Bradley Estates Nursing And Rehab Llc

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

of Resident Council (Resident R15). During an interview conducted on 12/30/25 at 8:35 AM, Resident R15 confirmed she was

the President of the Resident Council. Resident 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. Resident 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, Resident R29 was only able to answer yes/no questions by shaking her head. Resident 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, Resident 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.

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

12/30/2025

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

The wall heater had dust on the top of it. The floor around the resident's bed was sticky. The floorboard at

the head of the resident's bed was coming off the wall. The room for Resident R14 and Resident R15 was observed. The ceiling above Resident R14's bed had a large splatter on it. The window adjacent to Resident R15 had a towel in front of the base of the window. There were visible splash marks on the wall in which the television of Resident R15 was mounted. On the wall adjacent to Resident R14's bed were large scrapes. There were no patching and no paint in

this area. Resident R15 confirmed that the staff did not repair the walls in the residents' room. There was a broken sink plug in Resident R14 and R15s' room. The baseboard across from Resident R14's bed had two thick brown stains that could not be wiped off. The room for Resident R16 and Resident R17 was observed. There were deep scratches on the wall adjacent to Resident R17. The ceiling above Resident R17 had brown stains. The bed extenders for Resident R17 had brown and yellow dried material on them. The attached closet in the room had exposed pressed wood from under the closet.

A tour was conducted on 12/29/25 at 12:20 PM with the Regional Manager for (name of contracted housekeeping service for the facility). The Regional Manager confirmed all observations. Regional Manager stated there was a new Director of Housekeeping. The Regional Manager stated there were call offs during

the weekend and the person who was scheduled to clean this unit was late due to the weather. During this interview, the Regional Manager entered the room for Resident R18 and Resident 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: Resident R20, Resident R28, Resident R14, Resident R18, Resident R19, and Resident R16, and Resident 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.

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

12/30/2025

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

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

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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 Resident R7 of 31 sample residents. (Cross Reference F-F610)On 11/22/25 Resident R7 was found by Certified Nursing Assistant (CNA)9 to be hitting Resident R6 in the chest. Resident R7 and Resident 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 Resident 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 Resident 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 Resident 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 Resident R7 hitting the chest of Resident R6. CNA9 reported she immediately removed Resident R7 from

the resident-to-resident incident. 2. Review of Resident R7's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/08/23. Review of Resident 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 Resident R6 yelling out and went to his room. CNA9 found Resident R7 hitting Resident R6 in the chest. Resident 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 Resident 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 Resident 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, Resident 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, Resident 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, Resident 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 Resident R7 hitting Resident R6 in the chest. CNA9 confirmed she immediately removed Resident R6 from Resident 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 Resident R6 and Resident 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.

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

12/30/2025

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

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 Resident R7 of 31 sample residents. This had the potential to cause emotional and/or physical harm. Findings include:1. Review of Resident 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 Resident 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 Resident R6 yelling out and went to his room. CNA9 found Resident R7 hitting Resident R6 in the chest. Resident R7 stated I can't take it anymore. CNA9 separated the two residents. Resident R6 was assessed for injuries and there were none. The investigation included a written statement by CNA9 and an attempt to interview Resident R6 and Resident R7. The investigation failed to include interviews with other staff and residents around the location of Resident R6 and Resident 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 Resident R6 and Resident R7. The Administrator stated Resident 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).

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet