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....
Latest reports, citations, and penalties from CMS data
On the evening of April 3, 2026, a registered nurse at Bradford Place called 911 and sent Resident 67 to the hospital by ambulance....
A PEG tube, or percutaneous endoscopic gastrostomy tube, delivers nutrition directly into the stomach for residents who cannot eat by mouth....
Housekeeper F showed inspectors an empty gallon jug of P&G Proline, the product the facility had previously used....
They had not been delivered to him....
The inspectors found it hadn't....
That's what federal health inspectors documented at Desert Springs Post Acute when they visited the Palm Desert facility on April 24....
The resident, identified in inspection records as R5, approached the inspector on May 20, 2026, and asked if something could be done about her medications....
That was the state of Grove at Kirkwood's facility assessment when federal inspectors arrived on January 29, 2026....
When federal inspectors sat down with the DON on April 23, 2026, she acknowledged she was personally responsible for updating every care plan in the facility....
The January 2026 inspection turned up a gap between what the facility promised on paper and what it delivered in practice....
Both nephrostomy tubes, the drainage tubes running directly from her kidneys through her back, were draining dark amber urine with a foul odor....
The inspection took place on January 28, 2026....
The medication was never filled....
That's not a paperwork problem....
Housekeeper F said no one had told him or her how much of the new cleaner to use....
The resident, identified in inspection records as R4, had been living at Metropolis Rehab & Health Care Center since November 2023....
Resident 87 arrived at the facility in November 2024, recovering from hip surgery and living with dementia and anxiety....
The respiratory care citation fell under a category inspectors use specifically for failures in quality of life and care....
Inspectors visited Hillside Health Care Center on April 24, 2026, following a complaint....
That call took place on May 20, 2026....