Deficiency Records for Bradley Estates Nursing and Rehab LLC
Updated as of May 01, 2020
This is not the most recent data for Bradley Estates Nursing and Rehab LLC. For the most recent information, click here.
A list of the most recent deficiencies for Bradley Estates Nursing and Rehab LLC. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-12 | 2020-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-05 | 2019-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-15 | 2019-09-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-15 | 2019-09-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-15 | 2019-09-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-05 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-06-12 | 2019-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-12 | 2019-07-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-12 | 2019-07-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-12 | 2019-07-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-12 | 2019-07-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-18 | 2019-04-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-03 | 2019-01-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-12-03 | 2019-01-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-12-03 | 2019-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-03 | 2019-01-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-12-03 | 2019-01-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-03 | 2019-01-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-03 | 2019-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-03 | 2019-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-03 | 2019-01-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-05 | 2018-07-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-07-02 | 2018-07-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-25 | 2018-05-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-04-25 | 2018-05-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-25 | 2018-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-25 | 2018-05-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-25 | 2018-05-22 | Y |
| 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 | 2018-04-25 | 2018-05-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-25 | 2018-05-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-25 | 2018-05-22 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-10-26 | 2017-11-26 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-10-26 | 2017-11-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-10-26 | 2017-11-26 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-26 | 2017-11-26 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-10-26 | 2017-11-26 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-26 | 2017-11-26 | 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 | 2017-10-26 | 2017-11-26 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2017-10-26 | 2017-11-26 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-10-26 | 2017-11-26 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2017-10-26 | 2017-11-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-26 | 2017-11-26 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-26 | 2017-11-26 | Y |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-10-26 | 2017-11-26 | Y |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-10-26 | 2017-11-26 | Y |
| Provide clean bed and bath linens that are in good condition. | Health | 2017-10-26 | 2017-11-26 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-26 | 2017-11-26 | Y |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-10-26 | 2017-11-26 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-26 | 2017-11-26 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-10-26 | 2017-11-26 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-10-26 | 2017-11-26 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-10-26 | 2017-11-26 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-26 | 2017-11-26 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-10-26 | 2017-11-26 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-26 | 2017-11-26 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-10-17 | 2017-11-13 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-10-17 | 2017-11-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-10-17 | 2017-11-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-10-17 | 2017-11-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-04-26 | 2017-05-12 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-04-26 | 2017-05-12 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-26 | 2017-05-12 | Y |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2016-08-30 | 2016-09-23 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2016-09-01 | 2016-09-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-09-01 | 2016-09-23 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-09-01 | 2016-09-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2016-09-01 | 2016-09-23 | N |
| Try to resolve each resident's complaints quickly. | Health | 2016-09-01 | 2016-09-23 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2016-09-01 | 2016-09-23 | N |
| Provide housekeeping and maintenance services. | Health | 2016-09-01 | 2016-09-23 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-09-01 | 2016-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-01 | 2016-09-23 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-09-01 | 2016-09-23 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2016-09-01 | 2016-09-23 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-09-01 | 2016-09-23 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-09-01 | 2016-09-23 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-09-01 | 2016-09-23 | N |
