F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
R1-R3 shared a room.
On October 13, 2023, at 11:40 AM, R1's room had a sink with signage above the sink read Don't use. The
sink had standing water in it and a bucket under the sink to catch drips. R1 stated, I don't use the sink. We
can't wash up or brush our teeth. Even the CNAs can't use it when cleaning up my roommate (R3). I have
been in this room since September 16 (2023). We can't even wash our hands. R1 added no room change
was offered to her.
R1's admission MDS (Minimum Data Set) dated September 16, 2023, showed R1 was cognitively intact.
On October 13, 2023, at 12:52 PM, R2 (R1's roommate) stated You can't brush your teeth or wash your
face if the sink does not drain. It's been probably like for a month at least. I have asked the maintenance on
several occasions. He (maintenance) is no longer here. One gentleman (from maintenance) just put a
bucket underneath and said it will drain out. No other repair man has been here. I know I told
V1(Administrator) when it first started. No room change has been offered to me. R2's quarterly MDS dated
[DATE], showed R2 was cognitively intact.
On October 13, 2023, at 11:42 AM, V5 (Certified Nursing Assistant) stated R3 needs total assistance and
she uses the sink across the hallway (at other residents sink) for incontinence care and grooming for R3. V5
stated R1-R3's common bathroom does not have a sink. V5 added R3 was alert but confused. R3 was non
interviewable and was not able to articulate responses to enquires. R3's quarterly MDS dated [DATE],
showed R3 was severely impaired in cognition.
On October 13, 2023, at 11:46 AM, R4's room had a sink was half full of standing water with signage above
the sink showing Do not Use. V5 stated R4 was under Hospice care and needs assistance with care and is
confused. V5 also stated she uses the sink across the hallway if the residents in room allow her, to assist
with R4's grooming and toileting. R4's entry MDS dated [DATE], showed R4 was non interviewable.
On October 13, 2023, at 12:35 PM, R5's room had a sink was filled with standing water. R5 was sleeping
and V9 (CNA) who was in the area, stated R5 needs total assistance with care. V9 stated, I don't
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
146112
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146112
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arc at Bradley
650 North Kinzie Ave
Bradley, IL 60915
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
know what's wrong with it (sink). I go in the shower room and bring a tub of water to clean the resident.
Level of Harm - Minimal harm
or potential for actual harm
On October 13, 2023, at 1:25 PM and 3:30 PM, V1 (Administrator) stated the previous Maintenance
Director's post is vacant since September 22, 2023, and his assistance is currently on vacation. V1 stated
V3 (Social Service Director) does Guardian Angel rounds and logs concerns of the residents and offers
room changes as needed.
Residents Affected - Some
On October 13, 2023, at 2:50 PM, V3 stated she handles grievances and concerns. V3 added during
Guardian Angel rounds she found R4's sink was clogged about a couple of weeks ago and notified the
maintenance via a log. V3 stated she also found R5's sink was clogged during rounds she did today. V3
stated the rooms have been pretty full so she did not offer a room change to these residents.
Facility undated Maintenance Request forms for clogged sinks for R4 and R5 were incomplete. The same
form showed areas showing request received by work assigned to and approved by were left blank.
Facility undated policy for Maintenance included as follows:
Policy: It is the policy of the facility to provide a safe, accessible, effective, and efficient environment of care
is consistent with its mission, services and law and regulations.
Guidelines:
7. Plumbing fixtures and piping shall function properly and maintained in good repair.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146112
If continuation sheet
Page 2 of 2
