Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradley Home Infirmary/pavilion during CMS and state inspections, most recent first.
The facility failed to monitor and document targeted behaviors every shift for three residents receiving antipsychotic medications, despite care plans and physician orders specifying behavior-related indications such as excessive crying, suicidal ideation, paranoia, delusions, hallucinations, and dementia-related behavioral disturbances. Review of MARs for two consecutive months showed no behavior monitoring entries tied to these psychotropic drugs. The psychiatric APRN and DON both acknowledged that behavior monitoring should have been initiated and conducted each shift for all residents on antipsychotics, and facility policies required ongoing monitoring and documentation of behaviors and responses to psychotropic treatment.
A resident with bipolar disorder, depressive episodes, and Alzheimer’s disease was receiving Aripiprazole, with orders changing from a morning dose to a one-time morning dose and then to a daily bedtime dose. The MAR showed the one-time dose signed as given in the morning, but there was no documentation of the bedtime doses on two consecutive evenings. An RN incorrectly transcribed the new bedtime order so it appeared on the MAR for the same day as the one-time morning dose, and a 3–11 PM LPN did not administer or document the first bedtime dose and failed to write a note explaining the omission. Another 3–11 PM LPN reported giving the next day’s bedtime dose but did not sign the MAR. The DON confirmed the transcription error and that staff are expected to complete and accurately sign off all medication documentation in accordance with the facility’s charting policy.
A resident with dementia, generalized weakness, impaired cognition, and a high fall risk was care planned and ordered to receive assist of one for transfers and ambulation with a rolling walker. During ambulation from the dining area, a NA left the resident standing unattended in a hallway without a gait belt to assist another resident who was out of sight, despite knowing the resident required continuous assistance. While unsupervised, the resident began walking toward a roommate and staff member, turned to look at another person, lost balance, and fell onto the right side, later found to have a right femoral neck fracture requiring ORIF. The DON confirmed that the NA did not follow the MD orders or the facility’s ambulation policy and that a gait belt should have been used or any refusal documented.
Surveyors found that food was served at unsafe temperatures when meal trays were delivered using a non-insulated cart and without warming pellets, resulting in food below required safe levels. Additionally, staff reheated food for residents in a microwave without using a thermometer to verify proper temperature, relying instead on subjective methods. These actions did not comply with facility policies for food safety and reheating.
A resident with a history of dysphagia and other medical conditions was kept on a prescribed soft diet with thickened liquids despite being cognitively intact and repeatedly requesting a regular diet and thin liquids. The facility did not hold interdisciplinary meetings or collaborate with the resident or family to discuss care goals, and staff did not honor the resident's right to refuse treatment as outlined in facility policy.
A resident with dementia and severe cognitive impairment exhibited wandering and exit-seeking behaviors, leading to the application of a Wander guard. Despite these changes, the care plan was not updated to address the resident's increased elopement risk or the new interventions, and the MDS Coordinator was not notified in a timely manner. Facility policy requiring care plan updates with changes in condition was not followed.
The facility did not update care plans for two residents after significant changes in their conditions, including the development of a new wound and a confirmed UTI. Despite clinical documentation and physician orders, the care plans were not revised to include new interventions or monitoring until prompted by surveyors, contrary to facility policy.
A resident who was cognitively intact and his own decision maker repeatedly requested to discontinue thickened liquids and soft foods, preferring a regular diet and thin liquids to improve quality of life. Despite understanding the risks and making multiple requests with family involvement, the facility did not hold an interdisciplinary team meeting or collaborate to address the resident's goals of care. Staff questioned the resident's decision-making capacity without documentation and did not provide a waiver or policy on social services.
Failure to Monitor Target Behaviors for Residents on Antipsychotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents receiving antipsychotic medications had their targeted behaviors monitored as required, resulting in drug regimens that were not adequately evaluated for necessity. For one resident with bipolar disorder, depressive episodes, and Alzheimer’s disease, the care plan identified antipsychotic use (Aripiprazole) with interventions to observe for excessive crying and suicidal ideation. Physician orders showed dose changes over time, but the January and February 2026 Medication Administration Records (MARs) did not contain documentation that these targeted behaviors were monitored every shift in relation to the antipsychotic use. A second resident with schizophrenia, major depressive disorder, and anxiety disorder was prescribed Clozaril for schizophrenia, with a care plan directing observation for paranoia, delusions, and hallucinations. A third resident with dementia with behavioral disturbances and a cognitive communication deficit was prescribed Rexulti for dementia with behavioral disturbances, and the care plan required observation for targeted behaviors related to psychotropic use. For both of these residents, review of the January and February 2026 MARs failed to show that specific targeted behaviors were monitored every shift. The psychiatric APRN stated that all residents on antipsychotic medications should have behavior monitoring in place upon initiation of the medications, and the DON confirmed that targeted behavior monitoring should have been implemented every shift for these residents. Facility policies on psychotropic medication use and behavioral assessment required monitoring for efficacy, adverse consequences, and behavioral symptoms, but the required behavior monitoring and documentation were not carried out as specified.
Incomplete and Inaccurate Documentation of Antipsychotic Medication Orders and Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident receiving antipsychotic medication. The resident had diagnoses of bipolar disorder with depressive episodes and Alzheimer’s disease, with a BIMS score indicating some memory deficits, and a care plan identifying use of an antipsychotic for bipolar disorder with monitoring for excessive crying and suicidal ideation. Physician orders directed Aripiprazole 5 mg in the morning, later decreased to 2 mg, with a one-time 2 mg dose ordered for a specific morning and then an increase back to 5 mg at bedtime on a later date. On one date, the resident was found with a call bell cord wrapped around the neck, was assessed, and sent to the ED and returned the same day; the care plan included one-to-one observation. Review of the Medication Administration Record (MAR) for that month showed the one-time 2 mg dose was signed as given in the morning, but documentation did not show administration of Aripiprazole 2 mg at bedtime on two consecutive days. Interviews revealed that the 3–11 PM LPN on the first evening did not administer the bedtime dose because the 7–3 PM RN had communicated that the medication had already been given that morning as a one-time dose and that the daily bedtime dosing was to start the following day; the LPN did not sign the MAR and did not document a note explaining the omitted bedtime dose. The RN who transcribed the order acknowledged entering the daily bedtime Aripiprazole 2 mg order incorrectly so that it appeared on the MAR for the same day the one-time morning dose was given, instead of starting the next day, and stated she should have ensured the order was correct before signing it. Another 3–11 PM LPN reported administering the bedtime dose on the following day but failing to sign it on the MAR, acknowledging responsibility for ensuring complete and correct documentation. The DON confirmed that the order had been transcribed incorrectly and that staff are expected to sign off all medications and document reasons when medications are not administered, consistent with the facility’s Charting and Documentation policy, and that a policy on Transcription of Physician’s Orders was not available.
Failure to Provide Required Supervision During Ambulation Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe ambulation assistance to a resident with dementia, lack of coordination, abnormal posture, generalized weakness, and moderately impaired cognition (BIMS score of 7). The resident’s MDS and care plan identified dependence on staff for transfers and ambulation with a rolling walker, and a fall risk assessment classified the resident as high risk for falls. The care plan and physician’s orders specified assistance of one staff member for transfers and ambulation with a rolling walker for distances of 45–75 feet with rest breaks as needed. Facility policy for ambulation with a walker required staff assistance as indicated by MD orders and directed staff on how to support a resident if a fall began. The DON stated that a gait belt should have been used during ambulation and that any refusal should have been documented, although there was no specific provider order for a gait belt. On the evening of the incident, a nursing assistant assigned to the resident reported assisting the resident from the dining room toward the resident’s room. During this ambulation, the NA left the resident standing in the hallway, instructed the resident to remain there, and went to assist another resident who was out of her line of sight. The NA confirmed she did not have or apply a gait belt and did not remain with or hold onto the resident during ambulation, despite knowing the resident required assistance of one and a gait belt. While the NA was away, the resident began walking toward his/her roommate and another staff member, then turned to look at another person, lost balance, and fell onto the right side. The resident initially complained of back discomfort that subsided, later reported right upper leg discomfort, and was subsequently found at the hospital to have sustained a closed right femoral neck fracture requiring ORIF surgery. The DON confirmed that the NA should not have left the resident standing alone and that the NA failed to follow the facility’s ambulation policy.
Failure to Maintain Safe Food Temperatures During Meal Service and Reheating
Penalty
Summary
The facility failed to ensure that food was served at safe temperatures and in accordance with professional standards. During a lunch meal service, surveyors observed that food trays were delivered to residents using a Bunn rack with a zippered plastic cover, rather than an insulated Cambro meal delivery cart. The meal plates were covered with clear hard plastic covers that did not contain warming pellets. When the last tray was served, food temperatures were measured and found to be below the required safe levels, with sweet potatoes at approximately 106°F, chopped spinach at 114°F, and pork at about 96°F. The Assistant Food Service Director acknowledged that the food temperatures were low. The facility's policy required food to be maintained outside the danger zone of 41°F to 135°F, and for trays to be delivered in covered carts. Additionally, the report identified that nursing staff reheated food for residents upon request using a microwave in the kitchenette. However, nurse aides did not use a thermometer to verify that reheated food reached the required internal temperature of 165°F for 15 seconds, as specified in the facility's On-Unit Food Reheating policy. Instead, staff relied on subjective methods such as feeling the heat above the food or timing the microwave, and were unaware of the location of the thermometer in the kitchenette. This practice was more common when meals were delivered using the Bunn rack, as opposed to the insulated Cambro cart. The deficiency was further evidenced by interviews with staff who confirmed that they did not routinely check food temperatures after reheating and were not consistently following the policy for reheating and serving food. The Food Service Director confirmed that nursing staff were permitted to reheat food and that a thermometer was available in the kitchenette, but staff were not utilizing it as required. The failure to maintain and verify safe food temperatures during both initial meal service and reheating by nursing staff constituted a breach of food safety standards.
Failure to Honor Resident's Right to Dietary Choice
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to choose their diet and fluid consistency, despite the resident being cognitively intact and expressing a clear preference. The resident, who had diagnoses including dementia, chronic kidney disease, muscle weakness, and dysphagia, was placed on a soft and bite-sized diet with mildly thick liquids following radiological and swallowing tests that indicated a risk of aspiration. The resident repeatedly requested to return to a regular diet and thin liquids, citing a desire for improved quality of life and reporting adverse effects such as diarrhea from the thickener. Despite these requests and the resident's understanding of the associated risks, the facility continued to provide the prescribed diet and did not accommodate the resident's wishes. Interviews with facility staff revealed a lack of interdisciplinary team meetings or documented collaboration with the resident or family to discuss goals of care or the resident's dietary preferences. The social worker acknowledged awareness of the resident's complaints but had not discussed them with the advanced practice registered nurse (APRN) or initiated a team meeting. The APRN and the director of nursing services (DNS) both indicated that they did not believe the resident or spouse were capable of making informed decisions, despite the resident being his or her own decision maker and having no named representative or power of attorney. The APRN also did not contact the resident's daughter, who was mistakenly believed to be the legal decision maker. Facility policy and the resident's rights documentation indicated that residents have the right to refuse treatment and that such rights would be honored. However, the facility did not advance the resident's diet or provide a waiver, even after requests from the resident and family. The DNS stated that a diet change was considered unsafe and that the resident was not appropriate for palliative or comfort measures only status, as there had not been a decline. The lack of documented meetings, failure to involve the interdisciplinary team, and disregard for the resident's expressed wishes led to the deficiency.
Failure to Update Care Plan for Resident with Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who exhibited wandering and exit-seeking behaviors, despite documented evidence of these behaviors and the application of a Wander guard device. The resident, admitted with diagnoses including dementia and severe cognitive impairment, was initially assessed as low risk for elopement. However, nursing and APRN progress notes documented multiple instances of exit-seeking and wandering, leading to the application of a Wander guard for safety. Despite these changes in the resident's condition and interventions, the care plan was not updated to reflect the resident's increased risk or the new interventions. The care plan continued to address only cognitive loss related to dementia, without including specific interventions for elopement or wandering risk. The MDS Coordinator was not notified of the Wander guard application at the time it was ordered and did not update the care plan until months later, after being made aware during a quarterly assessment. Facility policy required care plans to be updated with changes in condition, but this was not followed, resulting in a lack of direction for staff regarding the resident's elopement risk and the use of the Wander guard.
Failure to Update Care Plans After Changes in Condition
Penalty
Summary
The facility failed to revise resident care plans following changes in condition for two residents. One resident, admitted with chronic conditions including COPD, hyponatremia, and chronic kidney disease, was identified as severely cognitively impaired and at risk for impaired skin integrity. Despite documentation of a new wound to the left lower shin, there were no updates made to the resident's care plan to address the new wound or to implement protective or preventative interventions. Another resident, also severely cognitively impaired and with a history of dementia, falls, and UTI, experienced a confirmed urinary tract infection as evidenced by clinical notes, physician orders, and lab results. However, the care plan was not revised to reflect the actual UTI diagnosis, monitoring, or treatment interventions. The care plan was only updated after surveyor inquiry, despite facility policy requiring care plans to be updated after changes in condition and at regular intervals.
Failure to Honor Resident's Goals of Care and Dietary Preferences
Penalty
Summary
The facility failed to identify and promote individualized care for a resident who expressed clear goals of care and dietary preferences. The resident, who was cognitively intact and his own decision maker, repeatedly requested to discontinue thickened liquids and soft foods, preferring a regular diet and thin liquids to improve quality of life, despite understanding the associated risks. The clinical record showed that the resident and his family participated in assessment and goal setting, but there was no documentation of an interdisciplinary team meeting or collaboration to discuss the resident's goals of care. The resident experienced diarrhea attributed to the thickener, which further impacted his well-being, and both the resident and his spouse made multiple requests for a change in diet and consideration of comfort measures only (CMO) status. Despite these requests, facility staff, including the APRN and Social Worker, did not facilitate a meeting with the interdisciplinary team, the resident, or the family to address the resident's wishes. The APRN questioned the resident's and spouse's decision-making capacity without documented evidence and did not contact the resident's daughter, who was believed to be the legal decision maker. The DNS confirmed that no waiver was provided for the requested diet change and stated that the resident was not considered appropriate for CMO status. The facility did not provide a policy on the provision of social services when requested.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Meriden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meriden Health And Rehab | 0.8 mi | ★★★★★ | 5 | 0 |
| Curtis Home St Elizabeth Center, The | 1.4 mi | ★★★★★ | 0 | 0 |
| Silver Springs Care Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Apple Rehab Coccomo | 2.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Meriden | 2.8 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.