The Bradley Gardens

Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective interventions for one of two residents reviewed for abuse (Resident 1) with known wandering (the act of moving about without a fixed plan, destination, or clear purpose) behavior. This failure resulted in a resident-to-resident altercation after Resident 1 entered Resident 2's room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and maintained under sanitary conditions when multiple food items were not labeled or dated once opened, containers had food residue, and shelving inside the walk-in refrigerator showed signs of rust. These failures had the potential to result in cross-contamination, bacterial growth, and attraction of pests, placing resident at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when one dumpster was overflowing with trash, and the lid was not closed. This failure had the potential to attract pests and rodents, which could cause food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for five of five sampled residents (Residents 5, 6, 10, 11 and 30) when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 5 and Resident 6 were receiving rivaroxaban (an anticoagulant, or blood thinning medication). Residents 10, 11, and 30 were receiving apixaban (an anticoagulant, or blood thinning medication). This failure had the potential for the medication not being optimized for best possible health outcome, and unnecessary or prolonged use of the medication which could lead to adverse effects such as bleeding or excessive bruising. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five of five sampled residents (Residents 5, 6, 10, 11 and 30) were free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning mediations. Resident 5 and Resident 6 were receiving rivaroxaban (an anticoagulant, or blood thinning medication). Residents 10, 11, and 30 were receiving apixaban (an anticoagulant, or blood thinning medication). This failure had the potential to result in unnecessary use of medications for Residents 5, 6, 10, 11 and 30; and for side effects of these medications (such as bleeding or excessive bruising) to go undetected or recognized for timely intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided for two of two residents reviewed for dignity (Residents 5 and 38) when Resident 5 and 38's lunch tray was not provided at the same time at their tables. This failure had the potential to negatively affect Residents 5 and 38's self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident reviewed (Resident 38) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when Resident 38 was administered risperidone (an anti-psychotic medication used for schizophrenia) without adequate monitoring. This failure resulted in unnecessary medications for Residents 38, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated according to the facility's policy when two of five sampled residents (Resident 5 and 6) received anticoagulant therapy with rivaroxaban (an anticoagulant, or blood thinning medication). This failure had the potential to result in delays in treatment and care for Residents 5 and 6. During an interview on August 20, 2025 at 2:47 p.m., Licensed Vocational Nurse (LVN) 3 described the process for when a resident was admitted to the facility on a blood thinning medication as follows: Nursing staff should have monitored daily for adverse effects such as bleeding; Nursing staff should have documented monitoring in the medication administration record (MAR); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely communication and implementation of a hospice physician's medication order (Prednisone - to reduce inflammation) for one of one resident reviewed for hospice (medical care provided to individuals with terminal illnesses) (Resident 3). This failure resulted in Resident 3 receiving Prednisone four days after it was ordered by the hospice physician, which had the potential to cause unnecessary delay in treatment and comfort.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during medication administration for one of nine residents (Resident 29). The facility did not administer Resident 29's stool softener (used for constipation) and laxative (used for constipation) medications according to the physician's orders. This failure had the potential to result in Resident 29 not receiving the full therapeutic benefit of their medication or experiencing side effects (such as diarrhea) from receiving the wrong dosage of a laxative.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when two opened and expired refrigerated multi-dose vials (MDV) of Tuberculin Purified Protein Derivative (PPD- test agent used in the diagnosis of tuberculosis, a serious illness that mainly affects the lung) were not discarded according to the manufacturer's specifications and the facility's policy. This failure had the potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.

Inspectors wroteBased on observation and interview, the facility failed to ensure the two resident bedrooms (rooms [ROOM NUMBERS]) did not accommodate more than four residents per room. This failure had the potential to have an adverse effect on the residents' safety and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the state survey agency within two hours for two of four residents (Residents 1 and 2). This failure had the potential for the state survey agency to investigate the allegation and ensure residents were safe.

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer or discharge requirements were met and the transfer was appropriate and necessary for two of 22 residents (Residents 1 and 2), when two cognitively impaired residents were transferred to another skilled nursing facility. This failure had the potential to cause confusion and discomfort for these residents due to unfamiliar environment.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer or discharge to two of 22 residents reviewed (Residents 1 and 2). Residents 1 and 2 were deemed with cognitive impairment and had no legal representative. In addition, the written notice of transfer or discharge for Residents 1 and 2, was not provided timely to the Office of the Long Term Care (LTC) Ombudsman. These failures had the potential to result in violation of the resident ' s rights, as issues related to the transfer or discharge may not be addressed promptly, leading to harm to the resident, especially if the transfer or discharge was not in the best interest of the resident or was done without proper procedure. This failure did not provide opportunity for the Ombudsman to advocate for the residents to ensure the transfer or discharge was necessary.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 22 sampled residents (Residents 1 and 2), was provided orientation in the form the residents could understand, to ensure a safe and orderly transfer from a skilled nursing facility (SNF A) to another skilled nursing facility (SNF B). Residents 1 and 2 were deemed with cognitive impairment, lacked the capacity to make decisions, and had no listed legal representatives. This failure of the facility had the potential to negatively affect the psychosocial well-being of Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The Prep sink did not have an air gap (is vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water); 2. The Quat sanitizer used to sanitize food preparation surfaces did not meet the right concentration requirements on 3/26/2024, 3/27/2024 and 3/28/2024; ( Cross referred 802) 3. Dust was observed on several areas in the kitchen; 4. Reach in refrigerator shelves had chipped paint; 5. Several equipment in the kitchen found to have buildup; 6. Trash were found in multiple areas in the kitchen; 7. Inside the containers used to store clean scoops, utensils and lids had food residuals; 8. Broken tiles found under reach in refrigerator and utility area; 9. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Federal (Center for Medicare & Medicaid Services- CMS) database for the first Fiscal Qaurter of the year. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Food service workers did not recognize that the Quat sanitizer concentration was not at the right concentration; (Cross referred F 812) This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. 2. Diet Aide 1 and [NAME] 2 were unable to properly clean working surface; This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. 3. [NAME] 2 did not follow the menu for serving on 3/27/24 lunch; [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. Correct portion sizes were not followed; 2. The [NAME] did not serve biscuit during lunch on 3/27/2024; and 3. The [NAME] did not serve gravy for pureed diet during lunch on 3/27/2024. These failures had the potential for 30 out of 31 residents receiving food prepared in the kitchen do not meet their nutritional needs which may lead to nutritional related health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the recipe for preparing puree was followed for seven of seven residents (Residents 1, 6, 8, 9, 10, 14 and 24) receiving pureed (any food item that has been processed into a smooth and uniform texture) foods. This failure had the potential to compromise the nutritional status of Residents 1, 6, 8, 9, 10, 14, and 24 resulting in decreased oral intake and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate liquid texture was provided when two of two (Residents 6 and 24) did not receive nectar thick liquids as prescribed by the physician and the residents were served jello during lunch on March 27, 2024 . This failure had the potential to place the residents at risk for aspiration (when food is breathed into the lungs).

Inspectors wroteBased on interview and record review, the facility failed, for one of 12 sampled residents (Resident 38), to ensure the resident or resident representative was informed and provided a written information regarding the formulation of an advance directive (written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself) upon admission to the facility. This failure had the potential for the residents to have inappropriate treatment and services in the event of a medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of bed-hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided to the resident/and or resident representative, for one of one resident reviewed for hospitalization (Resident 34) when Resident 34 was transferred to the acute hospital. This failure had the potential for the resident or resident representative not to be informed of their right to hold the bed while out of the facility and the right to be readmitted back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident reviewed (Resident 24) received care and treatment to maintain their highest practicable physical well-being when a dietitian recommendation for a diet upgrade was not made known to the physician by the licensed nurses. This failure resulted in the resident remaining on her current diet, which could potentially lead to a decline in resident's overall condition.

Inspectors wroteBased interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for two out of three residents (Residents 23 and 27). There was a total of 4 unaccounted controlled medications. This failure had the potential for misuse or abuse of controlled medications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for one of five sampled residents (Resident 4) when Resident 4 was administered Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer specified monitoring. This failure had the potential for the medication not being optimized for best possible health outcome, and unnecessary or prolonged use of the medication which could lead to adverse effects and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 4 was administered Seroquel (quetiapine, an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer specified monitoring. This failure had the potential for the medication not being optimized for best possible health outcome, and unnecessary or prolonged use of the medication which could lead to adverse effects and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a full-time director of food and nutrition services. The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in residents not being assessed regarding their nutritional needs, as well as lack of oversight of food preparations, services, and storage for 30 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection prevention program was implemented when a facility staff did not disinfect the automatic blood pressure (BP-pressure of blood in blood vessels) cuff machine before and after residents' use according to the facility policy. This failure had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections.

Inspectors wroteBased on observation and interview, the facility failed to ensure the two resident bedrooms (rooms [ROOM NUMBERS]) did not accommodate more than four residents per room. This failure had the potential to have an adverse effect on the residents' safety and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that accommodates one of three sampled residents' (Resident A) allergies and preferences. Resident A has peanut butter allergy and was provided peanut butter and jelly sandwich. This failure had the potential for Resident A to not receive the caloric intake needed when his preferences were not followed, this could result in poor nutrition and further compromised to Resident A ' s medical status.

Inspectors wroteBased on observation, interview, and facility policy and procedure review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals that met the nutritional needs of the facility residents when: 1. Two cooks did not follow the facility menu; 2. One cook did not follow the puree recipes; and 3. One [NAME] did not cook puree vegetables to preserve nutritive value. These failures posed a risk of 37 out of 39 highly susceptible residents who received food prepared in the kitchen to not meet their nutritional needs which could lead to nutritional related health concerns.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. Correct portion sizes were not followed; 2. Puree recipes were not followed; and 3. Fortified diets were not followed. These failures had the potential for 37 out of 38 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: 1. A sanitizing solution used to sanitize food preparation surfaces did not meet the proper sanitizing requirements; 2. The ice machine splash curtain (a plastic cover for the evaporator and water spillway; the parts of the ice machine that produce ice) had a thick white residue and the manufacturer's cleaning instructions were not followed for the splash curtain; 3. Inadequate hand washing; 4. Food was not properly labeled and dated; 5. Kitchen equipment was not clean; 6. Kitchen equipment was in poor condition; 7. Non dietary personnel in the kitchen did not wear hair nets; and 8. A drainpipe on the ice machine did not have an air gap. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Directives (AD-written instruction, such as a living will or durable power of attorney for healthcare, recognized under State Law, relating to the provision of healthcare when the individual is incapacitated) was discussed with the resident or resident representatives for three of seven residents reviewed for Advance Directives (Residents 18, 24, and 37). This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and or unable to speak for themselves.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's Drug Regimen Review (DRR) recommendations for four of seven residents reviewed for unnecessary medications (Residents 6, 34, 30, and 37), when: 1a. For Resident 6, there were recommendations for a Gradual Dose Reduction (GDR) on Risperdal (medication used to treat psychosis- a mental illness) and Remeron (a medication used to treat depressive disorder) dated June 28, 2021; and 1b. For Resident 6, there was a recommendation for a review on the Prilosec (medication used to treat Peptic Ulcer Disease [PUD]-type of digestive illness) maintenance dose dated July 28, 2021; 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the following items in the medication room were not expired and stored readily available for use: 1. Seven pre-filled 10 ml (milliliter) saline syringes; 2. 27 pre-filled 0.5 ml syringes of afluria Quadrivalent (brand name of influenza vaccine); 3. Four multi-dose vials of Fluzone (brand name of influenza vaccine); 4. Three vials of 10 ml sterile water (used for diluting medications); and 5. One vial of Ondansetron (medication used to treat nausea and vomiting) 4 mg (milligrams)/ 2 ml in the emergency kit (E-Kit-sealed container of medications used for emergency treatment). These failures had the potential for the residents to have ineffective treatments due to the use of expired medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three residents reviewed for closed record (Resident 39), the physician was notified when the resident was transferred to the hospital. This failure had the potential to result in the physician not being aware of the medical condition of the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide a Notice of Medicare Provider Non-Coverage (NONMC - a notice when the care the resident is receiving from a skilled nursing facility [SNF] is ending and how the resident can contact the agency to appeal) to the resident or resident representative for one of three residents reviewed for beneficiary notification (Resident 33). This failure had the potential for the resident not to be aware of the opportunity to appeal for the skilled services that was discontinued by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of two residents reviewed for PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) (Resident 37), the PASRR level I assessment was coded accurately. This failure had the potential for having residents that were not appropriate in the facility and for Resident 37 not to receive the appropriate services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 39 residents, (Resident 24), a care plan was developed and implemented to address the resident's contractures (shortening and hardening of the muscles, tendons or other tissues leading to deformity and rigidity of joints) to the right lower leg and left hand. This failure had the potential for the resident to not receive the necessary care and services and not be provided with the appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of 13 residents reviewed (Resident 19), to ensure Resident 19 was provided care when she requested for the staff to clean her ears. This failure resulted in Resident 19 being placed at risk for unattended daily needs and concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's change in skin condition was assessed and monitored for one of 13 residents reviewed (Resident 37). This failure had the potential to result in the delay in treatment which could lead to skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent, when during medication pass observation the medication order for Doxycline (antibiotic) and senokot (laxative) were not administered as ordered by the physician for one of five residents (Resident 12). This failure resulted in a medication error rate of 6.25% (two errors out of 32 opportunities).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Director of Food and Nutrition Services (DFNS) met the qualifications necessary to oversee the day to day operations of the Food and Nutrition Services department. This failure had the potential to put 37 residents who received food from the facility kitchen out of a census of 38 at risk for food borne illness and compromise their nutritional status.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure 10 out of 38 residents received pureed foods that were prepared by methods to conserve nutritive value. This failure placed residents receiving a pureed diet at risk for compromised nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection prevention program was implemented when a facility staff did not disinfect the wrist blood pressure (BP-pressure of blood in blood vessels) cuff machine before and after residents' use according to the facility policy. This failure had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the two resident bedrooms (rooms [ROOM NUMBERS]) did not accommodate more than four residents per room. This failure had the potential to have an adverse effect on the residents' safety and wellbeing.