Bradley Court

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure the facility was free of medication errors less than 5% or higher. The facility's medication error rate was 7.69 %. Two (2) medication errors were observed, a total of 28 opportunities, during the medication administration process for two (2) of 4 randomly observed residents (Residents 5, 52 ). As a result, the Facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication storage room was free of staff's food and personal belongings. This failure had the potential for lack of oversight and contamination for medications stored in the facility.

Inspectors wroteBased on observation and review of the Analysis of Accommodations (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to ensure that 1 of 10 resident rooms (room [ROOM NUMBER]) in Building 2 accommodated 4 or less residents.

Inspectors wroteBedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1 (rooms 2, 3, 4, and 5) and in Building 2 (rooms [ROOM NUMBERS]).

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a trash bin as a means for a resident to elope (leave without notice) the facility for one of one sampled resident (Resident 1). As a result, Resident 1 used the trash bin, jumped off the fence and left the facility unnoticed on 11/4/24.

Inspectors wroteBased 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. The cook continued to use his gloved left hand and spatula on the right hand to pick up the meat loaf and placed the meatloaf on the second and third plates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the MDS (MDS- a comprehensive assessment tool) for two of two sampled residents (Resident 11 and Resident 5) reviewed for MDS coding. This deficient practice had the potential for residents to not receive an individualized plan of care. In addition, inaccurate information was provided to the Federal database.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level I (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a resident's isolation was discontinued for one of two residents reviewed for PASRR (Residents 9). This failure had the potential for Resident 9 to not receive the appropriate mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive patient centered care plan for one of 16 residents (Resident 48) reviewed for care plans. This deficient practice had the potential to not meet the resident's needs for comfort and physical well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 48) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience).

Inspectors wroteBased on interview and record review, the facility failed to accurately record the discharge date of one of three residents (Resident 47) reviewed for closed medical records. This deficient practice resulted with Resident 47's discharge record to be inaccurately transmitted (submitted) to the federal database and the potential to cause confusion of Resident 47's discharge status.

Inspectors wroteBedrooms must accommodate no more than four residents. This requirement was not met as evidenced by: Based on observation, interview, and review of the current Client Analysis of Accommodations (document that shows room size and occupancy number), the facility failed to ensure one of 10 resident rooms in building 2, room five, accommodated no more than four residents.

Inspectors wroteBedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. This requirement was not met as evidenced by: Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1, Rooms 2, 3, 4, and 5 and in Building 2, rooms [ROOM NUMBERS].

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the needs and preferences for one resident, (Resident 17), reviewed for accommodation. This failure had the potential for Resident 17's needs to be unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care for one resident, (Resident 46), reviewed for quality of care. This failure had the potential for Resident 17's care needs to be unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was administered according to the physician's order for one of six residents (Resident 28) during a medication administration observation. As a result, the facility could not ensure medications were administered accurately to residents.

Inspectors wroteBedrooms must accommodate no more than four residents. This requirement was not met as evidenced by: Based on observation and review of the current Analysis of Accommodations, the facility failed to ensure one of 10 resident rooms in building 2, room five, accommodated no more than four residents.

Inspectors wroteBedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. This requirement was not met as evidenced by: Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1, Rooms 2, 3, 4, and 5 and in Building 2, rooms [ROOM NUMBERS].