Bradley Health Care & Rehab: Dementia Fall Violation - TN
CLEVELAND, TN. For 44 minutes on April 28, 2026, nobody at Bradley Health Care & Rehab knew where a dementia patient was. By the time staff located Resident #1, the patient had already fallen, sustained injuries, and would need a trip to the emergency department.
The facility's own Director of Nursing confirmed it.
Federal inspectors cited Bradley Health Care & Rehab following a complaint investigation completed May 28, 2026, finding the facility failed to adequately supervise, monitor, and redirect a dementia resident with known wandering and exit-seeking behaviors. The lapse was rated as causing actual harm.
What makes the finding harder to explain is what came before it. The inspection record references an earlier psychiatric hospitalization and a behavioral intervention involving a stop sign, both documented prior to the April 28 incident. Those details suggest the facility had already been put on notice that this resident required specific, active management. The dementia care plan, inspectors found, never reflected that. It contained no individualized interventions targeting the wandering and exit-seeking behaviors that staff already knew about.
The Director of Nursing, interviewed on May 19, confirmed the facility failed to adequately supervise and redirect Resident #1 on April 28. She confirmed the gap in awareness lasted approximately 44 minutes. She confirmed the fall was unwitnessed. She confirmed that what followed was an injury serious enough to require emergency evaluation and transport.
A second interview, conducted the evening of May 18, produced a separate confirmation: the facility had also failed to update the resident's dementia care plan after the April 28 incident and after the psychiatric hospitalization that followed. The stop sign intervention, referenced in the inspection record as something that had been tried, was never formally incorporated into the care plan either. From April 28 through at least May 11, when inspectors noted appropriate interventions finally appeared, the care plan did not reflect what this resident actually needed.
That window, April 28 to May 11, is the period inspectors identified as the span of actual harm.
Dementia residents with wandering behaviors require care plans built around their specific patterns, not generic language. A stop sign posted somewhere in a hallway is only useful if the people working a given shift know it exists, know where it is, know why it matters for this particular resident, and have been trained on what to do when the resident approaches an exit anyway. None of that happens without documentation. None of it transfers between shifts without a care plan that names the intervention and explains it.
Bradley Health Care & Rehab had a resident whose behaviors were serious enough to result in a psychiatric hospitalization. It had already tried at least one behavioral intervention. It had, in other words, information. What it did not have, inspectors concluded, was a care plan that turned that information into consistent, shift-to-shift awareness of where this resident was and what to do when she moved toward a door.
On April 28, that gap lasted 44 minutes. Resident #1 fell somewhere in that facility, alone, and no one saw it happen.
The Director of Nursing did not dispute any of it.
Inspectors classified the violation under the federal standard requiring facilities to develop and implement person-centered dementia care plans with specific interventions. The harm level was marked actual, not potential. The residents affected were listed as few, meaning the pattern did not extend across the unit, but the classification offers little comfort to the one resident who spent 44 minutes unaccounted for before hitting the floor.
The inspection report ends with the administrative confirmation and the care plan failure. It does not say how Resident #1 is doing now.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 21, 2026 · Our methodology
BRADLEY HEALTH CARE & REHAB in CLEVELAND, TN was cited for violations during a health inspection on May 28, 2026.
For 44 minutes on April 28, 2026, nobody at Bradley Health Care & Rehab knew where a dementia patient was.
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.