Bradley Creek Health Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Dec 22, 2022

  Based on observations and staff interviews the facility failed to remove expired food items stored for use in the walk-in refrigerator. This practice had the potential to affect the foods served to the residents. The findings included: Initial observation of the kitchen walk-in refrigerator occurred on [DATE] at 10:15 AM with the Director of Dining Services and revealed a plastic container of mandarin oranges with a discard date of [DATE]. A follow-up observation of the kitchen walk-in refrigerator on [DATE] at 11:25 AM revealed a plastic container of yellow sliced cheese with a discard date of [DATE] and a plastic container of chocolate mousse with a discard date of [DATE]. An interview with the Chef was completed on [DATE] at 11:25 AM. […]

• No harm, potential for more than minimal, patternF867Dec 22, 2022

  Based on observations and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of [DATE]. This was for 1 deficiency cited in the area of Food and Nutrition Services (F812). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F 812: Based on observations and staff interviews the facility failed to remove expired food items stored for use in the walk-in refrigerator. […]

• No harm, potential for more than minimal, patternF812Oct 8, 2021

  Based on observations and staff interviews the facility failed to: 1) maintain broccoli at 135 degrees Fahrenheit (F.) or higher on the lunch meal tray line, and 2) maintain chicken salad, at 41 (F.) or below on the lunch meal tray line. Both of these items could be potentially hazardous if not served at the appropriate temperatures. The findings include: 1. An observation of the lunch meal tray line on 10/04/21 at 12:15 PM revealed a large stainless-steel serving tray of broccoli on the serving line (with the warming tray's switch off). Temperature monitoring, by the Chef on 10/04/21 at 12:30 PM revealed the following temperatures: broccoli - 80 degrees F. and chicken salad 53 degrees F. […]

• No harm, potential for more than minimal, isolatedF580Apr 11, 2024

  Based on record review, Nurse Practitioner, Physician, Responsible Party, and staff interviews, the facility failed to notify the responsible party of a change in medication for 1 of 1 residents (Resident #85). Findings included: Resident #85 was admitted to the facility on [DATE]. Diagnoses included, in part, fracture of left femur, presence of left artificial hip joint, fall, and epilepsy. The Minimum Data Set admission assessment dated [DATE] revealed Resident #85 was moderately cognitively impaired and was coded as receiving scheduled pain medication and as needed pain medication. Resident #85's pain was assessed and noted to be frequent with difficulty sleeping at night and limited day to day activities. Pain described at severe. […]

• No harm, potential for more than minimal, isolatedF758Apr 11, 2024

  Based on observations, record review, Physician Assistant and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) was limited to 14 days or document the continued use with a rationale and duration for 1 of 5 residents (Resident #10) reviewed for unnecessary medications. Findings included: Resident #10 was admitted to the facility on [DATE]. Diagnoses included, in part, fracture of left humerus, metabolic encephalopathy, Parkinson's, and anxiety. A review of the physician orders written on 03/12/24 revealed an order for Alprazolam 0.5 milligrams (mg) one tablet every 8 hours as needed for anxiety. There was no stop date indicated on this order. […]