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

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.38

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.19

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.06

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.64

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.30

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.16

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.37

CMS adjusted RN staffing hours

Adjusted total hours

3.50

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

69%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

56%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,620

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.23

Composite VBP score used to determine payment impact.

Payment multiplier

0.9854

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

8.29

Baseline 17.83% · Performance 17.59% · Measure score 8.29 · Achievement 8.29 · Improvement 2.56

Healthcare-associated infections

0

Baseline 6.25% · Performance 7.75% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.07

Baseline 45.56% · Performance 55.24% · Measure score 2.07 · Achievement 2.07 · Improvement 0

Adjusted total nurse staffing

1.33

Baseline 3.03 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 1.06

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.43%	10.72% 1.7 pts worse	No Different than the National Rate · Eligible stays 189 · Observed rate 15.87% · Lower 95% interval 9.57%
Discharge to community	57.17%	50.57% 6.6 pts better	No Different than the National Rate · Eligible stays 168 · Observed rate 50.6% · Lower 95% interval 49.55%
Medicare spending per beneficiary	0.82	1.02 0.2 pts better
Drug regimen review with follow-up	97.98%	95.27% 2.7 pts better	Numerator 97 · Denominator 99
Falls with major injury	1.01%	0.77% 0.2 pts worse	Numerator 1 · Denominator 99
Discharge self-care score	61.84%	53.69% 8.2 pts better	Numerator 47 · Denominator 76
Discharge mobility score	64.47%	50.94% 13.5 pts better	Numerator 49 · Denominator 76
Pressure ulcers or injuries, new or worsened	5.05%	2.29% 2.8 pts worse	Numerator 5 · Denominator 99 · Adjusted rate 5.28%
Healthcare-associated infections requiring hospitalization	7.75%	7.12% 0.6 pts worse	No Different than the National Rate · Eligible stays 107 · Observed rate 8.41% · Lower 95% interval 4.69%
Staff COVID-19 vaccination coverage	7.02%	8.2% 1.2 pts worse	Numerator 12 · Denominator 171
Staff flu vaccination coverage	25.33%	42% 16.7 pts worse	Numerator 76 · Denominator 300
Discharge function score	59.21%	56.45% 2.8 pts better	Numerator 45 · Denominator 76
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 22 · Denominator 22
Transfer of health information to patient	98.31%	96.28% 2 pts better	Numerator 58 · Denominator 59
Resident COVID-19 vaccinations up to date	7.84%	25.2% 17.4 pts worse	Numerator 4 · Denominator 51

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 · Adjusted 2.7 · Observed 2.5 · Expected 1.7 · Used in QM five-star
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 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star
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 · Q1 91.4% · Q2 92.6% · Q3 96.5% · Q4 91.0% · 4Q avg 92.9%
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 · 4Q avg 94.0%
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 · Q1 2.2% · Q2 2.1% · Q3 1.2% · Q4 5.1% · 4Q avg 2.6% · Used in QM five-star
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 · Q1 0.0% · Q2 3.6% · Q3 1.3% · Q4 1.4% · 4Q avg 1.6%
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 · Q1 2.7% · Q2 9.2% · Q3 4.2% · Q4 0.0% · 4Q avg 4.2%
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 · Q1 30.3% · Q2 34.2% · Q3 28.8% · Q4 34.8% · 4Q avg 32.0%
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 · Q1 16.7% · Q2 20.0% · Q3 21.1% · Q4 25.5% · 4Q avg 20.6% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · Q1 36.2% · Q2 35.8% · Q3 7.1% · Q4 28.1% · 4Q avg 25.8% · Used in QM five-star
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 · Q1 15.0% · Q2 35.5% · Q3 9.8% · Q4 22.2% · 4Q avg 20.7% · Used in QM five-star
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 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star
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 · Q1 2.2% · Q2 1.1% · Q3 2.4% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star
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 · Q1 12.7% · Q2 30.8% · Q3 26.6% · Q4 22.5% · 4Q avg 23.2%
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 · Q1 7.8% · Q2 8.5% · Q3 4.1% · Q4 3.7% · 4Q avg 6.2% · Used in QM five-star
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 · Q1 80.5% · Q2 81.4% · Q3 85.7% · Q4 85.7% · 4Q avg 83.3%
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 · Adjusted 12.7% · Observed 12.6% · Expected 11.1% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.5% · Used in QM five-star
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 · 4Q avg 72.6%
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 · Adjusted 25.2% · Observed 25.3% · Expected 23.9% · Used in QM five-star

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