Arc at Bradley

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received timely incontinence care. This failure applies to 1 of 3 residents (R1) reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to properly transfer a resident from his bed to the wheelchair. This failure resulted in the resident sustaining an impacted spiral fracture of the left humerus. This applies to 1 of 3 residents (R2) reviewed for injuries in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' rooms and bathroom areas in a safe, clean and homelike condition. This failure applies to 5 of 7 residents (R1, R3, R4, R5, and R6) reviewed for environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise a resident's smoking activity and failed to implement interventions to prevent her from sustaining burn injuries. This failure resulted in a resident sustaining blistered (second degree) cigarette burns. This applies to 1 of 4 (R1) residents reviewed for smoking safety in a sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to provide bathing assistance to residents dependent for assistance. This applies to 2 of 4 (R2, R3) residents reviewed for bathing in a sample of 4 residents.

Inspectors wroteBased on interview and record review, the facility failed to transfer a dependent resident safely by failing to use a mechanical lift with two staff assistance for one of four residents (R1) reviewed for accidents. This failure resulted in R1 sustaining an acute nondisplaced proximal tib (tibia)-fib (fibula) fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was able to get into bed to use his urinal. This applies to 1 of 4 residents (R3) reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to implement pressure ulcer prevention interventions including completing and documenting physician ordered weekly skin assessments and failed to identify and treat a facility-acquired pressure ulcer for one of three residents (R1) reviewed for skin concerns on a sample list of eight. These failures caused R1 to develop a sacral pressure ulcer that was discovered and noted to be unstageable, upon assessment by a wound physician.

Inspectors wroteBased on observation, interview and record review the facility failed to provide call light access. This applies to 2 of 7 residents (R2, R3) reviewed for call light accessibility in a sample of 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide shower assistance to a resident. This applies to 1 of 3 (R1) residents reviewed for shower assistance in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine shower/bed bath care for residents who require extensive assistance for activities of daily living (ADL) care. This applies to 2 of 3 residents (R1, R2) reviewed for ADL care in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience to residents who require feeding assistance. The facility also failed to provide dignity in wound care by not closing windows during wound care. This applies to 5 of 8 residents (R5, R17, R18, R22, and R24) reviewed for dignified resident care in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities for 4 residents (R17, R29, R50 & R44) based on their care plans in a sample of 25. 1. on [DATE] at 11:44 AM, R17 was observed in her room. V15 (R17's son) was present at the time. V15 said that the facility does not provide activities for his mother. V15 said Someone used to come around and spend time with her, but she died. Now no one comes by. V15 said that he is at the facility everyday A review of R17's electronic health records showed no 1:1 activity for the last 30 days. R17's [DATE] care plan showed activities care need with interventions including, express satisfaction with level and type of involvement in leisure activities during one on one visits 3-4xweekly. 2. During tours of the facility on [DATE], [DATE] & [DATE], R29 was never observed in any 1:1 activity. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to identify environmental hazards that poses risks for potential accidents. This applies to 6 of 6 residents (R6, R8, R28, R33, R39, and R61) reviewed for accidents/hazards in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to contain, replace, and date respiratory equipment. This applies to 4 of 4 residents (R5, R11, R15, R38) reviewed for respiratory equipment in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance in Activities of Daily Living, a dignified dining experience and answering of call lights. This applies to 11 residents (R5, R9, R16, R18, R22, R24, R29, R32, R38, R46, R51) reviewed for staffing concerns in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: wear appropriate PPE (Personal Protective Equipment) when going into an isolation room, monitor and track residents who were on isolation, obtain physician orders for isolation, develop care plans for isolation, and perform hand hygiene during wound care. This applies to 4 of 4 residents (R17, R21, R31, R62) reviewed for infections in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotics prescribed to residents. This applies to 6 of 6 residents (R11, R25, R38, R47, R58, R60) reviewed for antibiotics in sample of 25.

Inspectors wroteBased on observation, interview and Record review the facility failed to provide a comfortable wheelchair for one (R65) resident reviewed for mobility in a sample of 25 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 1 resident (R50) was free from physical restraints imposed for staff's convenience in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to maintain their ability to carry out the activities of daily living with regards to communication for 2 Spanish speaking only residents (R45 & R77) in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely ADL (Activities of Daily Living) to 3 dependent residents (R9, R29 & R32) in a sample of 25. 1. On 05/14/24 at 12:41 PM, R29 was observed with long jagged nails and facial hair on her chin, about 1/2 inch long. On 05/15/24 at 12:14 PM R29 was observed with long jagged nails and facial hairs on her chin. R29's 5/21/24 care plan showed R29 had an ADL self-care/mobility performance deficit that may fluctuate with activity throughout the day. R29's 3/20/24 MDS (minimum data set) section GG showed under personal hygiene that R29 was dependent for personal hygiene. On 05/16/24 at 10:44 AM V1 (Administrator) said that R29 should not have had facial hair and her nails should have been maintained for dignity, hygiene and self-feeling good and safety. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide wound care as physician ordered. This applies to 1 of 6 residents (R74) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a restorative range of motion program to a resident with limited range of motion. This applies to 1 of 1 resident (R33) reviewed for limited range of motion in a sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility neglected to monitor a resident's change in condition, follow the orders to monitor a resident's vital signs and blood pressure as ordered and failed to notify the advanced practice nurse of signs and symptoms of a stroke. This failure resulted in a delay of treatment for R1 and causing a hemorrhagic stroke and right-sided weakness. This applies to 1 of 3 residents (R1) reviewed for facility response to change in condition and treatment in a sample of 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sinks in working order for resident's use. This applies to 5 of 6 residents (R1-R5) reviewed for physical environment in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during provisions of care and failed to ensure that the catheter is covered in a privacy bag. This applies to 5 of 20 residents (R7, R16, R17, R48, R49) observed for privacy during provision of care in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care and failed to ensure that the urinary catheter drainage bag and tubing was positioned in a manner that would prevent further infection and maintain hygiene. This applies to 4 of 4 residents (R7, R16, R49 and R55) reviewed for incontinence care and urinary catheter care in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication with shortened expiration dates were labeled upon opening of its container. This applies to 13 residents (R4, R12, R15, R19, R22, R44, R53, R75, R83, R86, R87, R141, R341) reviewed for medication storage and labeling. On 4/25/23 from 4:54 PM through 5:27 PM, 3 of the 5 medication carts of the facility were checked with V4, V7, and V8 (All Nurses). The following insulins and inhalers were observed: 1. R44's Lantus Solostar was open and not dated. 2. R12's Novolog Flex Pen, open and not dated 3. R75's Insulin Lispro Kwik Pen, pen and not dated, Symbicort 160/4.5 open and not dated. 4. R341's Levemir Insulin 1000 units/ml- unopened but not refrigerated 5. R53's Fluticasone Propionate and Salmeterol 100/50 was open and not dated. 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store resident's foods in a safe and sanitary manner in the unit refrigerator. This applies to 4 of 4 residents (R4, R35, R52, R87) observed for food's brought from outside in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of care. This applies to the 4 residents (R7, R16, R17, R49) observed for hand hygiene and gloving during incontinence care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with showers and personal hygiene/grooming for residents who require extensive assistance for the same. This applies 3 of 5 residents (R12, R17, R24) observed for activities of daily living in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to addressed residents' positioning needs during provisions of care based on their assessments and care plans. This applies to 3 of 4 residents (R7, R17, R49) observed for turning/positioning in the sample of 20

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide adaptive equipment and services to residents, to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 3 residents (R33 and R141) reviewed for mobility and range of motion in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 25 medication opportunities with 2 errors, resulting in an 8% medication error rate. This applies to 1 of 6 residents (R80) reviewed during medication pass in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutrition supplement as ordered by Physician. This applies to 2 of 2 residents (R38, R70) observed for dining in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow PPE (personal protective equipment) guidance during the provision of daily meals. This applies to all 56 residents that received meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident received an inhaler treatment as ordered by the physician, per plan of care and per manufacture's guidelines. This applies to 1 of 1 resident reviewed for self-administration of medication in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and provide devices to maintain and prevent further reduction in ROM (range of motion) for a resident. This applies to 1 of 1 resident (R20) reviewed for ROM in the sample of 19.