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 Arc At Bradley during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers and required 2 staff plus a mechanical lift sustained an impacted spiral fracture of the left humerus after a CNA transferred him alone without using the lift. The DON, Administrator, and APRN stated the improper transfer caused the injury, and the resident was later noted to have swelling and bruising of the shoulder and upper arm with x-ray confirmation of the fracture.
A facility failed to keep multiple resident rooms and bathrooms in a clean, safe, and homelike condition. Surveyors observed heavy rust, cracked and peeling paint, broken towel racks and grab bars, peeling tile and baseboards, holes in a room ceiling, torn wallpaper, and heavy dirt, dust, debris, trash, and dark stains in bathrooms and living areas. Several residents said the conditions had been present for some time and wanted them cleaned or fixed; the ADM said maintenance and housekeeping were expected to keep these areas in proper condition, but the facility was down to one maintenance staff member.
A resident with cognitive impairment, MS, COPD, and limited mobility sustained repeated cigarette burn injuries while smoking. Staff did not keep the smoking apron properly secured, left her chest exposed, and walked away while her cigarette was still lit, despite her needing assistance and supervision with smoking. Interviews and observations showed staff were not consistently staying with residents during smoking and the apron instructions required proper placement and supervision.
Two residents dependent on staff for bathing did not consistently receive scheduled showers or bed baths, as confirmed by resident interviews, staff statements, and documentation review. Both residents reported missed hygiene care, which was also noted in grievances and council meetings, and were observed with unpleasant body odor. Facility records showed gaps in documentation and failure to follow care plans and policy regarding bathing frequency.
A resident with multiple medical conditions and moderate cognitive impairment, who required a mechanical lift with two staff for transfers, was improperly transferred by a CNA without assistance, resulting in a fall and an acute nondisplaced proximal tibia-fibula fracture. The CNA was aware of the correct procedure but failed to follow it, leading to the resident's injury.
A resident was unable to use his urinal due to a malfunctioning bed, leading to him urinating on himself while in a wheelchair. Despite the resident's requests and the staff's awareness of the issue, the bed was not repaired in a timely manner. The resident, who required substantial assistance for transfers and toileting, remained in urine-soaked clothes during dinner. The facility's policy to report malfunctioning equipment immediately was not followed, contributing to the deficiency.
A resident with multiple health conditions developed an unstageable sacral pressure ulcer due to the facility's failure to implement pressure ulcer prevention interventions. The facility did not complete and document physician-ordered weekly skin assessments, missing several scheduled assessments. Despite being dependent on staff for care, the resident's skin issues were not documented or reported until discovered by a wound physician.
The facility failed to ensure call light access for two residents, one with quadriplegia and another with hemiplegia, as required by their care plans. The first resident's call light was out of reach when in a wheelchair, and the second resident's call light was tied to a stuffed duck on a nightstand, making it inaccessible. Both residents reported difficulties in calling for assistance, and staff confirmed the call lights should be within reach.
A resident, who required total assistance for showering, did not receive scheduled showers since admission. Despite being scheduled for showers twice a week, the facility only documented one bed bath, and the resident reported not receiving any showers. The facility's policy required offering showers according to the resident's preference, but this was not honored, leading to a lack of proper hygiene care.
The facility failed to provide routine bathing care for two residents requiring extensive assistance with ADLs. One resident, with multiple medical conditions, did not receive consistent bed baths despite a preference due to a tracheostomy. Another resident, with arthritis, was found unkempt and received infrequent showers, lacking regular hygiene care. The facility's policy on maintaining resident hygiene was not followed, leading to inadequate personal care and documentation issues.
The facility failed to provide a dignified dining experience to residents requiring feeding assistance and did not ensure privacy during wound care. Several residents were not fed promptly, and a resident was exposed during wound care due to missing window blind panels.
The facility failed to provide activities for four residents based on their care plans. One resident did not receive any 1:1 activities for the last 30 days, another was not observed in any 1:1 activities during multiple tours, and a third resident with severe dementia was given an unsuitable word puzzle. The Activities Director confirmed that the facility had not provided 1:1 services for the last 2 to 3 months.
The facility failed to securely store a portable oxygen tank, leaving it in a resident's closet for several days. This affected six residents, including those with mobility and respiratory issues, and violated the facility's storage policy for oxygen cylinders.
The facility failed to properly contain, replace, and date respiratory equipment for four residents, including leaving oxygen concentrators on and not storing masks in plastic bags, contrary to the facility's infection control policy.
The facility failed to provide adequate staffing, resulting in insufficient assistance with ADLs, delayed responses to call lights, and a lack of dignified dining experiences. Residents were often found soaked in urine and soiled with stool, and several were not fed in a timely manner. The facility's policies on morning care and nail care were not followed, leading to significant deficiencies in resident care and hygiene.
The facility failed to follow proper infection control protocols, including wearing appropriate PPE, tracking residents on isolation, obtaining physician orders for isolation, and performing hand hygiene during wound care. These deficiencies were observed in multiple residents with infections such as ESBL and MRSA.
The facility failed to use the McGeer's criteria form to determine the necessity of antibiotics for six residents with various infections. The Assistant Director of Nursing/Infection Preventionist acknowledged the oversight, and the facility could not locate antibiotic log sheets for two months, indicating lapses in infection control practices.
A resident with multiple mobility-related diagnoses was not provided with a comfortable wheelchair, leading to his refusal to use the facility-provided wheelchair, which was too small and painful. The process to obtain a custom wheelchair was not initiated, and there was no documentation explaining the resident's refusal.
A facility failed to ensure a resident was free from physical restraints used for staff convenience. The resident was observed at the nurses' station with his chair pushed against a table to prevent him from standing and wandering, despite being able to walk. The facility's administrator confirmed that restraints should not be used, and the resident's care plan did not include any orders for restraints.
The facility failed to provide necessary communication support for two Spanish-speaking residents, resulting in unmet needs. A CNA was unable to communicate with the residents due to a language barrier, and the residents did not have access to a communication board or interpreter as outlined in their care plans. The facility's administrator acknowledged the deficiency and the absence of a communication policy.
The facility failed to provide timely ADL care to three dependent residents, resulting in unmaintained personal hygiene, feelings of neglect, and inadequate incontinent care. The residents' care plans indicated a need for assistance, which was not consistently provided.
A resident with multiple diagnoses did not receive wound care as ordered by the physician. The resident's dressing was not changed daily as required, leading to an increase in the wound size and a failure to adhere to the facility's policy on pressure injury and skin condition assessment.
A resident with multiple diagnoses, including cerebral infarction and contractures, did not receive the recommended passive range of motion (PROM) exercises after being referred to restorative nursing. The facility failed to document or implement the necessary PROM, leading to a deficiency in care.
The facility failed to provide working sinks for residents' use, affecting five out of six residents reviewed. Residents reported being unable to use the sinks for basic hygiene tasks for at least a month, and no room changes were offered. CNAs had to use alternative methods to assist with grooming and incontinence care. Maintenance issues were logged but not addressed, and maintenance request forms were incomplete.
Improper Transfer Resulted in Resident Humerus Fracture
Penalty
Summary
The facility failed to properly transfer a resident from bed to wheelchair, resulting in an impacted spiral fracture of the left humerus. The resident was a male admitted with diagnoses including heart disease, chronic atrial fibrillation, hypertension, and a history of traumatic brain injury. Records showed he was dependent on staff for transferring, and his care plan directed that he required two staff and a mechanical lift for transfers. The facility’s policy also stated that mechanical lifting devices shall be used for any resident needing a two-person assist. On the early morning of the incident, a CNA transferred the resident by herself and did not use a mechanical lift. The Administrator stated that the CNA admitted she performed the transfer alone, and the DON said this caused the fracture. The resident was later observed with swelling and bruising of the left shoulder and upper arm, and an x-ray showed an impacted spiral fracture of the left humerus. The APRN stated the fracture was caused by blunt force trauma and that the improper transfer caused the injury. Other CNAs also stated the resident was a two-person mechanical lift transfer, but that staff sometimes transferred him by themselves.
Unsafe and Unclean Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain residents’ rooms and bathroom areas in a safe, clean, and homelike condition for 5 of 7 residents reviewed for environment. Observations on May 13, 2026 found multiple environmental issues, including heavy rust on bathroom vents, shower tile, and toilet commode frames; cracked and peeling ceiling paint; loose or broken grab bars and towel racks; peeling baseboard and tile; heavy dust, dirt, debris, trash, and dark stains on floors and in shower areas; and holes, yellow stains, and torn wallpaper in a resident room ceiling and wall areas. Several residents stated the conditions had been present for some time or since they were placed in the room and that they wanted the areas cleaned, serviced, or fixed. The affected residents included a male resident with a history of brain aneurysm, recurrent major depressive disorder, and vascular implants and grafts; a female resident with paraplegia, spinal cord injury at birth, scoliosis, muscle wasting and atrophy, wheelchair dependence, cellulitis of toe, and a personal history of other mental and behavioral disorders; a female resident with schizophrenia, recurrent major depressive disorder, COPD, and muscle wasting and atrophy; a male resident with partial paralysis due to stroke and hypertension; and a male resident with malignant rectal cancer and depression. The Administrator stated there should not be visible dust, dirt, trash, stains, rust, peeling or cracked paint, peeling tile, peeling baseboards, or broken equipment in resident rooms or bathrooms, and that maintenance and housekeeping staff were expected to keep the areas in homelike condition and address observed issues promptly. The facility also reported being down to one maintenance staff member as of three weeks earlier.
Failure to Supervise Smoking and Secure Smoking Apron
Penalty
Summary
The facility failed to supervise a resident during smoking activity and failed to ensure smoking interventions were implemented to prevent burn injuries. The resident had relapsing multiple sclerosis, scoliosis, COPD, age-related macular degeneration, alternating exotropia, dysarthria, and anarthria, and her MDS showed she was moderately cognitively impaired and dependent on staff for eating, oral hygiene, bathing, and dressing. Her smoking assessment indicated she required assistance and supervision with smoking and use of a smoking apron, and the facility’s smoking policy identified cognitive impairment, poor judgment, and compromised manual dexterity and/or mobility as conditions that jeopardize independent smoking privileges. The resident had a prior facility-acquired thermal burn to the chest after cigarette ashes fell on her chest when her bib fell down, and the care plan included staff assistance with smoking and ensuring the bib was in place before smoking. After another burn was identified as a facility-acquired thermal burn, staff observed the resident smoking with a smoking ring on her finger, her smoking apron positioned so her upper chest was exposed, and the neck ties unsecured. While she was smoking, ashes were seen dropping down the front of her, and the activity aide walked away to assist another resident into the building. The aide later stated she was doing one-on-one observation but did not realize she had walked away while the cigarette was still lit. Other interviews and observations showed staff did not consistently remain with the resident during smoking and did not secure the apron as instructed. A resident stated staff lit cigarettes and left residents outside unsupervised, and another resident stated staff allowed the resident to smoke by herself and she was burned on her chest. The smoking apron instructions stated it should be secured at the neck and sides and that it was not a substitute for proper supervision. The DON, activity director, administrator, physician, and activity aides all described that staff should remain with residents while smoking and that the apron needed to be properly secured, but the observed smoking activity showed the resident’s chest exposed, ashes falling onto her, and staff not staying with her throughout the smoking period.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing assistance to residents who were dependent on staff for activities of daily living, specifically bathing. Two residents reported missing scheduled showers or bed baths, with one resident stating she was not on the list for her scheduled shower and another reporting missed bed baths, which she had brought up in both a grievance form and a resident council meeting. Both residents were observed to have unpleasant body odor at the time of interview, indicating a lack of proper hygiene care. Documentation reviewed showed inconsistencies and gaps in the recording of provided baths, with some scheduled baths not documented as completed and no evidence of computer documentation for certain periods. Staff interviews confirmed that residents are scheduled for two showers per week, with refusals to be documented and signed by the resident. However, the affected residents and the social services director confirmed that concerns about missed showers and bed baths had been raised multiple times. The care plans for both residents indicated a need for substantial or maximal assistance with bathing, yet records showed missed or delayed care. Facility policy requires that bathing be offered at least once per week or according to resident preference, but this standard was not met for the residents in question.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a dependent resident, resulting in an acute nondisplaced proximal tibia-fibula fracture. The incident involved a resident with multiple medical conditions, including multiple sclerosis, reduced mobility, and moderate cognitive impairment, who was dependent on staff for transfers. The resident's care plan required the use of a mechanical lift with two staff members for transfers. However, a CNA attempted to transfer the resident alone without using the mechanical lift, leading to the resident falling and sustaining a fracture. Interviews and record reviews revealed that the CNA was aware of the correct transfer technique but chose to lift the resident without assistance, resulting in the resident being lowered to the floor and complaining of leg pain. The Director of Nursing confirmed that the CNA used the wrong transfer technique, and the Nurse Practitioner stated that the fracture could have been prevented if the proper transfer method had been used. The facility's policies on transfers and fall prevention emphasized the use of mechanical lifts for residents requiring two-person assistance, which was not followed in this case.
Failure to Accommodate Resident's Urination Needs Due to Bed Malfunction
Penalty
Summary
The facility failed to accommodate a resident's need to urinate by not ensuring his bed was functional, which led to the resident urinating on himself. The resident, who was cognitively intact and required substantial assistance for transfers and toileting due to impairments in both lower extremities, was left in his wheelchair from 11:00 AM until 7:00-7:30 PM because his bed was not working. Despite the resident's repeated requests to use the urinal, which he could only do while lying flat in bed, the staff did not resolve the issue in a timely manner. The resident ended up urinating on himself and remained in urine-soaked clothes during dinner. The issue was compounded by a lack of communication and timely action from the staff. The CNA who initially noticed the bed's malfunction did not report it, and the maintenance director was not informed until after he had left for the day. The CNA on the afternoon shift attempted to page maintenance, but the bed was not fixed until the maintenance director returned to the facility after being called at home. The facility's policy requires malfunctioning equipment to be reported immediately, but this protocol was not followed, resulting in the resident's discomfort and compromised dignity.
Failure to Implement Pressure Ulcer Prevention Leads to Unstageable Ulcer
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for a resident, leading to the development of a sacral pressure ulcer. The resident, who had multiple health conditions including type 2 diabetes, hypertension, and a leg amputation, was identified as being at risk for pressure ulcers. Despite this, the facility did not complete and document the physician-ordered weekly skin assessments, missing several scheduled assessments. The resident was dependent on staff for mobility and care, and there was no documentation of skin issues during his stay until a wound physician discovered an unstageable sacral pressure ulcer. Interviews with facility staff revealed that skin observations were supposed to be conducted biweekly on shower days, and any physician-ordered assessments should have been documented on the Treatment Administration Record (TAR). However, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that some assessments were missed, and the staff failed to document the resident's showers and any skin issues. The resident's family informed the facility of scrotal bleeding, which led to the wound physician's assessment and discovery of the pressure ulcer. The wound physician noted two wounds: an unstageable sacral pressure ulcer and a non-pressure wound on the scrotum, attributed to Moisture Associated Skin Damage (MASD). The facility's policy required daily skin observations during care and on bath days, with any changes promptly reported to the charge nurse. However, the staff did not adhere to these protocols, resulting in the failure to identify and treat the pressure ulcer in a timely manner.
Failure to Provide Call Light Access to Residents
Penalty
Summary
The facility failed to provide call light access to two residents, R2 and R3, which is a violation of their care plans. R2, who has quadriplegia, type 2 diabetes, and epilepsy, was observed in his motorized wheelchair without access to his call light, which was placed out of reach on the left side of his bed. R2 reported that the call light is never left near him when he is in his wheelchair, forcing him to seek assistance in the hallway. A CNA confirmed that all residents should have access to a call light to notify staff when they need assistance. R3, who has hemiplegia and hemiparesis following a cerebral infarction, carcinoma in situ of the anus and anal canal, hypertension, and dysphagia, was found lying in bed with her call light tied to a stuffed duck on her nightstand, out of her reach. R3 stated that her call light is always left on the nightstand, and she sometimes needs help but cannot call for staff. An RN observed the situation and noted that R3's call light could not be placed within reach due to a knot in the string. The Director of Nursing acknowledged that both residents are alert and able to make their needs known, and their call lights should be within reach. The facility's policy requires that all residents capable of using a call light should have it accessible at all times.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide shower assistance to a resident, identified as R1, who was admitted on an unspecified date. R1's admission Minimum Data Set (MDS) indicated that the resident was cognitively intact and required total assistance from the staff for showering. The facility's care plan task report scheduled R1 to receive showers on Tuesdays and Fridays in the morning. However, the facility could only present one shower sheet dated January 27, 2025, which was signed by a CNA, V10. V10 later stated that she did not provide a shower to R1 on that date but instead provided a bed bath. On February 4, 2025, R1, who was alert and oriented, stated in the presence of the Director of Nursing (V2) that she had not received any showers since her admission. R1's hair was observed to be greasy, and she expressed that she could smell herself, indicating a lack of proper hygiene care. R1 also mentioned that she was informed she would receive showers twice a week but was never asked for her preferred shower day and time. Despite asking the nursing staff daily for a shower, she was not assisted. The facility's policy required offering showers according to the resident's preference, no less than once a week, and as needed or requested. V2 acknowledged the failure to honor R1's shower preference and the expectation for nursing staff to provide ADL assistance, including showers, to maintain residents' hygiene and grooming.
Failure to Provide Routine Bathing Care for Residents
Penalty
Summary
The facility failed to provide routine shower or bed bath care for residents who require extensive assistance with activities of daily living (ADL). Resident 1 (R1), who has multiple medical diagnoses including chronic respiratory failure and morbid obesity, requires substantial assistance for bathing. Despite being alert and oriented, R1 did not receive a bed bath from June 4 to June 24, 2024, except on June 25 and 26. R1 expressed a preference for bed baths due to a tracheostomy and requested a schedule change from night to evening shift, which was not consistently honored. Documentation of R1's bathing schedule was inconsistent, and there was no record of R1 refusing care. Resident 2 (R2), who is alert and oriented with conditions such as rheumatoid arthritis and diabetes, also requires substantial assistance for bathing. R2 prefers showers due to arthritis relief but was found unkempt with overgrown nails and facial hair, indicating a lack of regular hygiene care. R2's shower records for June 2024 showed only three instances of bathing, with no documentation of refusals or additional care such as shaving and nail care. The facility's policy, last reviewed in January 2018, emphasizes the importance of maintaining resident hygiene and dignity through regular bathing. However, the facility's failure to adhere to this policy resulted in inadequate personal care for R1 and R2, as evidenced by the lack of consistent bathing and documentation. The staff's inability to provide the necessary care and document it properly contributed to the deficiency identified by the surveyors.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide a dignified dining experience to residents who require feeding assistance. Observations revealed that several residents, including a female with severe cognitive impairment and a male with intact cognition, were not fed promptly during lunch. Despite the presence of staff members feeding other residents, some residents expressed hunger and were not attended to in a timely manner. The Assistant Director of Nursing acknowledged that more staff should have been called to ensure all residents received a dignified feeding experience. Additionally, the facility failed to maintain dignity during wound care. A resident receiving wound care to her lower abdominal area was exposed due to missing panels in the window blinds, leaving her visible from the sidewalk leading to the patio and gazebo. The Assistant Director of Nursing attempted to close the blinds but was unsuccessful, resulting in the resident being exposed from her abdomen to her upper thighs. The facility's dignity policy emphasizes the importance of maintaining or enhancing each resident's dignity and respect, which was not upheld in this instance.
Failure to Provide Activities Based on Care Plans
Penalty
Summary
The facility failed to provide activities for four residents (R17, R29, R50, and R44) based on their care plans. R17 was observed in her room without any 1:1 activities for the last 30 days, despite her care plan indicating she should have 1:1 visits twice weekly. R17's son confirmed that no one has been spending time with her since a previous staff member passed away. Similarly, R29 was not observed in any 1:1 activities during multiple tours, and there was no documentation of such activities in the last 30 days, contrary to the care plan that required 1:1 visits twice weekly. The administrator acknowledged that R17 should have been receiving daily activities. R50, who has severe dementia and severely impaired cognition, was observed with a word puzzle he could not complete and no other stimuli like music or TV. His care plan indicated he should engage in activities like listening to music and watching television, but there was no documentation of 1:1 activities in the last 30 days. The administrator admitted that R50 should not have been given a word puzzle and should have been provided with suitable activities according to his care plan. R44, who has multiple diagnoses including aphasia and depression, also did not receive any 1:1 activities as required by the care plan. The Activities Director confirmed that the facility had not been able to provide 1:1 services for the last 2 to 3 months, despite the facility's policy requiring daily recording of residents' activity attendance and participation.
Failure to Securely Store Oxygen Tanks
Penalty
Summary
The facility failed to identify and address environmental hazards that posed risks for potential accidents. Specifically, a portable oxygen tank was stored unsecured in a resident's closet for several days, despite the resident not using oxygen and being unaware of its presence. The Assistant Director of Nursing confirmed that oxygen tanks should be stored in a designated oxygen room and secured in a holder to prevent accidents. The unsecured oxygen tank was observed on multiple occasions over three days, indicating a lapse in proper storage protocols. This deficiency affected six residents, including the resident in whose closet the oxygen tank was stored and five other residents in nearby rooms. These residents had various medical conditions, such as lack of coordination, reduced mobility, diabetes, and respiratory issues, which could increase their vulnerability to accidents. The facility's storage policy for oxygen cylinders mandates that they be secured and stored away from combustibles, which was not adhered to in this case, creating a potential hazard for the residents and staff in the area.
Failure to Properly Manage Respiratory Equipment
Penalty
Summary
The facility failed to properly contain, replace, and date respiratory equipment for four residents. During an initial tour, a surveyor observed that a resident's AVAPS machine face mask was not dated or contained in a plastic bag. Another resident's oxygen concentrator was left on, and their nasal cannula was uncontained and undated. Additionally, a third resident's nasal cannula, BIPAP mask, and nebulizer mask were not covered, and the oxygen humidifier container was dated 23 days prior, despite orders to change it weekly. The facility's policy requires respiratory equipment to be stored in clean plastic bags and dated when changed, which was not followed in these instances. A fourth resident with mild cognitive impairment and multiple respiratory conditions was observed with a nasal cannula on, while their nebulizer mask and C-PAP mask were not contained in plastic bags. The Assistant Director of Nursing confirmed that respiratory equipment should be stored in plastic zip lock bags. These observations indicate a failure to adhere to the facility's infection control policy, potentially increasing the risk of infection transmission among residents.
Inadequate Staffing and Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing to meet the care needs of residents, resulting in insufficient assistance with Activities of Daily Living (ADLs), a lack of dignified dining experiences, and delayed responses to call lights. Observations and interviews revealed that the facility had only four CNAs on night shifts and weekends, which was insufficient to meet the needs of the residents. Multiple residents reported that they often heard others calling out for help during these times, and staff confirmed that residents were frequently found soaked in urine and soiled with stool due to inadequate incontinence care. The facility also had a strong stench of urine, indicating a lack of proper hygiene and care for incontinent residents. Specific incidents highlighted the deficiencies in care. For example, one resident was found with a thick watery bowel movement smeared around her perineum, despite the care plan requiring checks and changes every two hours. Another resident was observed with long jagged nails and facial hair, which had not been maintained for dignity and hygiene. Additionally, several residents were not fed in a timely manner during lunch, with one resident explicitly stating that they were hungry. The Assistant Director of Nursing acknowledged that residents should have a dignified feeding experience and that more staff should have been called to assist. The facility's policies on morning care and nail care were not followed, as evidenced by residents with untrimmed nails and unshaven facial hair. One resident reported feeling neglected due to the lack of assistance with showers, and records showed that there was no documentation of bathing for several days. The Assistant Director of Nursing confirmed that night shift staff were expected to reposition and provide incontinence care every two hours, but this was not being done, especially on weekends when agency staff were involved. The overall lack of adequate staffing and failure to adhere to care plans and policies led to significant deficiencies in resident care and hygiene.
Failure to Adhere to Infection Control Protocols
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, resulting in multiple deficiencies. Staff did not wear appropriate PPE when entering isolation rooms, failed to monitor and track residents on isolation, did not obtain physician orders for isolation, and did not develop care plans for residents in isolation. Specifically, a housekeeper was observed cleaning a room of a resident with ESBL without wearing a gown and gloves, and the infection preventionist admitted to not maintaining a log of residents on isolation precautions. Additionally, there were no physician orders or care plans for residents with ESBL and MRSA, and these conditions were not documented in progress notes or infection charting notes as required by facility policy. One resident with ESBL was observed outside his room, and the housekeeper cleaning his room was not wearing the required PPE. Another resident readmitted from the hospital with ESBL had no documentation of isolation or contact precautions in his progress notes or care plans. Similarly, a third resident with MRSA and ESBL had no isolation orders or care plans documented. The facility's policies on infection prevention and control, infection surveillance, and care plan coordination were not followed, leading to these deficiencies. Additionally, during wound care for a resident, the Assistant Director of Nursing did not perform hand hygiene after cleaning the wound and before applying new gloves, which is against the facility's hand hygiene policy. The administrator confirmed that the nurse should have cleaned her hands before putting on new gloves. These actions and inactions demonstrate a failure to adhere to established infection control protocols, putting residents at risk of infection.
Failure to Utilize Standardized Tool for Antibiotic Necessity
Penalty
Summary
The facility failed to utilize a standardized tool, specifically the McGeer's criteria form, to determine the necessity of antibiotics prescribed to six residents. This deficiency was identified through interviews and record reviews. For each of the six residents, the Physician Order Sheets (POS) indicated various antibiotics prescribed for infections such as skin infections, urinary tract infections (UTIs), and eye infections. However, none of these residents had the required McGeer's criteria form in the infection control binder or uploaded into their electronic medical records. The absence of these forms indicates that the facility did not follow its own policy for tracking and monitoring antibiotic use, as outlined in their Infection Prevention and Control Program and Antibiotic/Antimicrobial Stewardship Program guidelines. The Assistant Director of Nursing/Infection Preventionist acknowledged the oversight and mentioned that both the nurses and she were responsible for completing the McGeer's criteria forms, but this was not being done consistently. Additionally, the facility could not locate the antibiotic log sheets for October and November 2023, further indicating lapses in their infection control practices. The specific cases included a resident with a skin infection on the left lower leg, another with a UTI showing symptoms like tea-colored urine and mental status changes, and another with a UTI confirmed by lab results showing E.coli. Other cases involved a resident with an eye infection secondary to MRSA, another with a UTI showing symptoms like burning and itching, and a resident with a skin infection presenting as a red, irritated lump under the armpit. In each case, the required McGeer's criteria form was missing, and the facility's policies were not adhered to, leading to the deficiency noted by the surveyors.
Failure to Provide Comfortable Wheelchair for Resident
Penalty
Summary
The facility failed to provide a comfortable wheelchair for a resident (R65) who was reviewed for mobility. R65, who is cognitively intact and has multiple diagnoses including morbid obesity, abnormal posture, lack of coordination, reduced mobility, osteoarthritis, and chronic gout, was admitted to the facility and required a wheelchair for mobility. Despite his needs, the facility did not document the reason for his refusal to use the provided wheelchair, which he found too small and painful. The resident was observed lying in bed and stated that the facility did not have a wheelchair suitable for his size and body type. The Director of Rehab (V17) confirmed that R65 refused the offered wheelchair because it was too low for him and acknowledged that a custom wheelchair, which would be more suitable, was never ordered. The process to obtain a custom wheelchair would require coordination with the Nurse Practitioner and the wheelchair company, but this process was not initiated. Additionally, the Facility Consultant (V16) did not have documentation explaining why R65 refused the previously provided wheelchair.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for staff's convenience. On 05/15/24, a nurse stated that the resident was brought to the nurses' station because he frequently tried to stand up. The resident was observed sitting at a table with his chair pushed up against it and the wheels locked, preventing him from standing. The nurse admitted that the table was used to keep the resident from standing and wandering, despite the resident being able to walk, albeit unsteadily. The nurse also mentioned that the resident was usually placed at the nurse's station to prevent him from standing and wandering in the hallway. The facility's administrator confirmed that staff should not be restraining residents and that there was a fall prevention care plan in place that did not include the use of restraints. A review of the resident's electronic health record showed no orders to restrain the resident's movement or mobility, nor did the care plan include any interventions involving restraints. The facility's restraint policy indicated that physical restraints should not be used for staff convenience and defined freedom of movement as any change in place or position that the resident is physically able to control.
Failure to Provide Communication Support for Spanish-Speaking Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the ability of two Spanish-speaking residents to carry out activities of daily living, specifically in terms of communication. On multiple occasions, a Certified Nurse's Assistant (CNA) was unable to communicate with the residents due to a language barrier, resulting in unmet needs. The CNA admitted to not understanding the residents and left the room without addressing their needs. This lack of communication was observed during a survey, and it was confirmed that the residents did not have access to a communication board or interpreter as outlined in their care plans. Resident R45, a Spanish-speaking female with poor cognition, had a care plan that included the use of a communication board or a Spanish-speaking employee, but these interventions were not implemented. Similarly, Resident R77, who also required an interpreter, did not receive the necessary communication support. The facility's administrator acknowledged the deficiency and noted the absence of a communication policy, which contributed to the failure in meeting the residents' needs.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely ADL (Activities of Daily Living) care to three dependent residents. One resident was observed on multiple occasions with long, jagged nails and facial hair, despite being dependent on staff for personal hygiene. The resident's care plan indicated a need for assistance with personal hygiene, which was not provided, leading to potential safety and dignity concerns. The administrator acknowledged that the resident's nails and facial hair should have been maintained for hygiene and safety reasons. Another resident was observed with long facial hair and reported feeling neglected due to not receiving showers when requested. The resident's care plan indicated a need for assistance with bathing, but documentation showed inconsistent provision of showers. The administrator confirmed that the resident should receive showers or bed baths as needed. Additionally, a third resident was found with a strong urine/feces smell in her room and was discovered with a thick watery bowel movement smeared around her perineum. The CNA stated that the resident was last checked several hours earlier, despite the care plan requiring checks every two hours. The DON confirmed that incontinent care should be provided every two hours and as needed.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered by the physician for a resident with multiple diagnoses, including metabolic encephalopathy, lack of coordination, reduced mobility, malignant neoplasm of the prostate, and hypertension. The resident had a physician's order to cleanse the area on the coccyx with wound cleanser, pat dry, apply calcium alginate, and secure with border gauze daily. However, the resident reported that his dressing had only been changed once during the week, and the Assistant Director of Nursing (ADON) confirmed that the dressing had not been changed as required on one of the days. The ADON observed that the dressing removed was dated two days prior, indicating a failure to follow the daily dressing change order. The resident's wound was initially discovered on 5/12/24 and measured 0.5 cm x 0.5 cm. By 5/14/24, the wound had increased in size to 0.8 cm x 0.6 cm x 0.1 cm. During the dressing change on 5/16/24, the wound was observed to have white slough with a perimeter of redness approximately 1 inch. The facility's policy on pressure injury and skin condition assessment states that dressings should be checked daily for placement, cleanliness, and signs of infection, which was not adhered to in this case, leading to the deficiency in wound care management for the resident.
Failure to Provide Restorative ROM Program
Penalty
Summary
The facility failed to provide a restorative range of motion (ROM) program to a resident with limited ROM. The resident, who had multiple diagnoses including cerebral infarction, hemiplegia, and contractures, was observed in bed with a contracted left leg and complained of pain. Despite being referred to restorative nursing for lower extremity ROM after completing occupational and physical therapy, there was no documentation or order for passive range of motion (PROM) exercises for the resident. The Assistant Director of Nursing confirmed the lack of documentation and was unaware of the referral for PROM, acknowledging that the contractures could worsen without the recommended exercises. The facility's policy stated that residents should be screened for restorative nursing programs and that ROM programs should be implemented as needed. However, the interdisciplinary team had identified the resident as needing PROM, but the facility failed to follow through with the recommendations. The resident's progress notes indicated a high risk for further decline and a willingness to perform ROM exercises in bed, yet the necessary PROM was not provided, leading to a deficiency in care for maintaining or improving the resident's ROM.
Facility Failed to Provide Working Sinks for Residents
Penalty
Summary
The facility failed to provide working sinks for residents' use, affecting five out of six residents reviewed for physical environment. On October 13, 2023, it was observed that the sinks in the rooms of residents R1, R2, R3, R4, and R5 were either clogged or had standing water, with signage indicating 'Do not use.' Residents R1 and R2, who were cognitively intact, reported that they had been unable to use the sinks for basic hygiene tasks such as washing hands and brushing teeth for at least a month. R1 and R2 also stated that no room changes were offered to them. Certified Nursing Assistants (CNAs) confirmed that they had to use sinks in other residents' rooms or bring water from the shower room to assist with grooming and incontinence care for residents R3, R4, and R5, who required total assistance and were either confused or non-interviewable. The facility's Administrator, V1, acknowledged that the Maintenance Director's position had been vacant since September 22, 2023, and that the maintenance assistant was on vacation. The Social Service Director, V3, who handles grievances and concerns, confirmed that she had logged maintenance issues for the clogged sinks but did not offer room changes due to high occupancy. Maintenance request forms for the clogged sinks were found to be incomplete, with sections for request received, work assigned to, and approval left blank. The facility's maintenance policy mandates that plumbing fixtures and piping should function properly and be maintained in good repair, which was not adhered to in this case.
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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 Bradley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arc At Kankakee | 1.7 mi | ★★★★★ | 0 | 0 |
| Citadel Care Center-kankakee | 2.3 mi | ★★★★★ | 0 | 0 |
| Citadel Of Bourbonnais,the | 2.3 mi | ★★★★★ | 9 | 0 |
| Miller Health Care Center | 2.7 mi | ★★★★★ | 7 | 1 |
| Momence Meadows Nursing & Rehab | 9.9 mi | ★★★★★ | 14 | 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.