Bradley Estates Nursing And Rehab Llc
Bradley Estates Nursing and Rehab LLC in MILWAUKEE, WI — inspection on December 30, 2025.
Found 4 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
During an interview conducted on 12/30/25 at 8:35 AM, R15 confirmed she was the President of the Resident Council. R15 stated that there had been multiple complaints filed by the members and attendees of the resident council meeting and there had been no follow-up by the facility. R15 stated this was extremely frustrating to see the same issues unaddressed from month to month with no resolution.
During an interview on 12/30/25 at 9:45 AM, R29 was only able to answer yes/no questions by shaking her head. R29 confirmed there were issues identified at each resident council meeting such as complaints about food and there had been no follow-up made by the facility.
During an interview on 12/30/25 at 11:43 AM, R31 confirmed she attended the Resident Council Meetings and verified that there had been complaints formulated and no follow-up was made by the facility.
During an interview on 12/29/25 at 3:14 PM, the Regional Nurse stated all grievances were to be resolved.Review of a facility's policy titled, Resident Council, dated 12/06, indicated .The facility supports residents' desire to be involved in and have input in the operation of the facility though the Resident Council.Minutes include names of the council members, and any guests present; issues discussed; recommendations from the council to the Administrator; and follow-up on prior issues.The Administrator reviews the minutes and any responses from departments within the facility.
Responses are presented at the next meeting, or sooner, if indicated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bradley Estates Nursing and Rehab LLC
6735 W Bradley Rd Milwaukee, WI 53223
SUMMARY STATEMENT OF DEFICIENCIES
During this interview, the Regional Manager entered the room for R18 and R19.
There was a missing tile under the residents' sink. A request was made for the cleaning schedules for the residents' rooms from 09/25 through 12/25. A review was conducted of the deep cleaning schedules provided by the Regional Manager.
The facility failed to provide evidence that the residents' rooms were deep cleaned for the month of 12/25.
During an interview on 12/30/25 at 10:14 AM, the Maintenance Assistant stated staff were to place any repair work into TELS (a building management system to log in repairs needed by staff).
The tour commenced at 10:20 AM.
The Maintenance Assistant entered the following resident rooms: R20, R28, R14, R18, R19, and R16, and R17.
The Maintenance Assistant stated he was not aware of the areas of disrepair.
Review of a facility's undated policy titled, Daily Cleaning Procedures, indicated .High Dust.
Work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces.
This includes, but is not limited to: pictures/prints, televisions, over-the-bed lights, blinds, vents, and all corners.Disinfect.
Work your way clockwise around the room (starting at the door and finishing at the door) and disinfect flat surfaces and high-touch items.
This includes, but is not limited to: doorknobs, light switches, call lights, TV removes, bed rails, bed frames, footboard and headboard, bedside tables, closet handles, windowsills, chair, heating unit, and any flat surfaces.Review of a facility's policy titled, Quality of Life-Homelike Environment, dated 04/14, indicated .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bradley Estates Nursing and Rehab LLC
6735 W Bradley Rd Milwaukee, WI 53223
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 6) reviewed for abuse/neglect was protected from physical abuse by R7 of 31 sample residents. (Cross Reference F-F610)On 11/22/25 R7 was found by Certified Nursing Assistant (CNA)9 to be hitting R6 in the chest. R7 and R6 were roommates at the time. A reasonable person would not expect to be hit by their roommate in their own room/living space.Findings include:1.
Review of R6's electronic medical record (EMR) titled admission Record located under the Profile' tab indicated the facility admitted the resident on 08/05/22.Review of R6's EMR titled Care Plan located under the Care Plan tab, dated 08/05/22, indicated the resident had limited physical mobility related to general weakness, Parkinson's disease, traumatic brain injury, and hemiplegia (paralysis affecting one side of the body).
Review of R6's EMR titled nursing Progress Notes located under the Prog (Progress) Notes tab, dated 11/22/25, indicated Certified Nurse Aide (CNA) 9 observed R7 hitting the chest of R6. CNA9 reported she immediately removed R7 from the resident-to-resident incident. 2.
Review of R7's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/08/23.
Review of R7's EMR titled Care Plan located under the Care Plan tab, dated 01/26/25, indicated that the resident had altered activities of daily living related to mobility impairment, hemiplegia, and cognitive impairment.
Review of a document provided by the facility titled Misconduct Incident Report, dated 11/22/25, indicated that CNA9 heard R6 yelling out and went to his room. CNA9 found R7 hitting R6 in the chest. R7 stated I can't take it anymore.
The residents' responsible parties were notified of the resident-to-resident incident, and the police were called.
There was evidence that the facility reported the resident-to-resident incident to the State Survey Agency (SSA) timely.
Review of a document provided by the facility titled .Summary., dated 12/01/25, revealed R6 had a recent Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was severely cognitively impaired.
The document indicated that R7 had a recent BIMS score of 10 which revealed that the resident was moderately cognitively impaired.
Both residents were unable to state what precipitated the resident-to-resident incident. In addition, R6 did not sustain any injuries and was moved to a private room.
There was evidence that the facility reported the five-day summary to the SSA timely.
During an interview on 12/29/25 at 9:17 AM, R6 stated he felt safe living at the facility and did not remember hitting another resident.
During an interview on 12/29/25 at 9:53 AM, R7 stated he felt safe living at the facility and the resident did not remember being hit by another resident.
During an interview on 12/30/25 at 8:22 AM, CNA9 confirmed she was the staff member who observed R7 hitting R6 in the chest. CNA9 confirmed she immediately removed R6 from R7 and reported the resident-to-resident incident.
During an interview on 12/30/25 at 9:03 AM, the Administrator stated that whenever there was a resident-to-resident incident they wanted to make sure if the situation was isolated or not.
The Administrator confirmed that both R6 and R7's responsible parties were notified and the police.
The Administrator stated both residents failed to have any insight during the incident.
Review of a facility's policy titled, Abuse, Neglect and Exploitation, dated 01/05/24, indicated .It is the policy of this facility to provide protection 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.'Abuse' means the willful inflection injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bradley Estates Nursing and Rehab LLC
6735 W Bradley Rd Milwaukee, WI 53223
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 6) reviewed for abuse/neglect was protected from physical abuse by R7 of 31 sample residents.
This had the potential to cause emotional and/or physical harm.
Findings include:1.
Review of R6's electronic medical record (EMR) titled admission Record located under the Profile' tab indicated the facility admitted the resident on 08/05/22.2.
Review of R7's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/08/23.
Review of a document provided by the facility titled Misconduct Incident Report, dated 11/22/25, indicated that Certified Nurse Aide (CNA) 9 heard R6 yelling out and went to his room. CNA9 found R7 hitting R6 in the chest. R7 stated I can't take it anymore. CNA9 separated the two residents. R6 was assessed for injuries and there were none.
The investigation included a written statement by CNA9 and an attempt to interview R6 and R7.
The investigation failed to include interviews with other staff and residents around the location of R6 and R7's room to rule out other instances of resident-to-resident abuse.
During an interview on 12/29/25 at 3:14 PM, the Regional Nurse stated that it was important to interview other staff and residents, even if it was an isolated incident to rule out abuse.
During an interview on 12/30/25 at 9:03 AM, the Administrator stated the resident-to-resident incident included the immediate separation of R6 and R7.
The Administrator stated R6 was assigned a new room.
The Administrator confirmed CNA9 was the only person interviewed since the staff member witnessed the resident-to-resident and it was an isolated event.Review of a facility's policy titled, Abuse, Neglect and Exploitation, dated 01/05/24, indicated .Investigation of Alleged Abuse.An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur.Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s).
Facility ID: