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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? |
|---|---|---|---|---|
| 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 | 2024-05-01 | 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 | 2024-05-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-11 | 2024-05-01 | 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 |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-07-17 | 2019-08-14 | N |
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