Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.
Residents Affected - Few
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].
On 11/07/23 at 10:15 AM, V8 (Hospital Registered Nurse) stated, On 10/31/23, R1 said to multiple staff at
multiple times to send him to ER (Emergency Room) as he was experiencing right side numbness and
tingling. But they don't let him for whatever reason. R1 said he began to tell people to send him to the
hospital on [DATE] at around 9-10 AM. He was sent to our ER on [DATE] with a right-side weakness and
facial droop. He had a Hemorrhagic stroke as per CT (Computerized Tomography) scan.
On 11/2/23 at 12:40 PM, V9 (Hospital [NAME] President of Nursing) stated, R1 was transferred to another
hospital as we don't have any neurosurgeon available with our hospital.
On 11/2/23 at 5:45 PM, R1 was observed in the neurology unit of the second hospital. R1 was observed on
his bed, with his right sided weakness. R1 was unable to lift his right arm or right leg.
On 11/2/23 at 5:45 PM, R1 stated, I know my body, and I knew something was going wrong on Tuesday,
10/31/23. I was so scared as I had numbness and tingling in my right arm. I told my nurse to send me to
hospital right away. My nurse was V5 and said 'No' to my request.
On 11/2/23 at 5:50 PM, V10 (Hospital Registered Nurse) stated, I just received R1 from neuro ICU
(Intensive Care Unit) to regular neuro floor. R1 had a thrombectomy done due to his stroke, and his right
side is weak.
On 11/2/23 at 1:45 PM, V5 (R1's nurse on 10/31/23 Day Shift) stated, On 10/31/23, R1 was complaining of
right arm tingling/numbness. I took his vitals, and his blood pressure (BP) was elevated at 177/102. I
notified the nurse practitioner about his elevated blood pressure, who ordered Metoprolol and Hydralazine.
(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
11/08/2023
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 0684
Level of Harm - Actual harm
Residents Affected - Few
On 11/2/23 at 11:00 AM, V6 (Nurse Practitioner/NP) stated, One of the Physical therapists called me saying
that R1 was not feeling well. I assessed him, and he said he was not feeling well after breakfast. He was
feeling dizzy. He was afebrile not complaining of chest pain. His BP was elevated at 172/109. When I
checked his medication profile, there were no BP medications on his medication list. So, I ordered
metoprolol 50 mg daily and Hydrochlorothiazide 25 mg. I was not notified of his right-side tingling. I would
have ordered a CT if I knew he had right-side tingling along with elevated blood pressure. They should have
notified the provider if R1 continued to have numbness and tingling after blood pressure medication was
given.
On 11/2/23 at 1:45 PM, V5 added, Maybe I didn't mention R1's right arm tingling/numbness to NP because
I was worried too much about his blood pressure. I endorsed to the night nurse to monitor him as he was
given two blood pressure medications (new to R1) due to his elevated BP.
Record review on progress note and vitals record indicates that R1's vital signs and BP were not monitored
or documented during the night shift of 10-31-2023.
On 11/2/23 at 1:45 PM, V12 (R1's agency CNA on 10/31/23 night shift) stated. I am not supposed to do
vitals unless the nurse tells me to take vitals. The nurse on duty that night was an agency nurse, V13. V12
stated V13 never requested to have R1's vital signs and blood pressure monitored. V13 was not available
for interview during the investigation. V12 added, nurses are the ones who usually take vitals and V12 was
unsure if V13 monitored R1's blood pressure and vital signs.
On 11/2/23 at 10:25 AM, V11 (Registered Nurse for R1 on 11/1/23 AM shift) stated, I worked yesterday,
and I was the one who transferred R1 to the hospital at around 6:20 AM. My CNA (Certified Nursing
Assistant) notified me that R1 was found on the floor while I was getting the shift report at around 6:15 AM.
He was bleeding from his right eyebrow. His BP was high at 157/95. He was not on any BP medications
and was very independent. R1 told me that he also reported to the night nurse about his right arm
numbness/tingling.
On 11/2/23 at 10:25 AM, V11 added, The night agency nurse (V13 was unavailable for the investigation)
endorsed me to monitor R1 due to his increased confusion. She (V13) never mentioned to me about his
right-side numbness. R1 had slurred speech and elevated BP, and his arm strength was not symmetrical
when I assessed him after the fall. He was telling me something was happening to him and sending him out
to the hospital. R1 is a resident who never calls for unnecessary things. If he complains about something,
there is something serious, and the staff should listen to him closely. When I called the hospital for
follow-up, the nurse told me that R1 was admitted there for hemorrhagic stroke.
Record review on Emergency Department Physician Report dated 11/01/23 (Page 5/15) documents that
R1 arrived in ER with right-sided facial droop, right upper and lower extremity weakness, right-sided
sensory deficit, mild dysarthria, and aphasia concerning acute stroke. The ER physician report documented
that the patient is outside of the window for TNK administration (clot buster). CT of the head demonstrated
acute intraparenchymal hemorrhage in the left globus pallidus.
On 11/7/23 at 12:00 PM, V2 (Director of Nursing / DON) stated, I was here on 10/31, and I knew about R1's
elevated BP. I wasn't notified of his numbness and tingling even after his blood pressure came down. The
nurses should have notified the Physician/NP If he still felt numbness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146112
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the November 8, 2023 survey of ARC AT BRADLEY?
This was a inspection survey of ARC AT BRADLEY on November 8, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARC AT BRADLEY on November 8, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.