A list of the most recent deficiencies for The Bradley Home and Pavilion. 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? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-11 | 2023-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-06-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-11 | 2023-06-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-11 | 2023-06-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-11 | 2023-06-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-11 | 2023-06-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-11 | 2023-06-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-11 | 2023-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-10 | 2023-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-14 | 2021-07-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-14 | 2021-07-14 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Establish methods for sharing information. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-07 | 2019-08-21 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-06-06 | 2019-07-31 | 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 | 2019-06-06 | 2019-07-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-06 | 2019-07-31 | 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 | 2019-06-06 | 2019-07-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-06-06 | 2019-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-06-25 | N |
