Bradley Health Care & Rehab
BRADLEY HEALTH CARE & REHAB in CLEVELAND, TN — inspection on May 28, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the medical record revealed Resident #13 was admitted to the facility 11/25/2025 with diagnoses including Adjustment-Disorder with Depressed Mood, Mild Cognitive Impairment, Generalized Anxiety, Unspecified Tremor, Moderate Malnutrition, and Muscle Weakness.
Review of admission and Quarterly Minimum Data Set (MDS) assessments dated 11/25/2025, revealed Resident #13 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated Resident #13 was cognitively intact.
Continued review revealed Resident #13 required set up and supervision with eating.
During multiple observations of Resident #13 and other peers seated in the main dining room on 5/18/2026 and 5/19/2026 during the lunch meal service, revealed on both dates, meals were served to residents atop service trays.
The plates and utensils were not removed from the service trays throughout the meal. Resident #13 was observed on 5/18/2026 and 5/1/2026 seated at a time during the lunch meal and waited for over 20 minutes while others seated at the same table, received and finished their meals, before staff served and assisted Resident #13 with his meal.
During an observation and interview on 5/19/2026 at 6:05 PM, in the dining room, Resident #13 was observed to have finished his meal, and sat at a table with another resident. Resident #13 stated he had frequently observed other residents being served their meals and had watched as the other residents sat at the same table consume the meals as he waited for assistance. Resident #13 (who was alert and oriented in all spheres) stated the practice of having to wait to be served and assisted with meals was customary for him and further stated .I am real easygoing, but sometimes it makes me feel left out .
During interview on 5/19/2025 at 6:30 PM, the Director of Nursing (DON) confirmed the facility failed to maintain Resident #13's dignity, in accordance with expectations of the facility policy, during the meal services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
445141 05/28/2026
Bradley Health Care & Rehab 2910 Peerless Rd Cleveland, TN 37312
Review of the facility FRI (incident 2998873) dated 4/29/2026 revealed the incident referenced in the FRI included allegations of potential resident versus resident abuse, which was documented to have occurred on the evening of 4/28/2026 around 7:50 PM between Residents #1 and #2.
Continued review of the documents revealed the allegations were received by the state agency on 4/29/2026 at 2:01 PM, 18 hours after the incident occurred.
Review of facility FRI (incident 2998805) dated as received by the state agency on 4/29/2026 at 1:41 PM, showed the incident referenced in the FRI occurred on the evening of 4/23/2026 (6 days earlier), and included allegations of potential resident versus resident physical abuse between Residents #3 and #4.
Continued review showed the facility abuse coordinator was not made aware of the allegations of potential resident on resident abuse, until the morning of 4/24/2026, (the day after the allegations were to have occurred) at which time the facility formally launched an investigation, which was not reported to the state agency until 5 days later.
During interview on 5/19/2026 at 10:30 AM, the Director of Nursing (DON) confirmed the facility failed to report allegations related to potential resident versus resident abuse to the state agency within 2 hours of the facility becoming aware of them, as mandated by state and federal requirements for both incidents.
445141 05/28/2026
Bradley Health Care & Rehab 2910 Peerless Rd Cleveland, TN 37312
intervention of using the stop sign after the incident on 4/28/2026, or the psychiatric hospitalization
the Director of Nursing (DON) confirmed the facility failed to develop and implement a
wandering and exit seeking behaviors. ˆ During interview on 5/19/2026 at 10:30 AM the DON confirmed the facility failed to adequately supervise, monitor, and redirect Resident #1's behaviors on 4/28/2026.
The DON confirmed the facility's failure resulted in the facility staff not having an awareness of Resident #1's whereabouts for approximately 44 minutes resulting in an unwitnessed fall with injury and transport to the local ED for evaluation and treatment.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.