Deficiency Records for Bradley Estates Nursing and Rehab LLC
Updated as of November 01, 2022
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? |
|---|---|---|---|---|
| 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 | 2022-07-16 | 2022-07-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-16 | 2022-07-19 | Y |
| 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 | 2022-05-25 | 2022-07-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-25 | 2022-07-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-07-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-07-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-10 | 2022-03-04 | Y |
| 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 | 2022-02-10 | 2022-03-04 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-10 | 2022-03-04 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-03-04 | Y |
| 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 | 2022-02-10 | 2022-03-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-10 | 2022-03-04 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-02-10 | 2022-03-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-10 | 2022-03-04 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-10 | 2022-03-04 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-10 | 2022-03-04 | 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 | 2022-02-08 | 2022-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-27 | 2021-11-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-27 | 2021-11-12 | 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 | 2021-08-03 | 2021-08-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-03 | 2021-08-20 | Y |
| 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 | 2021-08-03 | 2021-08-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-14 | 2021-08-20 | Y |
| Honor the resident's right to choose his or her attending physician. | Health | 2021-06-14 | 2021-08-03 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-06-14 | 2021-08-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-14 | 2021-08-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-06-14 | 2021-08-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-14 | 2021-08-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-14 | 2021-08-03 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-06-14 | 2021-08-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-11 | 2021-06-08 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-11 | 2021-06-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-11 | 2021-06-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-11 | 2021-06-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-01-12 | 2021-02-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-01-12 | 2021-02-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-01-12 | 2021-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-12 | 2021-02-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-11-24 | 2020-12-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-11-24 | 2020-12-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-09-30 | 2020-10-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-30 | 2020-10-16 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-09-30 | 2020-10-16 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-26 | 2020-03-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-26 | 2020-03-27 | 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 | 2020-02-26 | 2020-03-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-26 | 2020-03-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-26 | 2020-03-27 | 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 | 2020-02-26 | 2020-03-27 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-02-26 | 2020-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-26 | 2020-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-26 | 2020-03-27 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-02-26 | 2020-03-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-26 | 2020-03-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-02-26 | 2020-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-26 | 2020-03-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-26 | 2020-03-27 | 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 | 2020-02-26 | 2020-03-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-26 | 2020-03-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-26 | 2020-03-27 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-20 | 2020-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-20 | 2020-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-20 | 2020-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-12 | 2020-01-06 | 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-30 | 2019-01-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-30 | 2019-01-02 | N |
