Bridgeway Senior Living

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

check Resident R3 for incontinence every 2 hours and as needed.On August 12, 2025, at 1:33 PM, V14 (CNA) provided incontinence care to Resident R3. V14 and Resident R3 both stated Resident R3 had last been changed around 10:30 AM that morning. V14 opened Resident R3's brief, which was wet and visibly soiled with urine. As of August 12, 2025, at 5:00 PM, V2 was unable to provide documentation of Resident R3's incontinence care provided for the month of August

1. 2025. Resident R3's task documentation for bladder incontinence for the past 14 days showed no data found. 4. Resident R4's

EMR showed Resident R4 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, morbid obesity due to excess calories, and anxiety disorder unspecified. Resident R4's MDS dated [DATE REDACTED], showed Resident R4 was severely cognitively impaired and required assistance with ADL care including set up assistance for eating, supervision for oral hygiene, partial assistance with personal hygiene, substantial assistance with upper body dressing, dependent on staff for toileting, bathing, lower body dressing, and bed mobility. On August 12, 2025, at 1:53 PM, Resident R4 was provided incontinence care by V13 (CNA) and V14 (CNA). Resident R4 requested verbally to be provided with 2 briefs because she stated she doesn't like to lay in wetness. V13 provided 2 briefs for Resident R4 and explained that is Resident R4's preference because

she doesn't like to have her bed linens getting wet and having to be changed. As of August 12, 2025, at 5:00 PM, V2 was unable to provide documentation of Resident R4's incontinence care provided for the month of August 2025. Resident R4's task documentation for bladder incontinence for the past 14 days showed no data found.

On August 12, 2025, at 11:48 AM, V12 (LPN, 11-7 shift) stated there is no documentation to show the incontinence care is provided to the residents. V12 stated as the night nurse she is focused on administering her medications and treatments to her 48 assigned residents and hopes the 2 staff CNA assigned to the unit are providing the care to the residents.On August 12, 2025, at 2:14 PM, V2 (Director of Nursing) stated residents should be changed every 2-3 hours or as needed. The facility policy titled Perineal Care, dated August 2008, showed .Documentation: The following information should be documented in the resident's medical record .1.The date and time the perineal care was given, 2. The name and title of the individual giving the perineal care.6. If the resident refused the procedure, the reason why and the intervention taken.7. Th signature and title of the person recording the data.Reporting 1. Notify

the supervisor if the resident refuses the perineal care or of any abnormalities.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeway Senior Living

111 East Washington Bensenville, IL 60106

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 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the floor. V16 stated she works on all the units in the facility. V16 stated she was not sure of what Resident R12's care plan interventions to prevent falls were. V16 stated no facility staff had interviewed her as of yet as to how Resident R12 had fallen.On August 15, 2025, at 4:12 PM, V2 stated she had not spoken to V16 regarding the cause of Resident R12's fall and V2 stated she was unsure if the restorative nurse had spoken to V16.Resident R12's Xray report from the hospital dated August 12, 2025, showed Resident R12 sustained a mildly comminuted displaced right femoral intertrochanteric fracture, a right hip fracture.V11 (Resident R12's Physician) stated on August 15, 2025, at 3:53 PM, that Resident R12 having barriers on both sides of the bed would be an unsafe situation, especially due to Resident R12 being cognitively impaired. V11 stated the likely cause of Resident R12's hip fracture was the fall that occurred

on August 12, 2025.The facility's policy titled Evaluating Falls and Their Causes, dated August 2008, showed, General Guidelines .5. Residents must be evaluated for potential causes of falls immediately. 6.Environmental issues must also be addressed immediately. Steps in the Procedure.3. Identifying Causes of a fall or fall Risk a. Within 24 hours of fall, the nursing staff will begin to try to identify possible or likely causes of the incident.b. Staff will evaluate the chain of events or circumstances proceeding a recent fall including.3. The activity the resident was engaged in. 6. whether the resident was responding to an urge to void. 7. Whether there were environmental factors involved (e.g. slippery floor, poor lighting, furniture, or objects in the way.c. The staff will continue to collect and evaluate information until they either identify a cause of falling or determine the cause cannot be found .

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