Deficiency Records for The Bradley Gardens
Updated as of March 01, 2021
This is not the most recent data for The Bradley Gardens. For the most recent information, click here.
A list of the most recent deficiencies for The Bradley Gardens. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-06-18 | 2019-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-06-18 | 2019-07-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-18 | 2019-07-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-31 | 2019-06-28 | 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 | 2019-05-31 | 2019-06-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-05-31 | 2019-06-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-05-31 | 2019-06-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-31 | 2019-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-31 | 2019-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-31 | 2019-06-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-31 | 2019-06-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-31 | 2019-06-28 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-05-31 | 2019-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-31 | 2019-06-28 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-31 | 2019-06-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-31 | 2019-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-31 | 2019-06-28 | 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 | 2019-05-31 | 2019-06-28 | N |
| Develop a communication plan. | Fire Safety | 2018-10-03 | 2018-10-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-03 | 2018-10-17 | 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 | 2018-07-12 | 2018-08-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-12 | 2018-08-08 | 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 | 2018-07-12 | 2018-08-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-07-12 | 2018-08-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-07-12 | 2018-08-08 | N |
| Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2018-07-12 | 2018-08-08 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-07-12 | 2018-08-08 | 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 | 2018-07-12 | 2018-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-12 | 2018-08-08 | 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 | 2018-07-12 | 2018-08-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-03-22 | 2018-04-12 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-06-29 | 2017-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-29 | 2017-08-08 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-29 | 2017-08-08 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-29 | 2017-08-08 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-29 | 2017-08-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-29 | 2017-08-08 | N |
| Provide bedrooms that hold no more than 4 residents per room. | Health | 2017-06-29 | 2017-08-08 | N |
