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Deficiency Records for Bradley Estates Nursing and Rehab LLC

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.

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?
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-07-01 2024-07-17 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-07-01 2024-07-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-07-01 2024-07-17 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 2024-07-01 2024-07-17 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-07-01 2024-07-17 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 2024-07-01 2024-07-17 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 2024-07-01 2024-07-17 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-07-01 2024-07-17 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-07-01 2024-07-17 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2024-03-07 2024-04-05 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-03-07 2024-04-05 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 2024-03-07 2024-04-05 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2024-03-07 2024-04-05 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-03-07 2024-04-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-07 2024-04-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-03-07 2024-04-05 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 2024-03-07 2024-04-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-07 2024-04-05 Y
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 2024-03-07 2024-04-05 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-03-07 2024-04-05 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-03-07 2024-04-05 Y
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2024-03-07 2024-04-05 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-03-07 2024-04-05 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-03-07 2024-04-05 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 2024-03-07 2024-04-05 Y
Ensure that residents are free from significant medication errors. Health 2024-03-07 2024-04-05 Y
Provide or get specialized rehabilitative services as required for a resident. Health 2024-03-07 2024-04-05 Y
Provide and implement an infection prevention and control program. Health 2024-03-07 2024-04-05 Y
Implement a program that monitors antibiotic use. Health 2024-03-07 2024-04-05 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 2024-01-17 2024-04-05 Y
Respond appropriately to all alleged violations. Health 2024-01-17 2024-04-05 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-01-17 2024-04-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-17 2024-04-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-01-17 2024-04-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-17 2024-04-05 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-17 2024-02-09 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2024-01-17 2024-02-09 Y
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2024-01-17 2024-02-09 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 2024-01-17 2024-02-09 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-11-01 2023-12-01 Y
Give the resident's representative the ability to exercise the resident's rights. Health 2023-11-01 2023-12-01 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-11-01 2023-12-01 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-11-01 2023-12-01 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 2023-11-01 2023-12-01 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 2023-11-01 2023-12-01 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-11-01 2023-12-01 Y
Respond appropriately to all alleged violations. Health 2023-11-01 2023-12-01 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 2023-11-01 2023-12-01 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-01 2023-12-01 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 2023-11-01 2023-12-01 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-11-01 2023-12-01 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-01 2023-12-01 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-01 2023-12-01 Y
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 2023-11-01 2023-12-01 Y
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Health 2023-11-01 2023-12-01 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-11-01 2023-12-01 Y
Ensure medication error rates are not 5 percent or greater. Health 2023-11-01 2023-12-01 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 2023-11-01 2023-12-01 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-11-01 2023-12-01 Y
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2023-11-01 2023-12-01 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2023-11-01 2023-12-01 Y
Provide and implement an infection prevention and control program. Health 2023-11-01 2023-12-01 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-11-01 2023-12-01 Y
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-04-25 2023-06-14 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-04-25 2023-05-24 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 2023-04-25 2023-05-24 N
Have an enclosure around a vertical opening shaft. Fire Safety 2023-04-25 2023-05-24 N
Provide properly protected cooking facilities. Fire Safety 2023-04-25 2023-05-24 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-04-25 2023-05-24 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-04-25 2023-05-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-04-25 2023-05-24 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-04-25 2023-05-24 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-04-25 2023-05-24 N
Have restrictions on the use of portable space heaters. Fire Safety 2023-04-25 2023-05-24 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2023-04-25 2023-05-24 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-04-25 2023-05-24 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-04-26 2023-05-19 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2023-04-26 2023-05-19 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 2023-04-26 2023-05-19 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-04-26 2023-05-19 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-04-26 2023-05-19 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 2023-04-26 2023-05-19 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-04-26 2023-05-19 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-04-26 2023-05-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-04-26 2023-05-19 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 2023-04-26 2023-05-19 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 2023-04-26 2023-05-19 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 2023-04-26 2023-05-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-04-26 2023-05-19 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-04-26 2023-05-19 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2023-04-26 2023-05-19 N
Provide and implement an infection prevention and control program. Health 2023-04-26 2023-05-19 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-04-26 2023-05-19 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-04-26 2023-05-19 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-04-26 2023-05-19 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-04-26 2023-05-19 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-04-26 2023-05-19 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-04-26 2023-05-19 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-03-02 2023-03-07 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 2023-03-02 2023-03-07 Y
Ensure medication error rates are not 5 percent or greater. Health 2023-03-02 2023-03-07 Y
Ensure that residents are free from significant medication errors. Health 2023-03-02 2023-03-07 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 2022-12-29 2023-03-07 Y
Ensure medication error rates are not 5 percent or greater. Health 2022-12-29 2023-03-07 Y
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2022-12-29 2023-03-02 Y
Reasonably accommodate the needs and preferences of each resident. Health 2022-12-29 2023-03-02 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 2022-12-29 2023-03-02 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-12-29 2023-03-02 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-12-29 2023-03-02 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-29 2023-03-02 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-12-29 2023-03-02 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-12-29 2023-03-02 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-12-29 2023-03-02 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2022-12-29 2023-03-02 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-12-29 2023-03-02 Y
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 2022-12-29 2023-03-02 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-12-29 2023-03-02 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 2022-07-16 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
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
Perform COVID19 testing on residents and staff. 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
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2020-02-26 2020-03-27 N
Respond appropriately to all alleged violations. Health 2020-02-26 2020-03-27 N
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 appropriate treatment and care according to orders, resident?s preferences and goals. Health 2020-02-26 2020-03-27 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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
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

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