Bradbury Commons

In the surveyor’s words

From the most serious findings on record at Bradbury Commons, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Aug 15, 2022

  On 08/10/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have an effective infection control program to properly prevent and/or contain the spread of COVID-19. Staff members were not conducting COVID-19 screenings. Staff were not utilizing proper PPE when caring for COVID-19 positive residents and were not wearing face masks properly. COVID-19 positive resident rooms did not have the appropriate transmission based precautions signage and staff were not able to identify which residents were COVID-19 positive. COVID-19 testing was not conducted per facility policy and CDC/CMS guidance for staff and residents. The facility had no tracking of signs and symptoms of COVID-19 to ensure proper isolation timeframes. […]

• Immediate jeopardy, isolatedF760Mar 21, 2023

  A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 02/21/23 related to the facility's failure to ensure a resident was administered medication as ordered in the discharge instructions. The facility failed to ensure Plavix and Aspirin were not continued upon admission when the Resident had a diagnosis of traumatic subdural hematoma. (A serious condition where blood collects between the skull and the surface of the brain.) Resident #1's CT scan of the head, dated 03/04/23 documented the resident's subdural hematoma had increased in size and had an increased right to left midline shift which measured 1.4 cm. […]

• Immediate jeopardy, isolatedF580Sep 22, 2022

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician when a resident had an abnormal blood pressure and medication was held. Resident #1 had blood pressure readings of ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Resident #1' medical record revealed the physician was not notified when the resident's blood pressure was low and when the cardiac medication was held. Resident #1 had a [CONDITION(S)] on [DATE] which resulted in death on [DATE]. […]

• Immediate jeopardy, isolatedF684Sep 22, 2022

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor and intervene when a resident had an abnormal blood pressure. Resident #1 had blood pressure readings of ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Resident #1' medical record revealed the blood pressure was not rechecked, the resident was not assessed, and the physician had not been notified of the blood pressure readings. Resident #1 had a [CONDITION(S)] on [DATE] which resulted in death on [DATE]. […]

• No harm, potential for more than minimal, widespreadF563Sep 30, 2021

  Based on interview and record review, the facility failed to ensure the rights of residents to receive visitors for one ( #1) of three residents reviewed for visitation. The ADON identified 52 residents resided in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An Admission Assessment, dated 09/06/21, read in part, the resident's cognition was intact and they required a walker for mobility. A care plan, read in part, the resident was at risk for isolation related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A nursing note, dated 09/17/21, read in part, Pt has been dc'd from the COVID unit et moved to room (# withheld) . On 09/30/21 at 11:40 a.m., resident #1 was asked if she had received visitors. […]