Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bradley Estates Nursing and Rehab LLC
MILWAUKEE, WI · 198 certified beds · Last Life Safety survey September 17, 2025
CMS Certification Number 525325 · first certified January 1983
Ownership
Operated by SHLOMO HOFFMAN · For profit - Corporation
- Ownership changed January 1, 2023 (change of ownership)from VILLA AT BRADLEY ESTATES, LLC
Position within WI
34 citations — more than 93% of the 323 certified nursing homes in WI. Compared within WI 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 9 citations; the earlier surveys in the window averaged 12.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was September 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 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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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 34 citations on file are 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)
21 physical-environment citations 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 34 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 34 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 26, 2023 | 13 |
| July 1, 2024 | 12 |
| September 17, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-09-17 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-09-17 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-09-17 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2024-07-01 |
| 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. | 2 | 2025-09-17 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-07-01 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-07-01 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-09-17 |
What the citations cover
- Smoke Deficiencies 16
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 4
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 4 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 17, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 15, 2025) |
| 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 (October 3, 2025) |
| 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 (October 3, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 2, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 3, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 10, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (October 10, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 10, 2025) |
July 1, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 17, 2024) |
| 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 (July 17, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (February 4, 2025) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 17, 2024) |
April 26, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 24, 2023) |
| 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 (May 24, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (June 14, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 24, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.