Bradley Court

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 17, 2022

  Based on observation, interview, and record review, the facility failed to provide supervision and assistance for two of three sampled residents (1, 5) who were identified as high risk for choking. As a result, Resident 1 was not supervised during mealtime, choked on food, and died . There was potential for other residents identified as high risk to choke, if not supervised. Findings: On [DATE] at 11:39 A.M., an unannounced onsite visit was conducted related to a reported unusual occurrence (death). On [DATE], Resident 1's record was reviewed. 1. Resident 1 was readmitted to the facility on [DATE] from an acute hospital for long term care after she had an altered level of consciousness. […]

• No harm, potential for more than minimal, patternF812Mar 13, 2025

  Based on observation, interview and record review, the facility failed to ensure proper food storage and sanitation practices were met in the kitchen according to standards of practice when: 1. A cut up onion was undated, covered in a clear plastic wrap, and stored in a bin with uncut onions. 2. Whipped topping 11 days past the use-by date was stored in the refrigerator. 3. A floor sink had piping without an air gap (space) of at least 1 (inch) between the pipe and drain. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Findings: 1. During the initial kitchen tour on [DATE] at 7:50 A.M., an observation and interview with the Food Service Director (FSD) was conducted. […]

• No harm, potential for more than minimal, patternF880May 17, 2024

  Based on interview, observation and record review, the facility did not ensure food was served in a sanitary manner. This failure potentially put residents at risk for foodborne illness as well as bacterial contamination of foods. Tray line observation was conducted on 5/15/24, at 11:40 A.M. in the kitchen. The menu consisted of meatloaf, vegetables, mashed potatoes, and garlic bread. During plating, the cook picked up the meatloaf from the tray with his gloved left hand and a spatula on the right hand, then place the meatloaf on the first plate. The cook then picked up a garlic bread with his right hand and placed it on the same plate. […]

• No harm, potential for more than minimal, patternF689Jul 25, 2023

  Based on observation,interview and record review, the facility failed to conduct hourly checks in the locked unit of Building 2 and also failed to ensure accurate documentation of hourly checks. This failure led to the elopement (leaving the facility without permission) of Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (episodes of recurring delusions and hallucinations with a pattern of feeling suspicious or mistrustful of other people); Anxiety Disorder (excessive worrying); and Atrial Fibrillation (an irregular heartbeat) per the facility's Admission record. Resident 1 was admitted to the facility under conservatorship due to no capacity to make decisions and no known family. […]

• No harm, potential for more than minimal, patternF880Aug 17, 2022

  Based on observation, interview, and record review, the facility failed to implement infection control program practices when licensed nurse (LN) 1 and two certified nursing assistants (CNAs 1 and 2) did not consistently perform hand hygiene (hand washing or use hand sanitizer) when assisting and feeding the three of 14 sampled residents (3, 4, 5) during a dining observation. As a result, there was the potential for residents exposure to infections. Findings: On 2/25/20 at 11:59 AM, an observation of the dining room in Building 1 was conducted. There were five tables in the dining room and an automatic hand sanitizer was attached to the wall by the entrance door. […]