Bradford Place Care Center: DNR Order Ignored - OH
On the evening of April 3, 2026, a registered nurse at Bradford Place called 911 and sent Resident 67 to the hospital by ambulance. The resident had been living at the facility since late February, admitted with chronic obstructive pulmonary disease, peripheral vascular disease, type two diabetes, and encephalopathy. Cognitively intact, according to a formal assessment completed the previous month, the resident required help with daily activities but could participate in decisions about their own care.
One of those decisions was a do-not-resuscitate comfort care order, documented in the physician's orders on March 2. The order was clear. What Bradford Place never obtained was the actual signed DNRCC form, the state document that paramedics are required to have in hand before they can honor any advance directive.
When the ambulance crew arrived, care staff told them the resident's code status was DNRCC. They had no form to back it up.
One paramedic, identified in the inspection report as Paramedic 500, confirmed the facility did not have a signed copy of the DNRCC form when the resident was transferred. Because the paperwork wasn't there, EMS treated the resident as full code during the ambulance ride and upon arrival at the hospital. A second paramedic, Paramedic 501, told inspectors the same thing. Staff had handed him a face sheet that listed the DNRCC status, but he explained that EMS required the actual state form to honor the directive. A face sheet wasn't enough.
The registered nurse who made the 911 call, RN 189, confirmed to inspectors on April 20 that the facility did not have a signed copy of the DNRCC form on file to give to EMS when the resident left.
The inspection report does not say whether the resident survived the hospitalization. The discharge date listed in the medical record is April 12, nine days after the ambulance transfer. What happened during those nine days, and what interventions the resident may have received against their stated wishes, the report does not say.
Bradford Place's own policy on advance directives, dated September 2022, required the nurse supervisor to inform EMS personnel of a resident's advance directive and provide a copy of that directive to the crew. The policy existed. The form did not.
Inspectors reviewed the medical record from the resident's admission on February 27 through April 3 and found no signed DNR form anywhere in the chart. More than five weeks passed between the physician's order establishing the code status and the night paramedics arrived and found nothing they could legally act on.
The deficiency was cited at a level of minimal harm or potential for actual harm, a designation that reflects the regulatory floor, not the full weight of what the finding describes. A cognitively intact person had chosen the terms under which they did not want to be treated. A nursing home failed to secure the one document that would have given those terms legal force in an emergency. Two paramedics confirmed it. The nurse confirmed it. The EMS run report confirmed it.
The inspection was completed April 24, 2026, triggered by a complaint. The resident had already been discharged twelve days before inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bradford Place Care Center from 2026-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 16, 2026 · Our methodology
BRADFORD PLACE CARE CENTER in HAMILTON, OH was cited for violations during a health inspection on April 24, 2026.
On the evening of April 3, 2026, a registered nurse at Bradford Place called 911 and sent Resident 67 to the hospital by ambulance.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.