteoarthritis, had large online purchases made in her name, including a tablet, tablet keyboard, clothing, personal care items, and other supplies totaling thousands of dollars. These purchases were made by former SS staff without authorization from the resident or her representative, and there was no documentation of these purchases in the progress notes. The resident reported that a cart of items was brought to her, including a tablet and clothing she had not requested, and that she sent the items back. The Administrator later verified that the purchase was made with the intent to withdraw the full amount from the resident’s account, even though the account had not yet been charged at the time of the initial internal review. Additional residents with varying levels of cognitive impairment and dependence for ADLs also had unauthorized online purchases made from their trust accounts. One moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had hearing aids and a television purchased without representative authorization, and the television could not be located. Another severely cognitively impaired resident with epilepsy, end-stage renal disease, and aphasia had multiple clothing and personal items ordered without authorization, with some items not found in his room. A further severely cognitively impaired resident with Alzheimer’s disease, congestive heart failure, and diabetes had numerous items such as cologne, boys’ pajamas, slippers, socks, snack foods, televisions, a record player, dementia activity items, and other products purchased without authorization, with some items missing and some found in the activities department. Interviews with former BOM and AD staff revealed that they used resident funds, including for Medicaid residents over the $2000 resource limit, to order items via an online retailer, and that some items purchased under resident accounts were kept and used in the activities department rather than being provided to the residents. An activities staff member reported she suspected misappropriation when large quantities of items ordered under resident accounts were stored in the activities room and not delivered, but she did not report these suspicions to the Administrator, DON, or corporate office, contributing to the facility’s failure to timely report the misappropriation allegations as required by its abuse policy. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that misappropriation of resident property be reported to the state agency within required timeframes. Despite these policies, multiple residents’ accounts showed unauthorized debits for online purchases without the required signatures or documentation, and staff interviews confirmed that items were ordered and sometimes used for general activities rather than for the specific residents whose funds were charged. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because an activities staff member did not escalate her suspicions of misappropriation to facility leadership, resulting in delayed recognition and reporting of the misappropriation of resident funds.
Failure to Thoroughly Investigate Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of misappropriation of resident funds, including failure to investigate all alleged perpetrators. For one resident with CHF, Alzheimer’s disease, and aphasia who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed unauthorized debits to an online retailer, including purchases of clothing and snack items. The resident’s representative did not authorize these purchases, and there was no progress note documentation by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff regarding these transactions. Online retailer receipts showed that the former AD made several purchases under the resident’s name, and the Administrator later confirmed that items such as a cowboy outfit and other clothing could not all be verified as having been provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional products. The quarterly fund statement reflected significant activity, and receipts showed that the former SS used the resident’s funds for these items without authorization from the resident or her representative. The resident reported that a cart of items was brought to her, that she had not requested them, and that she sent them back, including a tablet when she already had one. The Administrator confirmed that the former SS placed a large order under this resident’s name without authorization and that the purchase was made with the intent that the cost be withdrawn from the resident’s account. A moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had unauthorized online retailer debits for hearing aids and a television, with no documentation in progress notes by the former BOM, former AD, or former SS. Receipts showed the former AD purchased hearing aids and the former BOM purchased a television using the resident’s funds, and the Administrator confirmed these purchases were unauthorized and that the television’s location was unknown. Another severely cognitively impaired resident with epilepsy, ESRD, and aphasia had unauthorized debits for clothing and personal items, with no documentation of purchases in the medical record. Receipts showed the former BOM and former AD purchased multiple clothing items and labels using the resident’s funds without authorization, and some items could not be found in the resident’s room. A further severely cognitively impaired resident with Alzheimer’s disease, CHF, and diabetes had multiple unauthorized online purchases for televisions, snacks, clothing, activity items, and other goods, with no documentation by the former BOM, former AD, or former SS. Receipts showed the former BOM and former AD used this resident’s funds for numerous items, some of which were later found stored in the activities department rather than with the resident. Interviews with former and current staff revealed that the former BOM, former AD, and former SS were involved in directing and placing orders using resident funds, including for residents on Medicaid who were over the $2000 resource limit, and that some items purchased with resident funds were used by the activities department. The former BOM stated that the Administrator was aware of and approved all online orders, and the former AD stated he ordered items as directed by the Administrator and former BOM. The current AD reported that the former AD told her he would order items for one resident using another resident’s funds and that numerous snack and activity items ordered under resident fund accounts were kept in the activities room and never delivered to residents; she discussed her suspicions with other staff but did not report them to the Administrator, DON, or corporate office. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because the AD did not report her suspicions, and leadership interviews confirmed that the Administrator and a corporate clinical operations leader had access to and approved online orders but were not fully investigated as potential perpetrators. The facility’s own policies required resident or designee signatures for fund disbursements and mandated thorough investigation and timely reporting of misappropriation, which did not occur in these cases.
Failure to Provide Required DNRCC Documentation to EMS During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to properly implement and document a resident’s do not resuscitate comfort care (DNRCC) status and provide the required documentation to EMS during transfer. The resident was admitted with multiple diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, type 2 diabetes mellitus, and encephalopathy, and was documented as cognitively intact and needing assistance with ADLs. A physician’s order dated 03/02/26 indicated the resident’s code status as DNRCC, but review of the medical record from admission through 04/03/26 showed there was no DNR or DNRCC form signed by a physician in the chart. The medical record also did not contain a DNRCC form, despite the code status order. On 04/03/26, a nurse received an order to send the resident to the hospital via EMS and called 911; EMS transported the resident. The EMS run report documented that facility staff stated the resident’s code status was DNRCC, but they were unable to provide a DNRCC form to accompany the resident. Interviews with the RN who arranged the transfer and with two paramedics confirmed that the facility did not have a signed DNRCC form on file to give to EMS, and that only a face sheet indicating DNRCC status was provided. EMS personnel reported that, without the required state DNR form signed by a physician, they were required to treat the resident as full code during transport and upon hospital admission. Review of the facility’s Advanced Directives policy showed that the nurse supervisor was required to inform EMS of a resident’s advanced directive and provide a copy of the directive, which did not occur in this case.
Failure to Provide DNR Documentation During Resident Transfer
Penalty
Summary
The facility failed to ensure a resident was adequately prepared for a transfer by not providing EMS and the hospital with the resident's code status and other pertinent information. The resident, who had severe cognitive impairment and multiple diagnoses including spinal stenosis, type 2 diabetes mellitus, Alzheimer disease, and hypertension, was found unresponsive in her room. Despite the facility staff calling 911 and notifying the hospital of the resident's DNRCC-Arrest status, the EMS run report indicated that no documentation or further information was provided. Consequently, the resident was transported to the hospital without her DNRCC-Arrest paperwork, leading to her being intubated against her pre-existing code status due to the lack of available information upon arrival at the hospital. Interviews with facility staff revealed that the failure to provide the necessary documentation was due to a malfunctioning printer, which prevented the staff from printing the resident's DNRCC-Arrest form and other pertinent information. The facility's policy required a transfer summary to be completed when a resident is transferred to the hospital, but this was not adhered to in this case. The hospital records confirmed that the resident was intubated and later had life support withdrawn once the appropriate paperwork was obtained and the family was contacted. This deficiency was investigated under Complaint Number OH00153365.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkeley Square Retirement Cen | 0.8 mi | — | 4 | 0 |
| Westover Retirement Community | 1.1 mi | — | 6 | 0 |
| Jamestowne Rehabilitation | 1.2 mi | — | 0 | 0 |
| Golden Years Nursing Center | 2.8 mi | — | 0 | 0 |
| Residence At Huntington Court | 3.4 mi | — | 2 | 0 |
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