Inspection visit
Fire Safety inspection
Citations
24 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0007GeneralS&S Dpotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Dpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0020GeneralS&S Dpotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Dpotential for harm
Establish policies and procedures for sheltering.
- 0025GeneralS&S Dpotential for harm
Create arrangements with other facilities to receive patients.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Dpotential for harm
Provide emergency officials' contact information.
- 0032GeneralS&S Dpotential for harm
Provide primary/alternate means for communication.
- 0034GeneralS&S Dpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Dpotential for harm
Implement emergency and standby power systems.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0325GeneralS&S Dpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0342GeneralS&S Dpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0346GeneralS&S Dpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Dpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0923GeneralS&S Dpotential for harm
Have proper medical gas storage and administration areas.
- 0006GeneralS&S Dpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0918GeneralS&S Dpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the August 12, 2021 survey of THE BRADLEY GARDENS?
This was a inspection survey of THE BRADLEY GARDENS on August 12, 2021. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE BRADLEY GARDENS on August 12, 2021?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address patient/client population and determine types of services needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.