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Deficiency Records for Bradley Creek Health Center

A list of the most recent deficiencies for Bradley Creek Health Center. 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 Bradley Creek Health Center. 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?
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-05-08 2024-05-31 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-05-08 2024-05-31 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-04-11 2024-05-02 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 2024-04-11 2024-05-02 Y
Ensure that residents are free from significant medication errors. Health 2024-04-11 2024-05-02 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-02-02 2023-03-18 N
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 2023-02-02 2023-03-18 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-02-02 2023-03-18 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-02-02 2023-03-18 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-02-02 2023-03-18 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-02-02 2023-03-18 N
Have proper medical gas storage and administration areas. Fire Safety 2023-02-02 2023-03-18 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 2022-12-22 2023-01-31 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-12-22 2023-01-31 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-12-22 2023-01-31 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-10-08 2021-10-22 N

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