Cleveland, TN

Bradley Health Care & Rehab

4-star overall rating with 4-star inspections with $8,999 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

2910 Peerless Rd, Cleveland, TN

(423) 472-7116

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

213

Certified beds

Average residents

91

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1981-05-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.38

Registered nurse staffing

LPN hours / resident day

1.19

Licensed practical nurse staffing

Aide hours / resident day

2.06

Nurse aide staffing

Weekend hours

3.30

Weekend nurse staffing

RN turnover

69%

Annual RN turnover

Total nurse turnover

56%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.7	1.6 1.1 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.6 About the same	1.8 0.2 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.9%	89.9% 3 pts better	93.4% 0.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.0%	94.5% 0.5 pts worse	95.5% 1.5 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	2.6%	3.6% 1 pts better	3.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	1.6%	11.8% 10.2 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	4.2%	6.2% 2 pts better	5.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	32.0%	32.2% 0.2 pts better	19.6% 12.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	20.6%	18.1% 2.5 pts worse	16.7% 3.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	25.8%	19.9% 5.9 pts worse	16.3% 9.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	20.7%	15.3% 5.4 pts worse	14.9% 5.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.9% 0.5 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	2.0%	1.9% 0.1 pts worse	1.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.2%	20.2% 3 pts worse	19.8% 3.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	6.2%	5.4% 0.8 pts worse	5.1% 1.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	83.3%	79.6% 3.7 pts better	81.7% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	12.7%	11.2% 1.5 pts worse	12.0% 0.7 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.6% 1.1 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	72.6%	79.8% 7.2 pts worse	79.7% 7.1 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.2%	22.2% 3 pts worse	23.9% 1.3 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2022-11-02 · Fire 2022-11-02

4 health deficiencies

Top issue: Administration (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2019-12-18 · Fire 2019-12-18

0 health deficiencies

No concentrated health issue counts in this cycle.

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2018-10-31 · Fire 2018-10-31

6 health deficiencies

Top issue: Resident Rights (2 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2022-11-02

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-11-23

F · Potential for more than minimal harm 2022-11-02

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-02

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-11-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-11-23

F · Potential for more than minimal harm 2019-12-18

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2020-02-01

F · Potential for more than minimal harm 2019-12-18

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2020-02-01

D · Potential for more than minimal harm 2019-12-18

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2020-02-01

D · Potential for more than minimal harm 2019-12-18

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2020-02-01

D · Potential for more than minimal harm 2019-12-18

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2020-02-01

D · Potential for more than minimal harm 2019-12-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-02-01

F · Potential for more than minimal harm 2018-10-31

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2018-12-15

E · Potential for more than minimal harm 2018-10-31

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2018-12-15

C · Minimal harm 2018-10-31

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2018-12-15

Inspection history

Recent health citations

G · Actual harm 2024-02-27

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-01-05

D · Potential for more than minimal harm 2022-11-02

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-11-02

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-11-02

F849 · Administration Deficiencies

Health

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.

Corrected 2022-11-23

C · Minimal harm 2022-11-02

F888 · Infection Control Deficiencies

Health

Ensure staff are vaccinated for COVID-19

Corrected 2022-11-23

F · Potential for more than minimal harm 2018-10-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2018-12-15

F · Potential for more than minimal harm 2018-10-31

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2018-12-15

D · Potential for more than minimal harm 2018-10-31

F571 · Resident Rights Deficiencies

Health

Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.

Corrected 2018-12-15

D · Potential for more than minimal harm 2018-10-31

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2018-12-15

D · Potential for more than minimal harm 2018-10-31

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2018-12-15

Penalties and ownership

What sits behind the stars

$8,999 2024-02-27

Fine

Fine · fine $8,999

Fine