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Deficiency Records for Arc at Bradley
A list of the most recent deficiencies for Arc at Bradley. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Arc at Bradley. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-23 | 2024-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-23 | 2024-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-23 | 2024-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-02 | 2024-07-05 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-23 | 2024-07-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-31 | 2024-06-17 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-05-31 | 2024-06-14 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-31 | 2024-06-14 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-05-23 | 2024-06-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-23 | 2024-06-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-23 | 2024-06-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-23 | 2024-06-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-05-23 | 2024-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-23 | 2024-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-23 | 2024-06-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-31 | 2024-06-01 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-23 | 2024-05-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-23 | 2024-05-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-23 | 2024-05-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-23 | 2024-05-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-05-23 | 2024-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-23 | 2024-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-17 | 2024-05-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-17 | 2024-05-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-17 | 2024-05-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide activities to meet all resident's needs. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-05-17 | 2024-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-17 | 2024-05-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-17 | 2024-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-11-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-14 | 2023-10-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-16 | 2023-06-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-05-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-05-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-05-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-27 | 2023-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-27 | 2023-05-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-27 | 2023-05-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-27 | 2023-05-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-27 | 2023-05-01 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-04-27 | 2023-05-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-04-27 | 2023-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-27 | 2023-05-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-15 | 2023-02-16 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-02 | 2023-02-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-02 | 2023-02-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-24 | 2023-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-22 | 2023-01-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-01 | 2022-11-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-01 | 2022-11-30 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-11-01 | 2022-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-29 | 2022-10-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-08 | 2022-08-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-08 | 2022-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-08-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-23 | 2022-03-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-02-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-13 | 2022-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-02-11 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-01-13 | 2022-02-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-13 | 2022-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-13 | 2022-02-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-13 | 2022-02-11 | N |
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