Health inspection·May 4, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve residents with non-disposable cutlery and dishware. This applies to 5 of 8 residents (R9, R10, R11, R12, and R13) reviewed for dignity in a sample of 14. The findings include: 1. On May 2, 2023, at 12:40 PM, R9 was in the dining room, eating lunch on a disposable plate with a plastic fork, knife, and spoon. On May 3, 2023, at 12:19 PM, R9 said, I would prefer to have my food on a regular plate. It would make me feel more at home. On May 3, 2023, at 12:32 PM, R9 received his lunch tray on a disposable plate with plasticware. The EMR (Electronic Medical Record) shows R9 was admitted to the facility on [DATE]. 2. On May 2, 2023, at 12:40 PM, R10 was in the dining room, eating lunch on a disposable plate with a plastic fork, knife, and spoon. On May 3, 2023, at 12:19 PM, R10 said, I do not like getting my food on disposable plates. I feel like a dog when I eat off the disposable plates. On May 3, 2023 at 12:32 PM, R10 received her lunch tray on a disposable plate with plasticware. The EMR shows R10 was admitted to the facility on [DATE]. 3. On May 2, 2023, at 12:40 PM, R11 was in the dining room, eating lunch on a disposable plate with a plastic fork, knife, and spoon. On May 3, 2023, at 12:38 PM, R11 was eating lunch in the dining room eating lunch. R11's lunch was served on a disposable plate with plasticware. R11 said, It is ridiculous we get our food on these disposable plates. That is not how it is supposed to be. The plasticware is difficult to eat food with. We should have metal utensils. Page 1 of 7 145420 145420 05/04/2023 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0550 The EMR shows R11 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm 4. On May 2, 2023, at 12:40 PM, R12 was in the dining room, eating lunch on a disposable plate with a plastic fork, knife, and spoon. Residents Affected - Some On May 3, 2023, at 12:34 PM, R12 was in the dining room eating lunch. R12's lunch was served on a disposable plate with plasticware. R12 said, I do not like receiving my meals on disposable plates. The plasticware is too flimsy and it makes it difficult to eat with. I would prefer real plates and silverware. The EMR shows R12 was admitted to the facility on [DATE]. 5. On May 2, 2023, at 12:40 PM, R13 was in the dining room eating lunch on a disposable plate with a plastic fork, knife, and spoon. On May 3, 2023, at 12:34 PM, R13 was in the dining room eating lunch. R13's lunch was served on a disposable plate with plasticware. R13 said, I do not like the disposable plates, and the plastic forks make it difficult to eat with. I would prefer real plates and silverware. The EMR shows R13 was admitted to the facility on [DATE]. On May 2, 2023, at 12:06 PM, V11 (Executive Chef) said, The dishwasher is functional so we can serve on regular plates. We do not have enough plates for all for all of the residents, so we have to use disposable plates. On May 2, 2023, at 10:37 AM, V1 (Administrator) said the dishwasher is currently being serviced. As of May 4, 2023, at 2:30 PM, the facility could not provide any documentation regarding dishwasher repairs. The facility's April 12, 2023, Resident Council Meeting Minutes shows, Council all agreed that they don't want to use plastic silverware with their meals. Activity Director informed them the dishwasher was broken and the kitchen is going back to regular silverware. The facility's April 20, 2023, Food Meeting Minutes shows, Where are china plates and real silverware. Tired of [disposable]. 145420 Page 2 of 7 145420 05/04/2023 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received wound care as ordered by the physician. Residents Affected - Few This applies to 2 of 3 residents (R6 and R7) reviewed for wound care in a sample of 14. The findings include: 1. The EMR (Electronic Medical Record) shows R6 was admitted to the facility on [DATE], with multiple diagnoses including: stroke with left sided paralysis, epilepsy, anxiety, depression, and right femur fracture. R6's MDS (Minimum Data Set) dated March 21, 2023, shows R6 has moderate cognitive impairment. The MDS continues to show R6 requires extensive assistance of facility staff for bed mobility, and is dependent on facility staff for transfers between surfaces and toilet use. R6's skin care plan dated September 26, 2022, shows [R6] is at risk for skin breakdown related to impaired mobility, incontinent of bowel and bladder, multiple comorbidities, disease process, history and presence of wounds. The care plan continues to show multiple interventions dated September 26, 2022, including, Treatment per physician orders. R6's Order Summary Report dated May 3, 2023, shows the following order dated February 15, 2023, Right leg, cleanse with NSS (Normal Saline Solution), apply dry dressing every three days and as needed. The report continues to show the following order dated April 30, 2023, Xeroform dressing, apply three times a week to open blister on the left inner thigh. R6's April 2023 TAR (Treatment Administration Record) does not show documentation R6 received right leg wound treatment on April 5, April 8, April 17, and April 29. R6's May 2023 TAR does not show documentation R6 received left inner thigh wound treatment on May 1, 2023. 2. R7's EMR shows R7 was admitted to the facility on [DATE], with multiple diagnoses including: stroke with right side paralysis, type 2 diabetes, chronic kidney disease, and heart failure. R7's MDS dated [DATE], shows R7 is cognitively intact. The MDS continues to show R7 requires extensive assistance of facility staff for bed mobility and is dependent on facility staff for transfers between surfaces and toilet use. R7's skin care plan dated December 5, 2022, shows [R7] is at risk for skin breakdown related to impaired mobility, incontinence of bowel and bladder, multiple comorbidities and history of wounds. The care plan continues to show multiple interventions dated March 16, 2023, including treatment per physician order. R7's Order Summary Report dated May 3, 2023, shows the following order dated January 6, 2023, Left first toe, may apply betadine daily. R7's April 2023 TAR printed on May 3, 2023, does not show documentation R7 received left toe wound 145420 Page 3 of 7 145420 05/04/2023 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0684 treatment on April 4, April 5, April 8, April 9, April 18, and April 22. Level of Harm - Minimal harm or potential for actual harm R7's May 2023 TAR printed on May 3, 2023, does not show documentation R7 received left toe treatment on May 2, 2023. Residents Affected - Few On May 2, 2023, at 1:12 PM, V12 (Agency RN/Registered Nurse) said I am an agency nurse, but I work here often. I just found out the wound nurse is not here today so I am unsure what to do about wound care. V12 did not identify R7 as requiring wound care. On May 3, 2023, at 12:42 PM, V3 (ADON/Assistant Director of Nursing) said, The expectation of staff is to document in a timely manner when the treatment was administered or refused. On May 3, 2023, at 1:28 PM, V3 said staff should be following the Medication Administration Policy for documentation of wound treatments. The facility's undated policy titled, Medication Administration Policy, shows, Policy: it is the policy of this facility to authorize licensed nursing personnel and Qualified Medication Aides to prepare and administer drugs and biologicals Standards: 17. Medications shall be recorded on the medication record promptly after each administration by the individual who administered the drug. 145420 Page 4 of 7 145420 05/04/2023 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to have sufficient, competent dietary staff to ensure residents are provided adequate portion sizes of food that meet the planned menu. Failed to ensure adequate staff to ensure food is prepared in a safe and palatable manner. This failure has the potential to affect all residents receiving meals from the kitchen. The findings include: The facility's Diet Type Report dated May 3, 2023, shows 170 residents receive a diet. The report continues to show the facility has a total census of 172 residents. On May 2, 2023, at 11:25 AM, V11 (Executive Chef) said V16 (Cook) is using a #6 scoop (2/3 cup) to serve the chicken and broccoli stir fry with rice, and residents are getting one scoop of the stir fry for lunch. V11 continues to say a #8 scoop is a five ounce scoop. On May 2, 2023, at 11:29 AM, V11 said the chicken and broccoli stir fry is being served combined with rice. V11 said the recipe shows the chicken and broccoli should be served separately from the rice. V11 continues to say he is unsure how to tell if the residents are getting the correct portion size of protein since the chicken and broccoli is combined with the rice. On May 2, 2023, at 12:06 PM, V11 said, Last week we were making trays for residents who had already been discharged and were no longer residing in the facility. On May 2, 2023, at 12:24 PM, V16 served the last portion of the chicken and broccoli stir fry. V11 said, We ran out of the stir fry so we are serving chicken tenderloins and fries. On May 2, 2023, at 3:39 PM, V11 said residents on regular and mechanical soft consistency diets were under served at lunch because the recipe and spreadsheet were not followed. V11 said he did not know how the kitchen ran out of stir fry for lunch. V11 continues to say he asked V16 and V16 was unable to answer why there was not enough stir fry for lunch service. V11 said the pork egg rolls served at lunch appeared burnt. V11 said right now there are residents who will receive meals on disposable plates because the facility does not have enough plates for all of the residents. The facility terminated their Food Service Director the week prior to the survey. V11 is assisting in the role of Director. V11 was noted to lack knowledge of portion sizes and meeting protein requirements per the menu spread sheet. In addition, V11 was unable to ensure adequate amount of food was prepared since the facility ran out of the chicken and broccoli stir fry. 145420 Page 5 of 7 145420 05/04/2023 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to prepare adequate food to serve portion as planned on the menu. The facility also failed to prepare enough food to ensure all residents were served the planned menu. This failure has the potential to affect all residents receiving a regular and mechanical soft constituency diet. The findings include: The facility's Diet Type Report dated May 3, 2023, shows 159 residents receive a regular or mechanical soft consistency diet. The report continues to show the facility has a total census of 172 residents. The facility's undated Diet Spreadsheet and planned menu shows the chicken and broccoli stir fry portion size is two servings of a #8 dip that is equivalent to 1 cup. The serving size for the rice is listed as 1 #8 scoop or 1/2 cup. The 1 cup of stir fry per the menu is equivalent to 3 ounces of protein and 1/2 cup of vegetables ( 1 serving). On May 2, 2023, at 11:29 AM, V11 (Executive Chef) said the chicken and broccoli stir fry is being served combined with rice. V11 said the recipe shows the chicken and broccoli should be served separately from the rice. V11 continues to say he is unsure how to tell if the residents are getting the correct portion size of protein since the chicken and broccoli is combined with the rice. On May 2, 2023, at 11:25 AM, V11 (Executive Chef) said V16 (Cook) is using a #6 scoop (2/3 cup) to serve the chicken and broccoli stir fry with rice, and residents are getting one scoop of the stir fry for lunch. V11 continues to say a #8 scoop (1/2 cup) is a five ounce scoop. On May 2, 2023, at 12:24 PM, V11 said, We ran out of the stir fry. On May 2, 2023, at 3:39 PM, V11 said, We made the stir fry a single dip item using a five ounce dipper. The recipe called for two scoops of chicken and broccoli using a 3.7 ounce scoop, and one 3.7 ounce scoop of rice. We were two ounces short on portion sizes for the regular and mechanical soft consistency diets. The expectation is the staff should be following the recipe and the spreadsheet. Review of the facility's April 20, 2023 Food Committee Meeting minutes shows residents are requesting larger portions. 145420 Page 6 of 7 145420 05/04/2023 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to serve food that is palatable and at an appetizing temperature. Residents Affected - Many This failure has the potential to affect all resident receiving a regular and mechanical soft consistency diet. The findings include: The facility's Diet Type Report dated May 3, 2023, shows 159 residents receive a regular or mechanical soft consistency diet. The report continues to show the facility has a total census of 172 residents. On May 2, 2023, at 12:46 PM, a test tray was sent to the resident unit and the chicken and broccoli stir fry tasted only slightly warm, and the pork egg roll looked burnt and tasted slightly warm. Resident interviews about the meal of May 2, 2023 also confirm that the food was cold. On May 2, 2023, at 1:17 PM, R14 said lunch was cold today. On May 2, 2023, at 2:00 PM, R8 said her egg roll was cold today. On May 3, 2023, at 12:19 PM, R9 said the food served is usually just warm or cold. On May 3, 2023, at 12:19 PM, R10 said the food served is usually cold. On May 3, 2023, at 12:38 PM, R11 said the food served is usually cold. On May 2, 2023, at 3:39 PM, V11 (Executive Chef) said he noticed the pork egg rolls being served during lunch appeared burnt. The facility's undated policy titled, Monitoring Food Temperatures for Meal Service, shows, Guideline: Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. Procedure: g. Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident. Any complaint regarding food temperatures by residents will be documented on the Food Temperature Log. Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining about 120 degrees Fahrenheit. The investigation is recommended to be completed within 72 hours of the complaint. 145420 Page 7 of 7