Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BRADLEY HEALTH CARE & REHAB
CLEVELAND, TN · 213 certified beds · Last Life Safety survey November 2, 2022
CMS Certification Number 445141 · first certified May 1981
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TN
13 citations — more than 75% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2024 to July 2026). Most TN facilities have been surveyed by September 2027. This facility’s last Life Safety survey was November 2022. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 13 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0908 Keep all essential equipment working safely.
How that compares
Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 31, 2018 | 3 |
| December 18, 2019 | 6 |
| November 2, 2022 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-11-02 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2022-11-02 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 1 | 2019-12-18 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2019-12-18 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2019-12-18 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2018-10-31 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2019-12-18 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 1 | 2018-10-31 |
What the citations cover
- Smoke Deficiencies 8
- Services Deficiencies 1
- Miscellaneous Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Egress Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 2, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 23, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 16, 2022) |
December 18, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (February 1, 2020) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 1, 2020) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (February 1, 2020) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (February 1, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 1, 2020) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 1, 2020) |
October 31, 2018 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 15, 2018) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 15, 2018) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 15, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.