Bradley Home Infirmary/Pavilion

In the surveyor’s words

From the most serious findings on record at Bradley Home Infirmary/Pavilion, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 5, 2026

  Based on review of the clinical record, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) who required staff assistance for ambulation, the facility failed to provide adequate supervision during ambulation with a rolling walker, which resulted in a fall with a right femoral neck fracture requiring surgical intervention. The findings include:Resident #1's diagnoses included dementia, lack of coordination, abnormal posture, and generalized weakness. […]

• No harm, potential for more than minimal, widespreadF802Aug 25, 2026

  Based on observation, review of facility documentation, facility policy and interviews, the facility ensure that dietary staff were educated and in-serviced on a new sanitization method including the manufacturer's instructions and facility policy regarding use. The findings include:During an initial tour of the facility kitchen with Dietary Director on 8/23/26 beginning at 7:33AM, observation identified several red buckets throughout the kitchen that did not contain chemical sanitizer. Interview with the Dietary Director immediately following these observations identified the facility had recently switched to a premixed quaternary chemical sanitizing spray for sanitizing food contact surfaces and prep areas. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2026

  Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner. The findings include:Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner. The findings include:Initial tour of the facility kitchen with the Dietary Director on 8/23/26 beginning at 7:33 AM identified the following.Observation of the food prep areas, refrigerator and freezer units, dishwashing area, 3 Bay sink area, food storage areas, cooking and steam table areas, juice and ice areas identified the kitchen flooring had a significant amount of dirt, debris, and staining among. […]

• No harm, potential for more than minimal, widespreadF908Aug 25, 2026

  Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure that the dishwasher was operating within the manufacturer's recommendations and facility policy to ensure proper sanitization temperatures. The findings include:Observation during initial tour of the kitchen with Dietary Director on 8/23/26 beginning at 7:33 AM identified the following related to dishwasher rinse temperatures. Observation of 3 wash and rinse cycles for the dishwasher identified that while the initial wash cycles registered at or above 160 F, two of the three rinse cycles registered below 180 F. […]

• No harm, potential for more than minimal, widespreadF925Aug 25, 2026

  Based on observation, review of facility documentation, facility policy and interview, the facility failed to have an effective pest control program to ensure that food storage, preparation, and service areas were free of pests. The findings include:During an initial tour of the facility kitchen with Dietary Director on 8/23/26 beginning at 7:33 AM, initial observations identified a significant amount of active black flying winged insects throughout multiple areas. Multiple active black flying winged insects were observed flying through the kitchen food preparation area around the stove and ovens, steam table, dry storage area, ice machine area, dishwashing area, and the 3 bay sinks. […]