Bradley Estates Nursing and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Bradley Estates Nursing and Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 6, 2025

  Based on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R3) of 1 resident (with the potential to affect 26 of 141 other residents) when R3 obtained a loaded firearm from a staff's bag and carried it onto a secured memory care unit and for 1 (R2) of 1 resident who incurred a third degree cryogenic burn from a portable oxygen tank that was placed on the foot pedals of the resident's wheelchair. R3 was on 1:1 supervision related to wandering and aggressive behavior toward staff. Certified Nursing Assistant (CNA)-C was assigned to complete 1:1 supervision for R3 on the 1/22/25 PM shift. […]

• Immediate jeopardy, patternF600Jan 12, 2021

  Based on observation, interview and record review the facility failed to ensure 2 of 10 residents residing on the 200 unit were free from sexual abuse. This deficient practice had the potential to affect 10 out of 10 female residents on the 200 unit. On 9/17/20, R14 entered R13's room exposing his penis while approaching R13 saying sexually inappropriate comments. Staff did not immediately report this incident of abuse and did not immediately protect additional residents from potential further abuse that night. After facility staff developed interventions on 9/18/20, the facility failed to follow through with one on one (1:1) supervision for R14, failed to assess the effectiveness of interventions and failed to ensure frequent checks were done for R14. […]

• Immediate jeopardy, isolatedF745Jul 1, 2024

  Based on record review and interviews, the facility did not comprehensively provide medically related social services, to attain the highest psychosocial well-being, of a resident for 1 (R124) of 30 residents reviewed. *R124 verbalized, and attempted, to leave the facility to go home. The facility did not look at whether R124 still needed activation of power of attorney for health care and could, thus make own health decisions, did not look at alternatives to Sertraline, an antidepressant that R124 refused to take, did not look at discharge alternatives, and did not develop a plan of care for supervising R124 when agitated and expressing a desire to leave. […]

• Immediate jeopardy, isolatedF689Jan 17, 2024

  Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 (R1 and R4) of 18 residents reviewed for accidents. R1, who is severely cognitively impaired, was assessed to be at risk for wandering/elopement upon admission to the facility. The facility implemented the use of a wander guard and R1 was placed on a secure unit on the second floor upon admission. R1 eloped from the facility on 9/30/20. R1 again eloped from the facility on 10/29/2023 around 3:28 AM. R1 was found outside the facility around 4:26 AM. When the door alarm sounded, staff did not immediately search the stairwell, even though it led to a area with an unsecured/unalarmed door to the outside. […]

• Immediate jeopardy, isolatedF684Jun 14, 2021

  Based on observation, interview and record review the facility did not ensure residents received care and services consistent with professional standards of practice for 3 of 5 sampled residents (R4, R2 and R6). R4 admitted to the facility with a surgical wound of amputated toes on her right foot. The surgical site was not routinely assessed and monitored, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in decline of the wound (infection) resulting in hospitalization for further debridement of the surgical incision and intravenous antibiotics. The facility's failure to comprehensively assess and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]