Bradley Estates Nursing And Rehab Llc

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

circumstances of the incident but remembered that Resident R4 was punched. Review of written statements revealed LPN1 and Certified Nursing Assistant (CNA)1 observed the resident-to-resident altercation. Review of a written statement, dated 7/24/25 and signed by CNA1, revealed CNA1 witnessed Resident R2 punching Resident R4 in the face and head. On 8/19/25 at 9:44 AM, the Surveyor attempted to call CNA1 who was no longer employed by the facility. A voice message was left requesting CNA1 call the Surveyor at the facility.An interview with LPN1 on 8/18/25 at 2:56 PM, revealed LPN1 was at the nursing station and witnessed Resident R2 hit Resident R4 multiple times in the face and head with a closed fist. LPN1 stated staff immediately separated Resident R2 and Resident R4 and sent Resident R4 to the hospital. LPN1 stated Resident R2 was new and LPN1 had never witnessed or heard that Resident R2 was aggressive or hit residents prior to the incident. LPN1 stated Resident R2 had not been aggressive or hit anyone since the incident. LPN1 stated LPN1 was behind the nursing station and could see the dining room. LPN1 stated Resident R4 had a bump on the side of the head and redness on the side of the face that later turned into a bruise. LPN1 stated Resident R2 said Resident R4 kept bumping into Resident R2's wheelchair and Resident R2 kept telling Resident R4 to stop. LPN1 stated Resident R2 was blind and felt it made Resident R2 anxious that Resident R4 was going to hurt Resident R2 so Resident R2 punched Resident R4 in self-defense. LPN1 stated Resident R2 was sorry and remorseful after the incident.Review of Resident R4's electronic medical

record (EMR) revealed Resident R4 was admitted to the facility on [DATE REDACTED] and had diagnoses including end stage renal disease, dependence on renal dialysis, schizophrenia, chronic pain, major depressive disorder, generalized anxiety disorder, and Parkinson's disease with dyskinesia.According to Resident R4's activities of daily living care plan, with an initiation date of 2/27/25, Resident R4 was dependent on a wheelchair for mobility and required assistance with transfers, personal hygiene, toileting, and dressing. Review of Resident R4's five-day MDS assessment, with an ARD of 7/1/25, revealed Resident R4 had a BIMS score of 9 out of 15 indicating Resident R4 had moderately impaired cognition. Resident R4 was able to understand and be understood. A progress note, dated 7/14/25 at 11:22 AM, indicated Resident R4 had a right side head hematoma and right cheek bruising. Review of Resident R2's EMR revealed Resident R2 was admitted to the facility on [DATE REDACTED]. Resident R2's admission MDS assessment, stated Resident R2 had a BIMS score of 15 out of 15 indicating Resident R2 was cognitively intact. The MDS assessment indicated Resident R2 did not have any behaviors. During an interview on 8/18/25 at 11:30 AM, Resident R4 said no when asked if a resident ever hit or punched Resident R4.During an interview on 8/18/25 at 2:38 PM, Resident R2 was asked if Resident R2 had a problem with any residents. Resident R2 stated Resident R2 got into a fight a while back because some guy told Resident R2 to move.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bradley Estates Nursing and Rehab LLC

6735 W Bradley Rd Milwaukee, WI 53223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, the facility failed to ensure an allegation of missing money was reported to the State Agency (SA) for 1 resident (R) (Resident R10) of 3 sampled residents. Resident R10 reported $650 was missing from a pill bottle in Resident R10's dresser drawer. The allegation of misappropriation was not reported to the SA.Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, with a revised date of 1/5/24, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under the reporting/response section of the policy it states alleged violations will be reported to the required agencies no later than 24 hours if the events do not involve abuse.Review of a grievance form for Resident R10, dated 6/25/25, revealed Resident R10 stated when Resident R10 came back from dialysis on 6/23/25, Resident R10 realized $650 that Resident R10 had in a pill bottle in Resident R10's dresser drawer was missing. Resident R10 also stated Resident R10 was removed from the 600 unit because Resident R10 had $3900 missing. According to the grievance form, Resident R10's room was searched but the money was not found. The Actions Taken section stated there was no evidence that Resident R10 had $650 and no evidence that Resident R10 had money when Resident R10 resided on the 600 unit. The risks and benefits of locking up valuables or sending them home with family were discussed. According to the grievance form, Resident R10 changed the amount of money several times and did not know the denominations. Resident R10 was informed the facility was not responsible for the missing money.During an interview on 8/20/25 at 9:39 AM, Resident R10 stated Resident R10 twice had missing money while residing in the facility, once while residing on the second floor and once while residing on the first floor. Resident R10 stated Resident R10 reported the missing money but nothing was done. An admission Record located in Resident R10's electronic medical record (EMR) revealed Resident R10 was admitted to the facility on [DATE REDACTED]. Resident R10's diagnoses included end stage renal disease, schizophrenia, and blindness of the left and right eye.Review of Resident R10's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 5/16/24, revealed Resident R10 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated Resident R10 had intact cognition. Review of Resident R10's care plan, with an initiated date of 11/8/24, revealed Resident R10 preferred to keep money on Resident R10's person and declined the use of a lock box. The care plan contained an intervention, dated 6/24/5, to encourage Resident R10 to keep money in a lockbox and continue to re-iterate the risks/benefits of using a lockbox for money and valuables or send them home with family and friends. Resident R10's progress notes from 1/1/25 to the present did not refer to Resident R10's complaint of missing money.

During an interview with the Director of Nursing (DON) on 8/20/25 at 4:05 PM, the DON verified Resident R10's allegation of missing money was not reported to the SA because there was no evidence that Resident R10 ever had

the money. The DON indicated Resident R10 kept changing the amount of missing money and did not know the denominations of the missing money.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bradley Estates Nursing and Rehab LLC

6735 W Bradley Rd Milwaukee, WI 53223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, record review, and policy review, the facility failed to thoroughly investigate an allegation of missing money for 1 resident (R) (Resident R10) of 3 sampled residents.Resident R10 reported $650 was missing from a pill bottle in Resident R10's dresser drawer. The allegation of misappropriation was not thoroughly investigated. Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, with a revised date of 1/5/24, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under the reporting/response section of the policy it states alleged violations will be reported to the required agencies no later than 24 hours if the events do not involve abuse.Review of a grievance form for Resident R10, dated 6/25/25, revealed Resident R10 stated when Resident R10 came back from dialysis on 6/23/25, Resident R10 realized $650 that Resident R10 kept in a pill bottle in Resident R10's dresser drawer was missing. Resident R10 also stated Resident R10 was removed from the 600 unit because Resident R10 had $3900 missing. According to the report, Resident R10's room was searched but the money was not found. The Actions Taken section stated there was no evidence that Resident R10 had $650 and no evidence that Resident R10 had money when Resident R10 resided on the 600 unit. The risks and benefits related to locking up valuables or sending them home with family were discussed. According to the grievance form, Resident R10 changed the amount of money several times and did not know the denominations. Resident R10 was informed the facility was not responsible for the missing money.During an interview on 8/20/25 at 9:39 AM, Resident R10 stated Resident R10 twice had missing money while residing in the facility, once while residing on the second floor and once while residing

on the first floor. Resident R10 stated Resident R10 reported the missing money but nothing was done. An admission Record located in Resident R10's electronic medical record (EMR) revealed Resident R10 was admitted to the facility on [DATE REDACTED]. Resident R10's diagnoses included end stage renal disease, schizophrenia, and blindness of the left and right eye.Review of Resident R10's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 5/16/24, revealed Resident R10 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated Resident R10 had intact cognition. Review of Resident R10's care plan, with an initiated date of 11/8/24, revealed Resident R10 preferred to keep money on Resident R10's person and declined the use of a lock box. The care plan contained

an intervention, dated 6/24/25, to encourage Resident R10 to keep money in a lockbox and continue to re-iterate the risks/benefits of locking up valuables or send them home with family and friends. Resident R10's progress notes from 1/1/25 to the present did not mention Resident R10's complaint of missing money.During an interview with the Director of Nursing (DON) on 8/20/25 at 4:05 PM, the DON verified Resident R10's allegation of missing money was not investigated because there was no evidence that Resident R10 ever had the money. The DON also indicated Resident R10 kept changing the amount of the missing money and did not know the denominations of the missing money.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet