Bradley Health Care & Rehab: Dining Dignity Failures - TN
Resident #13 is cognitively intact, alert and oriented in all directions, according to the inspection report from Bradley Health Care & Rehab. He was admitted to the facility in November 2025 carrying diagnoses that include moderate malnutrition and muscle weakness, along with an unspecified tremor that left him needing help to eat. When inspectors observed him during lunch on May 18 and again on May 19, 2026, they watched him sit at a table with other residents and wait. Other residents received their meals. Other residents ate their meals. Other residents finished their meals. Resident #13 waited more than 20 minutes before staff came to serve and assist him.
This happened both days.
Inspectors also found that meals across the dining room were being delivered to all eight observed residents on service trays, with plates and utensils left sitting on the trays throughout the meal rather than being removed and placed properly in front of residents. The facility's own policy on resident dignity, though undated, states plainly that each resident will be treated with respect and dignity and provided equal access to quality care regardless of diagnosis or severity of condition.
On the evening of May 19, at 6:05 PM, an inspector sat with Resident #13 after he had finished eating. He described what had become routine. He said he had frequently watched other residents get served and eat while he waited. He said the waiting was customary for him.
Then he said something that inspectors recorded word for word: "I am real easygoing, but sometimes it makes me feel left out."
That sentence is doing a lot of work. Resident #13 is not complaining. He is explaining himself, offering reassurance, softening what he is about to say. He is describing a pattern he has accepted because he has no real alternative, and he is doing it gently, the way a person does when they have learned that making too much of something doesn't change anything.
He has moderate malnutrition. He has muscle weakness. He has an anxiety disorder and adjustment disorder with depressed mood. He is living in a facility that is supposed to monitor his nutritional status and support his mental health, and he is sitting at a lunch table watching other people eat while he waits for someone to help him.
Twenty-five minutes after the inspector spoke with Resident #13, the facility's Director of Nursing sat down for an interview. The DON confirmed that the facility had failed to maintain Resident #13's dignity during meal service, in accordance with its own policy.
That was the end of the documented conversation.
The inspection was a complaint survey, meaning someone had already flagged concerns before investigators arrived. Inspectors observed the dining room on two separate days and found the same problems both times: trays not properly set, a dependent resident waiting while his table finished without him. The deficiency was rated at minimal harm or potential for actual harm, the lowest tier on the federal harm scale.
Minimal harm is a regulatory category. It does not mean nothing happened. Resident #13 told inspectors what happened, in his own words, on the record, and described it as a pattern so established he had come to expect it.
He is 63 days past his quarterly assessment as of the inspection date. He scored a 14 out of 15 on the cognitive status exam, meaning he missed one question. He understands his situation. He can describe it. He did describe it, to a federal inspector, at a table in the dining room where he had just finished a meal he waited 20 minutes to receive.
The facility is located at 2910 Peerless Road in Cleveland, Tennessee. The Director of Nursing agreed, on the record, that what happened to Resident #13 was not acceptable under the facility's own standards.
Resident #13 said he was real easygoing about it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bradley Health Care & Rehab from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
BRADLEY HEALTH CARE & REHAB in CLEVELAND, TN was cited for violations during a health inspection on May 28, 2026.
Resident #13 is cognitively intact, alert and oriented in all directions, according to the inspection report from Bradley Health Care & Rehab.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.