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Deficiency Records for The Bradley Gardens
View the most recent health deficiencies and inspection results for The Bradley Gardens. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Bradley Gardens. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Dispose of garbage and refuse properly. | Health | 2025-08-21 | 2025-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-21 | 2025-09-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2025-08-21 | 2025-09-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-08-21 | 2025-09-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-08-21 | 2025-09-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-08-21 | 2025-09-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-08-21 | 2025-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-21 | 2025-09-15 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-08-21 | 2025-09-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-21 | 2025-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-08-21 | 2025-08-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-08-21 | 2025-08-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-08-21 | 2025-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-08-21 | 2025-08-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-08-21 | 2025-08-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-04-02 | 2025-04-08 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-08-23 | 2024-08-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-23 | 2024-08-27 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-08-23 | 2024-08-27 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-03-29 | 2024-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-29 | 2024-04-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-03-29 | 2024-04-29 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-03-29 | 2024-04-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-03-29 | 2024-04-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-03-29 | 2024-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-29 | 2024-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-29 | 2024-04-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-29 | 2024-04-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-03-29 | 2024-04-29 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-03-29 | 2024-04-29 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-03-29 | 2024-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-29 | 2024-04-29 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-03-29 | 2024-04-29 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-03-29 | 2024-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-29 | 2024-04-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-11 | 2024-03-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-08-12 | 2021-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-12 | 2021-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-12 | 2021-09-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-12 | 2021-09-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-12 | 2021-09-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-12 | 2021-09-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-12 | 2021-09-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-12 | 2021-09-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-12 | 2021-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-12 | 2021-09-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-12 | 2021-09-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-12 | 2021-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-12 | 2021-09-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-12 | 2021-09-13 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-08-12 | 2021-09-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-08-12 | 2021-09-07 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2025-08-21 | Not Fixed | N |