Bradley Estates Nursing And Rehab Llc
Bradley Estates Nursing and Rehab LLC in MILWAUKEE, WI — inspection on August 20, 2025.
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 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 R2 punching 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 R2 hit R4 multiple times in the face and head with a closed fist. LPN1 stated staff immediately separated R2 and R4 and sent R4 to the hospital. LPN1 stated R2 was new and LPN1 had never witnessed or heard that R2 was aggressive or hit residents prior to the incident. LPN1 stated 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 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 R2 said R4 kept bumping into R2's wheelchair and R2 kept telling R4 to stop. LPN1 stated R2 was blind and felt it made R2 anxious that R4 was going to hurt R2 so R2 punched R4 in self-defense. LPN1 stated R2 was sorry and remorseful after the incident.Review of R4's electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE] 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 R4's activities of daily living care plan, with an initiation date of 2/27/25, R4 was dependent on a wheelchair for mobility and required assistance with transfers, personal hygiene, toileting, and dressing.
Review of R4's five-day MDS assessment, with an ARD of 7/1/25, revealed R4 had a BIMS score of 9 out of 15 indicating R4 had moderately impaired cognition. R4 was able to understand and be understood. A progress note, dated 7/14/25 at 11:22 AM, indicated R4 had a right side head hematoma and right cheek bruising.
Review of R2's EMR revealed R2 was admitted to the facility on [DATE]. R2's admission MDS assessment, stated R2 had a BIMS score of 15 out of 15 indicating R2 was cognitively intact.
The MDS assessment indicated R2 did not have any behaviors.
During an interview on 8/18/25 at 11:30 AM, R4 said no when asked if a resident ever hit or punched R4.
During an interview on 8/18/25 at 2:38 PM, R2 was asked if R2 had a problem with any residents. R2 stated R2 got into a fight a while back because some guy told R2 to move.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bradley Estates Nursing and Rehab LLC
6735 W Bradley Rd Milwaukee, WI 53223
SUMMARY STATEMENT OF DEFICIENCIES
According to the grievance form, R10's room was searched but the money was not found.
The Actions Taken section stated there was no evidence that R10 had $650 and no evidence that R10 had money when 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, R10 changed the amount of money several times and did not know the denominations. R10 was informed the facility was not responsible for the missing money.
During an interview on 8/20/25 at 9:39 AM, R10 stated 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. R10 stated R10 reported the missing money but nothing was done. An admission Record located in R10's electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE]. R10's diagnoses included end stage renal disease, schizophrenia, and blindness of the left and right eye.Review of R10's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 5/16/24, revealed R10 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R10 had intact cognition.
Review of R10's care plan, with an initiated date of 11/8/24, revealed R10 preferred to keep money on R10's person and declined the use of a lock box.
The care plan contained an intervention, dated 6/24/5, to encourage 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. R10's progress notes from 1/1/25 to the present did not refer to 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 R10's allegation of missing money was not reported to the SA because there was no evidence that R10 ever had the money.
The DON indicated R10 kept changing the amount of missing money and did not know the denominations of the missing money.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bradley Estates Nursing and Rehab LLC
6735 W Bradley Rd Milwaukee, WI 53223
SUMMARY STATEMENT OF DEFICIENCIES
According to the report, R10's room was searched but the money was not found.
The Actions Taken section stated there was no evidence that R10 had $650 and no evidence that R10 had money when 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, R10 changed the amount of money several times and did not know the denominations. R10 was informed the facility was not responsible for the missing money.
During an interview on 8/20/25 at 9:39 AM, R10 stated 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. R10 stated R10 reported the missing money but nothing was done. An admission Record located in R10's electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE].
R10's diagnoses included end stage renal disease, schizophrenia, and blindness of the left and right eye.Review of R10's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 5/16/24, revealed R10 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R10 had intact cognition.
Review of R10's care plan, with an initiated date of 11/8/24, revealed R10 preferred to keep money on R10's person and declined the use of a lock box.
The care plan contained an intervention, dated 6/24/25, to encourage 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. R10's progress notes from 1/1/25 to the present did not mention 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 R10's allegation of missing money was not investigated because there was no evidence that R10 ever had the money.
The DON also indicated R10 kept changing the amount of the missing money and did not know the denominations of the missing money.
Facility ID: