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Deficiency Records for The Bradley Gardens
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.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-08-23 | 2024-08-27 | Y |
| 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 |
| 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 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-03-29 | 2024-04-29 | N |
| 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 |
| 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 |
| 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 |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-03 | 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-12 | 2022-02-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-12 | 2022-02-16 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-14 | 2022-02-03 | Y |
| 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 |
| 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 |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-12 | 2021-09-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | 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 |
| 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 appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| Ensure medication error rates are not 5 percent or greater. | 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 |
| 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 |
| 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 |
| 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 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 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 |
| Provide and implement an infection prevention and control program. | 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 |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| 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 |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-03 | 2019-07-30 | N |
| 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 |
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