Bradley Health Care & Rehab

Based on review of the facility policy, observation, and interview, the facility failed to remove resident plates and utensils from serving trays, to promote a dignified dining experience for 8 of 8 residents observed in the [NAME] 1 dining room and delayed assistance to 1 dependent resident (Resident #13) for 20 minutes who was seated at the same table as other residents received and finished their meals.The findings include: Review of the undated facility policy titled, Promoting/Maintaining Resident Dignity, revealed .It is the practice of this facility to .promote .and treat each resident with respect and dignity .care for each resident in a manner and in an environment, that maintains or enhances quality of life .Each Resident will be provided equal access to quality of care, regardless of diagnosis, severity of condition . Review of the medical record revealed Resident #13 was admitted to the facility 11/25/2025 with diagnoses including Adjustment-Disorder with Depressed Mood, Mild Cognitive Impairment, Generalized Anxiety, Unspecified Tremor, Moderate Malnutrition, and Muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility abuse policy, review of facility investigations, and interviews, the facility failed to ensure facility reported incidents (FRI) related to allegations of abuse were reported within a timely manner for 4 residents (Residents #1, # 2 #3 and #4) of 11 residents sampled for abuse or neglect.The findings included: Review of the facility policy and procedure Resident Abuse revealed .When an incident of suspected resident abuse, mistreatment, or neglect is reported the following will occur .The case of suspected abuse will be reported per regulation to the Department of Health by Administrator or Designee .If you have witnessed or have knowledge of such actions in this facility, please give an immediate report to Administration .Resident Abuse May Also Be Reported to . (State Agency) . (Ombudsman) . Review of the facility FRI (incident 2998873) dated 4/29/2026 revealed the incident referenced in the FRI included allegations of potential resident versus resident abuse, which was documented to have occurred on the evening of 4/28/2026 around 7:50 PM between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record reviews, and interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for 1 resident (Resident #8) and the facility completed a 5-day MDS assessment for 1 resident (Resident #62) after discharged from the facility of 20 residents reviewed for MDS assessments. The findings include: Resident #8 was admitted to facility on 1/31/2020 with diagnoses including Disorders of the Kidney and Ureter, Abnormal Weight Loss, Hallucinations, Delusions, and Anxiety. Review of the quarterly MDS assessment dated [DATE] showed Resident #8 was currently admitted in the facility. Continue review showed a discharge assessment was not completed on 5/26/2022 by the facility upon discharge. Review of a nurses' notes dated 5/26/2022, showed Resident #8 was transferred to the Emergency Department (ED) for evaluation and treatment. Review of a nurses' note dated 6/1/2022, showed the resident's daughter called the facility and was taking Resident #8 home on hospice services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper storage of oxygen cylinders (tanks) (metal container filled with compressed gas and held under high pressure) in 1 resident's room (Resident #10) of 9 residents reviewed for oxygen usage. The findings include: Review of the undated facility policy, titled, POLICY AND PROCEDURE OXYGEN CYLINDERS, showed .Never drop cylinders or permit them to strike each other .Store cylinders of oxygen in a cool place, away from radiators . Resident #10 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Localized Edema, Dyspnea, Morbid Obesity, Dependence on Supplemental Oxygen, Encounter for Palliative Care, Chronic Obstructive Pulmonary Disease (COPD), and on 9/13/2022 COVID-19. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #10 received oxygen and hospice services. Review of the current physician's orders revised 10/4/2022, showed Oxygen continuous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on hospice contract review, medical record review, and interview, the facility failed to ensure timely and collaborative communication between the hospice provider and the facility for 1 resident (Resident #24) of 6 residents reviewed for hospice services. The findings include: Review of the hospice contract titled, HOSPICE AND SKILLED NURSING FACILITY AGREEMENT, dated [DATE] and renewed annually, showed .Hospice shall provide Facility with the following information immediately upon the information becoming available to Hospice .the most recent hospice plan of care specific to each Resident under Hospice's care .Hospice physician and attending physician .orders specific to each Resident .All physician orders communicated to Facility on behalf of Hospice in connection with the Hospice Plan of Care shall be in writing and signed by the applicable Attending Physician or Hospice Physician .Hospice shall comply with the Coordination of Services .Communication Protocol .Hospice and Facility shall work together…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen free from undated, unlabeled foods, or opened to air food items in 2 coolers; and free from dirt and debris in 1 ice cream freezer, 1 walk in cooler, 1 of 3 steam tables, and on 1 dish in the kitchen, potentially affecting 149 of 151 residents. The findings include: Review of facility policy, Dietary Food Storage Policy with an implementation date of 10/29/18 revealed .It is the policy of this facility to avoid inappropriate storage of food products for the safety and well-being of the residents .Improper food storage may include, but not be limited to .Foods uncovered and/or exposed to air .Foods undated .Foods unlabeled .Broken seals, leakage . Review of the facility policy, Refrigerators and Freezers, dated 10/31/18, revealed .Supervisors will inspect refrigerators and freezers .for .ice buildup .Refrigerators and freezers will be kept clean, free of debris, and mopped .on a scheduled basis and more often as necessary . Review of the facility policy, Dietary Equipment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation, and interview the facility failed to maintain 1 of 3 three compartment steam tables in safe operating condition in 1 of 1 kitchens potentially affecting 149 of 151 residents. The findings include: Review of the facility policy, Dietary Equipment Serviceability Policy, with an implementation date of 10/29/18, revealed .It is the policy of this facility to maintain proper working equipment .free from .disrepair .Staff members of the Dietary Department must recognize that they have responsibility to insure [ensure] the safe and sanitary working condition of all equipment used in the preparation and delivery of food to the residents of our facility . Observation and interview with the Dietary Manager (DM) on 10/29/18 at 11:16 AM, in the kitchen, of the 3 compartment portable steam table, next to the ice cream freezer, revealed 1 of 3 missing control knobs in 1 of 3 bays. Interview with the DM confirmed the facility used the portable steam table in preparation and delivery of food to the residents in the facility. Continued interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility admission packet, medical record review, review of trust transaction history, observation, and interview, the facility charged the personal fund account for incontinence care items for 1 resident (#72) of 34 incontinent residents reviewed of 44 sampled residents. The findings include: Review of the facility admission packet and resident rights revealed the facility would provide incontinence care supplies for the residents. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Dysuria (painful urination), Type 2 Diabetes Mellitus, Major Depression, Bipolar Disorder, Primary Insomnia, and Anxiety. Medical record review of Resident #72's admission Record revealed the resident's primary payer source was Medicaid ICF (Intermediate Care Facility). Medical record review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #72's Brief Interview for Mental Status score was 15, indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to obtain consent and notify the resident representative of changes to the psychiatric drug regimen of 1 resident (#82) of 5 residents reviewed for unnecessary medications of 44 residents sampled. The findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses of Dementia, History of Transient Ischemic Attack (Stroke), and Anxiety Disorder. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #82 was moderately cognitively impaired. Medical record review of the Order Listing Report, dated 10/31/18, revealed .Lexapro [antianxiety and antidepressant medication] 5 MG [milligrams] Give 1 tablet by mouth one time a day .Last Order Date .01/26/18 . Medical record review of the Psychiatric Progress Note, dated 1/26/18, revealed .Treatment Plan .1.) Start Lexapro 5 mg PO [by mouth] QDAY [daily] .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to refer to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review), after the resident was identified with a possible serious mental disorder, for 1 resident (#112) of 7 residents reviewed for PASARR. The findings include: Review of facility policy admission Criteria, revised December 2016, revealed .Any new psychiatric diagnosis may indicate the need for a PASSAR . Medical record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Psychotic Disorder with Delusions, and Hypertension. Medical record review of the PASARR form dated 7/26/17 revealed Resident #112's diagnoses included suspected anxiety disorder and mild depression. Further review revealed the resident was negative for the level one screening, and if the nursing facility determined any inaccuracies in diagnoses, a Status Change review would be required.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.