Arc at Bradley

In the surveyor’s words

From the most serious findings on record at Arc at Bradley, in the surveyor’s own words.

• Actual harm, isolatedF689May 29, 2026

  Based 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.Findings include:R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including heart disease, chronic atrial fibrillation, hypertension, and a history of traumatic brain injury. On 5/15/26, R2 was admitted to the hospital for an impacted spiral fracture of the left humerus and discharged on 5/18/26. […]

• Actual harm, isolatedF689May 1, 2026

  Based 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.The findings include:The facility's Reportable Incident form showed that on 4/6/26 at 11:40 AM, R1 was observed with a wound to left side of chest. [R1] was outside on a smoke break and was wearing the smoker's apron. Resident was observed with what appeared to be a cigarette burn on the left side of her chest. […]

• Actual harm, isolatedF689Mar 6, 2025

  Based 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. Findings include: The facility's 2/24/2025 Report to the State Survey Agency showed R1 .was observed on his right side Stat Xray done .Upon investigation that included review of clinical records, assessment, hospital documentation, and statements of staff on duty; it was found that resident is a 2 transfer assist This serves as final report. […]

• Actual harm, isolatedF686Feb 21, 2025

  Based 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. Findings include: R1's Face Sheet showed his diagnoses included type 2 diabetes, adult failure to thrive, hypertension, blindness in one eye unspecified, left side hemiplegia and hemiparesis, chronic kidney disease, and acquired absence of left leg below the knee. […]

• Actual harm, isolatedF684Nov 8, 2023

  Based 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. The findings include: R1 is a [AGE] year-old male admitted on [DATE] having a mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. […]