Bridgeway Senior Living: Incontinence Care Failures - IL
It was 1:33 PM. Nearly three hours had passed.
The resident, identified in inspection records as R3, told the nursing assistant the same thing the nursing assistant already suspected: she hadn't been changed since mid-morning. The care plan required checks every two hours. When inspectors later asked for documentation of R3's incontinence care for the month of August, the Director of Nursing could not produce any. The electronic records for the past 14 days showed the same thing for every entry: no data found.
Twenty minutes later, inspectors were in another room.
R4 had been admitted to Bridgeway with a list of conditions that made her entirely dependent on staff: chronic obstructive pulmonary disease, paralysis on her left side following a stroke, morbid obesity, and severe cognitive impairment. She could not toilet herself, could not dress her lower body, could not move in bed without help. When two nursing assistants came to change her that afternoon, she made a specific request. She wanted two briefs layered together. She'd learned, apparently through experience, that a single brief wasn't enough to keep her bed linens dry between changes, and she didn't like lying in wetness.
One of the nursing assistants confirmed this was R4's standing preference. She explained it mattered because otherwise the bed would get wet and need to be changed too.
When inspectors asked for documentation of R4's incontinence care for August, the answer was the same as it had been for R3. No records for the month. Fourteen days of task documentation showing no data found.
The night shift nurse, a licensed practical nurse identified as V12, was interviewed at 11:48 that morning. She was direct about what was happening. She said there was no documentation to show incontinence care was being provided to residents. She said that on the overnight shift, she was focused on administering medications and treatments to her 48 assigned residents, and that she hoped the two CNAs assigned to the unit were providing the care.
Hoped.
Two aides. Forty-eight residents. One nurse whose attention was consumed by medications and treatments, working through the night on the assumption that somewhere on the unit, the people in her care were being changed.
The Director of Nursing, interviewed at 2:14 PM, said residents should be changed every two to three hours or as needed. The facility's own perineal care policy, written in August 2008, laid out exactly what was supposed to be documented each time care was given: the date, the time, the name and title of the person who provided it, and the reason if a resident refused. That policy had been in place for nearly 17 years. The records for August 2025 showed it wasn't being followed.
Inspectors classified the violations under a federal tag covering basic personal hygiene and grooming, with a finding of minimal harm or potential for actual harm affecting some residents. The complaint inspection was completed August 15, 2025.
What the records don't show is how many other residents on that unit spent hours in soiled briefs during the weeks when nothing was being documented. The entries don't say no care was provided. They say there's no way to know.
R4 had figured out her own workaround. Two briefs instead of one, because she'd learned she couldn't count on being changed before the wetness reached her sheets. That's not a preference born from comfort. That's adaptation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bridgeway Senior Living from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
BRIDGEWAY SENIOR LIVING in BENSENVILLE, IL was cited for violations during a health inspection on August 15, 2025.
The care plan required checks every two hours.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.