Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradley Health Care & Rehab during CMS and state inspections, most recent first.
Failure to Supervise a Resident with Dementia and Wandering Behaviors: A resident with severe cognitive impairment, high wandering risk, and repeated falls did not have an individualized person-centered behavior plan for wandering or exit-seeking. Video showed the resident moving around the unit, attempting to follow visitors out an exit, entering another resident’s room, and remaining there undetected for about 44 minutes before being found crawling out with forehead bleeding. EMS transported the resident to the hospital, where the bleeding was documented as reinjury of prior sutured lacerations.
Failure to Maintain Resident Dignity During Meal Service: During lunch meal service, meals were served on trays with plates and utensils left on the trays for all observed residents, and one resident who required set up and supervision with eating waited more than 20 minutes while others at the same table received and finished their meals. The resident, who had diagnoses including depression, mild cognitive impairment, anxiety, tremor, malnutrition, and muscle weakness, stated that waiting to be served made him feel left out; the DON confirmed the dignity concern.
Failure to Timely Report Allegations of Resident-to-Resident Abuse: The facility did not report allegations of potential resident-to-resident abuse within the required timeframe for two separate incidents involving four residents. One report was sent 18 hours after the event, and another was not reported until 5 days later, despite the DON confirming the reports were not made within 2 hours of the facility becoming aware of the allegations.
Failure to Supervise and Individualize Dementia Behavior Care
Penalty
Summary
The facility failed to provide individualized behavioral interventions and sufficient supervision for a resident with dementia, severe cognitive impairment, wandering, and exit-seeking behaviors. The resident was admitted with diagnoses including dementia, bipolar disorder, macular degeneration, repeated falls, and a displaced comminuted fracture of the left tibia. The admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and the wandering risk assessment identified the resident as high risk for wandering. The resident’s record also documented impaired thought processes and wandering behaviors occurring 4 to 6 days weekly. The resident’s care plan addressed mood-related concerns and psychoactive medication use, but it did not include an individualized person-centered plan to address the resident’s dementia-related wandering, elopement risk factors, or known history of wandering. The record also showed multiple falls after admission, including falls on several dates before the incident in question, and the resident was transferred to an ED after sustaining forehead lacerations and bruising from a prior fall. A psychiatric note described worsening confusion, anxiety, restlessness, agitation in the evenings and at night, and severe cognitive impairment, with the resident oriented to person only. On the day of the incident, video surveillance showed the resident wandering the unit in a wheelchair, approaching the nurse’s station without staff noticing until close proximity, attempting to follow visitors out an exit door, testing doors, and entering another resident’s room. The resident remained in that room for approximately 44 minutes without staff awareness or redirection and was later found crawling out of the room with blood on the forehead. Staff responded after the resident was discovered, and EMS transported the resident to the hospital. Hospital records documented that the forehead bleeding was due to reinjury of previously sutured laceration sites from an earlier fall. The facility later confirmed that it had not developed or implemented a person-centered dementia care plan with specific interventions for the resident’s wandering, exit-seeking, combative behaviors, or frequent falls, and had not adequately supervised or redirected the resident during the incident.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to remove resident plates and utensils from serving trays during lunch meal service, resulting in an undignified dining experience for 8 of 8 residents observed in the [NAME] 1 dining room. During multiple observations on 5/18/2026 and 5/19/2026, meals were served on service trays and the plates and utensils remained on the trays throughout the meal. The facility policy titled, Promoting/Maintaining Resident Dignity, stated that residents are to be treated with respect and dignity and cared for in a manner and environment that maintains or enhances quality of life. The facility also delayed assistance to Resident #13, who was admitted with diagnoses including Adjustment Disorder with Depressed Mood, Mild Cognitive Impairment, Generalized Anxiety, Unspecified Tremor, Moderate Malnutrition, and Muscle Weakness. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and the resident required set up and supervision with eating. During lunch observations, Resident #13 waited more than 20 minutes while other residents at the same table received and finished their meals before staff served and assisted him. During interview, the resident stated that he had frequently watched other residents eat while he waited for assistance and said, "I am real easygoing, but sometimes it makes me feel left out." The DON confirmed the facility failed to maintain the resident’s dignity during meal services.
Failure to Timely Report Allegations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure facility reported incidents related to allegations of abuse were reported within the required time frame for 4 residents. Review of the facility abuse policy stated that suspected resident abuse, mistreatment, or neglect must be reported per regulation to the Department of Health by the Administrator or designee, and that immediate reports should be given to Administration when abuse is witnessed or known. The deficiency involved allegations of potential resident-to-resident abuse between Residents #1 and #2 and between Residents #3 and #4. Review of the incident records showed that one allegation involving Residents #1 and #2 occurred on the evening of 4/28/2026 around 7:50 PM, but the state agency did not receive the report until 4/29/2026 at 2:01 PM, 18 hours later. Another incident involving Residents #3 and #4 occurred on the evening of 4/23/2026, but the abuse coordinator was not made aware until the morning of 4/24/2026, when the facility began its investigation, and the report was not sent to the state agency until 5 days later. During interview, the DON confirmed the facility failed to report the allegations of potential resident-on-resident abuse to the state agency within 2 hours of becoming aware of them, as required by state and federal requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Cleveland | 0.6 mi | ★★★★★ | 9 | 0 |
| Signature Healthcare Of Cleveland | 0.9 mi | ★★★★★ | 6 | 0 |
| Tennessee State Veterans Home- Cleveland | 3.6 mi | ★★★★★ | 5 | 0 |
| Life Care Center Of Ooltewah | 13 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Collegedale | 14 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.