Health inspection·January 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 and interview the facility failed to place residents' indwelling catheter urinary drainage bags into a privacy bag. This applies to 2 of 5 residents (R51, R114) reviewed for dignity. The findings include: 1. R51's EMR (Electronic Medical Record) showed R51 was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, dementia, and benign prostatic hyperplasia. R51's MDS (Minimum Data Set) dated November 21, 2023, showed R51 had moderately impaired cognition. On January 23, 2024, at 9:39 AM, R51's indwelling urinary catheter bag was hanging on the side of the bed facing the door and was visible from the hallway. R51's drainage bag was not in a privacy bag. 2. R114's EMR showed R114 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy acute benign prostatic hyperplasia, and kidney failure. R114's MDS dated [DATE], showed R114 was cognitively intact. On January 22, 2024, at 10:04 AM, R114's indwelling urinary catheter drainage bag was hanging on the side of the bed facing the door and was visible from the hallway. On January 23, 2024, at 9:36 AM, R114's indwelling urinary catheter drainage bag was hanging on the side of the bed facing the door and was visible from the hallway. On January 23, 2024, at 11:04 AM, V32 (CNA/Certified Nurse Assistant) stated the privacy bag for the indwelling urinary catheter drainage bag is only used when the resident leaves the room. The privacy bags are not needed when the resident stays in their room. On January 24, 2024, at 10:25 AM, V2 (DON/Director of Nursing) said if a resident has an indwelling urinary catheter bag and they refuse to wear a leg bag under their clothing, then the staff need to put the indwelling urinary catheter drainage bag into a privacy bag even if the resident is in the Page 1 of 23 145420 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0550 room. If the drainage bag is hung on the side of the bed facing the door and is visible from the hallway, it needs to be in a drainage bag. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145420 Page 2 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation and interview, the facility failed to have the required IDPH (Illinois Department of Public Health) Complaint Hotline information posted in the facility for residents and/or residents' representatives' information. This affects all 168 residents residing in the facility. The findings include: On January 24, 2024, at 2:33 PM, during a search of the facility's common area accompanied by V1 (Administrator) we were unable to locate the required IDPH Complaint Hotline information posted. V1 stated he believed the IDPH Complaint Hotline posting was in the entry to the facility and doesn't know why it is not posted now. 145420 Page 3 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include a plan of care for pain management in the Comprehensive Care Plan for residents experiencing pain. This applies to 2 residents (R102 and R132) reviewed for care planning in the sample of 34. 1. R132's face sheet showed R132 has resided in the facility since January 2023 and has diagnoses that include but are not limited to rheumatoid arthritis, Parkinson disease, and myasthenia gravis. R132's comprehensive care plan was reviewed and there was no plan identified or interventions for pain management found in R132's comprehensive care plan. On January 22, 2024, at 10:02, R132 stated she has pain in both knees that makes it very difficult for her to stand. R132 stated there is a prescription for lidocaine pain patches to be placed on each knee daily. On January 24, 2024, at 11:01 AM, V2 (Director of Nursing) stated the comprehensive care plan for R132 should include a plan and interventions for pain management. 2. R102's face sheet documents a [AGE] year old female admitted to the facility on [DATE], with diagnoses that include Fracture of one rib, Fracture of shaft of Femur, Dementia, Anxiety, Depressive Disorder, History of falling, and Schizoaffective disorder. On January 22, 2024, at 10:41 AM, R102 stated she was in pain. R102 stated her neck, legs, back and head hurt. R102 stated her pain level was an 8 out of 10. R102 stated she had pain medication about an hour ago and the nurse said she would give her more pain medication after 12:00 PM. R102 stated, I can't bear the pain. On January 22, 2024, at 10:47 AM, R102 told V4 (LPN/Licensed Practical Nurse) her pain level was 8 out of 10 and she had heart burn. V4 stated you have to wait 3 to 4 hours for pain medication. I can only give you ibuprofen and you are not due for that yet. R102 stated her neck, back and legs hurt, and it is always worse when she is in bed. V4 stated she heard R102 say her pain was 8 out of 10. V4 stated, I know her and how she is. On January 22, 2024, at 11:32 AM, R102 told V4 her pain level was a 9 out of 10 as V4 was helping R102 to bed. R102 stated, Its hurts so bad, and I don't feel great. I feel terrible honey. On January 23, 2024, at 10:36 AM, R102 stated I'm doing terrible. R102 stated her pain was a 9 out of 10 . R102 stated the nurse gave her some acetaminophen about 1/2 hour ago and it didn't work. R102 stated the generic acetaminophen doesn't work well. On January 23, 2024, at 11:45 AM, V4 stated R102 has complained of pain every day for one year. V4 stated last week R102 was complaining of pain and asking for more acetaminophen after V4 had already given R102 acetaminophen. V4 said she told R102 she could not give her acetaminophen again, and R102 said well give me something different. V4 stated she told R102 she would call the doctor to get something more. V4 stated she called the V33 (Nurse Practitioner) last week and asked if she could give R102 something stronger because she complained of pain everywhere. V4 stated V33 said no, and to give R102 ibuprofen 400 Mg every 8 hours for pain. 145420 Page 4 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On January 23, 2024, at 12:17 PM, V35 (CNA/Certified Nursing Assistant) stated that R102 complained of pain. On January 24, 2024, at 3:27 PM, V34 (CNA) said, this week she's complaining of pain, and she is asking for more medication than she is allowed even after the nurse has given her medication. V34 stated, for 2 - 3 hours she calls for pain medication and she will keep doing it until she calls her children, and they will calm her down. On January 25, 2024, at 9:11AM, V13 (CNA) stated R102 always says she is in pain. V13 stated the resident says she has pain in her head and everywhere. Review of R102's plan of care indicated that R102 did not have a care plan for pain until it was created on January 23, 2024. 145420 Page 5 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R11 is 80 years-old with multiple medical diagnoses which include dementia, needs assistance with personal care, generalized muscle weakness, and abnormalities of gait and mobility. R11's Minimum Data Set (MDS) dated [DATE] shows that R1 is total dependent on staff for toileting and hygiene. Residents Affected - Some On January 22, 2024, at 11:47 AM, V13 (Certified Nursing Assistant/CNA) was providing care to R11. There was a pervasive urine odor in the bedroom. R11's linen sheet was heavily saturated with urine, there were layers of brown ring stain in the linen which showed the different drying stages of the urine in the linen. R1's wound dressing to his sacral area was wet with urine. V13 stated that the last time she changed R11's incontinence brief was at 7:00 AM On January 24, 2024, at 2:58 PM, V3 (Assistant Director of Nursing/ADON) stated that the residents are to be checked and changed for incontinence every 2 hours and as needed to prevent skin breakdown, urinary tract infection, and promote comfort. Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and oral care. This applies to 5 of 10 residents (R10, R11, R61, R80, R114) reviewed for activities of daily living in the sample of 34. The findings include: 1. R61's face sheet included diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, or mood disturbance, anxiety, cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility. R61's quarterly MDS (minimum data set) dated January 2, 2024, showed that R61 required partial moderate assistance in personal hygiene. On January 22, 2024, at 10:11 AM, R61 was seated in a wheelchair near nurse's station. R61's nails were short but jagged with blackish substance underneath nail beds. R61 stated that he would like his nails cut and cleaned. On January 23, 2024, at 9:40 AM, R61 seated in wheelchair in the dining room eating lunch. R61's nails remain jagged with blackish substance underneath nail beds. R61's request to have them cut and cleaned was relayed to V10 (Certified Nursing Assistant). 2. R80's face sheet included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, anxiety disorder, other abnormalities of gait and mobility, repeated falls, cognitive communication deficit. R80's quarterly MDS dated [DATE], showed that R80 was severely impaired in cognition and required substantial maximum assistance in personal hygiene. On January 22, 2024, at 10:54 AM, R80 was seated on couch in the dining room and noted to have extensive facial chin hairs covering her chin. R80's skin on forehead also appeared dry and flaky. On January 23, 2024, at 10:42 AM, R80 was seated on couch in the dining room and still had facial hair on her chin with dry flaky skin on forehead. R80 stated Yes I would like to have it (facial 145420 Page 6 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0677 hair) removed. I also want my nails cut and cleaned. R80's requests were relayed to V10. Level of Harm - Minimal harm or potential for actual harm 4. R10's EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE]. R10's diagnoses included multiple sclerosis, dementia, neuralgia and neuritis, abnormal posture, osteoarthritis, and generalized muscle weakness. R10's MDS (Minimum Data set) dated November 9, 2023, showed R10 had moderately impaired cognition. R10's functional assessment showed R10 was dependent on staff for toileting, shower/bath, and personal hygiene. R10 was always incontinent of bowel and bladder. R10's Care plan showed R10 had an ADL (Activity of Daily Living) self- care deficit related to immobility. Residents Affected - Some On January 23, 2024, 10:34 AM, R10 was in bed and had several white chin hairs and several dark hairs on her upper lip giving the impression of a mustache. R10's nails were long, uneven, and jagged with a dark substance underneath them. R10 said she would really like to be shaved and to have her nails cut. R10 said she is unable to do it herself and would really like it if the staff would offer to help her. 5. R114's EMR showed R114 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy acute benign prostatic hyperplasia, kidney failure, gout, foot drop, and rheumatoid arthritis. R114's MDS dated [DATE], showed R114 was cognitively intact. R114's functional assessment showed R114 was dependent on staff for toileting, shower/bath, and required staff set-up assistance for personal hygiene. R114 had an indwelling urinary catheter and was always incontinent of bowel. R114's care plan showed R114 had a self-care deficit related to weakness. On January 22, 2024, at 10:04 AM, R114 was in bed asleep but it was noted that R114 had long jagged fingernails and dry cracked lips coated with a dark substance. On January 23, 2024, at 9:36 AM, R114 was lying in bed and R114's teeth were noted to be a dark yellow almost brown color with a dark substance noted between some of his teeth. In addition, R114's mouth and lips were noted to be very dry. R114 said the deformity in his hands was from rheumatoid arthritis and it makes it very had hard for him to grip things with his hands. On January 23, 2024, at 10:48 AM, R114 was complaining about his mouth being so dry that he has a hard time talking. R114 said no one has offered to help brush his teeth, clean his mouth, or cut his fingernails. R114 said there is a doctor that comes in to cut his toenails. On January 24, 2024, at 10:25 AM, V2 (DON/Director of Nursing) said the CNAs (Certified Nursing Assistants) are to provide grooming and perineal care. V2 said grooming includes oral care, shaving facial hair for both men and women, and nail care including cleaning, trimming, and filing the nails. On a non-shower day, the expectation is that the CNAs still provide shaving, nail care if needed, washing the resident's face, hands, underarms, and perineal area. The CNAs are to get the resident dressed in clean clothes, up out of bed, and to make sure they are wearing proper footwear. Facility provided policy titled, Care of Fingernails/Toenails with a revision date of April 2007. The policy showed, The purpose of this procedure is to clean the nail bed, to keep trimmed, and to prevent infection General Guideline 1. Nail care includes daily cleaning and trimming. 145420 Page 7 of 23 145420 01/25/2024 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** 3. R22's face sheet included diagnoses of Type 2 diabetes without complications, chronic kidney diseases, acute kidney failure, urinary tract infection. Residents Affected - Few R22's POS (Physician Order Sheet) included order for Insulin Aspart Injection Solution (Insulin Aspart) Inject 8 unit subcutaneously before meals and at bedtime for hold if blood glucose is less than 110. [Novolog is the brand name of Insulin Aspart]. On January 23, 2024, at 2:54 PM, the medication carts in E wing were monitored in presence of V5 (Licensed Practical Nurse). R22 had a 100 units/ml (milliliters) vial (10 ml) of Humalog that was half used stored in the medication cart. V5 was not aware of discrepancy of the ordered insulin and what was administered. On January 24, 2024, at 11:11 AM, V15 (Pharmacist) stated that both Novolog and Humalog are both short acting insulins. V15 stated that generally there should be an order for using different formulation. V15 added that sometimes substitutes are allowed but there needs to be a doctor's order. On January 24, 2024, at 12:39 PM, V23 (Nurse Practitioner) stated that the medications should be administered based on pharmacy recommendation, physician order and/or facility policy. Facility policy (Effective January 1, 2015) included as follows: Policy: It is the policy of this facility to administer some generic drug substitutions. Standards: 1. Generic drugs will be substituted for brand-name drugs only if there is authorization to do so from both the resident or their representative and the attending physician. Based on observation, interview, and record review, the facility failed to obtain prescriber's orders for holding a dose of insulin and for a formulary exchange of insulin; and failed to assess for medication self -administration and provide a secure bedside storage for self administered medications. This applies to 3 of 3 (R8, R22, R83) residents reviewed for medication administration and medication storage in a sample of 34. 1.R8's EMR (Electronic Medical Record) showed R8 admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified, type 2 diabetes mellitus with hyperglycemia, unspecified diastolic congestive heart failure, and cerebral infarction unspecified. R8's MDS (Minimum Data Set) dated January 2, 2024, showed R8 with severe cognitive impairment, and required partial assistance from staff for bed mobility, transfer, toileting and lower body dressing, putting on and taking off shoes, moderate assistance for bathing and set up assistance for eating. R8's order summary report dated January 24, 2024, at 4:51 PM, showed an order initiated on November 29, 2023, for insulin aspart 100 unit/ml inject 10 units subcutaneously three times a day before meals scheduled at 08:00 AM, 12:00 PM, and 4:00 PM. This order did not include parameters of when to hold the dose. R8's MAR (Medication Administration Record) for January 2024 showed insulin dose not being given at the following times: On January 6, 2024, 4:00 PM aspart insulin dose was documented as code 14 (no 145420 Page 8 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin required) and the blood glucose results documented at 4:19 PM was recorded as 125. On January 22, 2024, the 8:00 AM aspart insulin dose was documented as given and the blood glucose result documented at 08:20 AM was 87. On January 22, 2024, the 4:00 PM dose was documented as code 9 (other see nurses notes) was not given and the blood glucose result was documented as 91. There is no documentation that the prescriber was notified of the blood glucose results nor was there an order written to hold the insulin dose for these dates. The facility's policy titled Guidelines for Notifying Physicians of Clinical Problems dated April 2007, showed When contacting the practitioner the nurse should have the following information available .1. Detailed description of the current issue or problem including vital signs, symptoms, and results of physical assessment and 6. Significant medication error .b. If the nature of the medication or severity of the reaction to the medication warrants discussion with the Physician. 2. R83 EMR showed R83 was admitted to the facility on [DATE], with multiple diagnoses including Flaccid hemiplegia affecting the left nondominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dependence on oxygen, anxiety disorder, morbid obesity due to excess calories, nicotine dependence, and chronic pain syndrome R83's MDS dated [DATE], showed R83 was cognitively intact, and showed R83 was dependent on staff assistance for toileting, bathing, bed mobility, transfer, and putting on shoes and required extensive assistance for dressing, and personal hygiene and supervision/touching assistance with eating. On January 22, 2024, at 4:30 PM, V28 administered R83 medication except for the Advair HCl inhaler. V28 stated R83 self-administers the Advair inhaler. R83 stated the inhaler is in her room and she uses the inhaler in the morning and at bedtime. V28 did not observe R83 administer the inhaler. R83's order summary showed R83 had an order for Advair HFA inhaler, 2 puff two times a day, scheduled for 08:00 AM and 5:00 PM, unsupervised self-administration-initiated on July 19, 2023. On January 22, 2024, at 5:10 PM, R83 had 2 Advair inhalers, with no date when they were opened or when they would expire, sitting on the bedside table with many other items. R83 stated that is where she keeps her inhaler, on top of the bedside table, not in a secure location. R83's care plan for self-administration of inhaler dated September 7, 2020, intervention Give R83 her inhalers as ordered and watch her administer them to herself, the care plan does not identify where the inhaler should be stored. V2 provided R83's self medication assessment dated [DATE]. There were no self-medication assessments completed prior to that date. On January 23, 2024, at 10:41 AM, V2 stated for a resident to self-administer the medication there needs to be an assessment, an order for self-administration, and normally that medication is kept at the bedside. V2 stated she is unsure how long R83 has had her inhaler at the bedside. The facility's policy titled Self-Administration of Medications dated November 3, 2014, showed Procedures C. For those residents who self-administer, the Interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment, conducted on a quarterly basis or when there has been a significant change in condition and .D. The results of the Interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are 145420 Page 9 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0684 Level of Harm - Minimal harm or potential for actual harm recorded in the resident's medical record on the care plan . E. If the resident demonstrates the ability to safely self-administer medications a further assessment of the safety of bedside storage is conducted F. Bedside medication storage is permitted only when it does not present a risk to a confused resident who wander into the rooms of or room with residents who self-administer, Conditions outlined in ID3: Bedside Medication Storage are met for bedside storage to occur . Residents Affected - Few The facility's policy titled Bedside Medication Storage dated October 27, 2014, showed C.2) The medications provided to the resident for bedside storage are kept in the containers dispensed by MAC Rx or in the original container if a nonprescription item. 145420 Page 10 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide wound care as ordered by physician and failed to ensure that a resident with a sacral pressure injury was kept clean and dry to promote wound healing per plan of care. This applies to 1 of 8 residents (R11) reviewed for pressure ulcer in the sample of 34. Residents Affected - Few The findings include: R11 is 80 years-old with multiple medical diagnoses which include unstageable pressure ulcer in the sacral region, dementia, generalized weakness, and need assistance with personal care. On January 22, 2024, at 11:47 AM, V13 (Certified Nursing Assistant/CNA) was providing care to R11. There was a pervasive urine odor in the bedroom. R11's linen sheet was heavily saturated with urine, there were layers of brown ring stain in the linen. R1's wound dressing to his sacral area was wet. The label date of the dressing change was faded and illegible. The surrounding skin of the wound was macerated. V13 stated that the last time she changed R11's incontinence brief was at 7:00 AM. On January 24, 2024, at 10:58 AM, V22 (Wound Care Nurse) stated that R11 has a stage 4 sacral ulcer full thickness which means according to the wound doctor, that the wound is deep with exposed muscle. V22 went on to add that R11's dressing should be changed once a day and as needed when it is soiled. The staff nurse does not have to wait for V22 to change the dressing, V22 added that the staff nurse should change the dressing when it is soiled and not wait for the wound nurse. V22 expects that nursing staff will change the dressing when he is not available and that leaving R11 wet with urine would cause worsening of the wound. Physician Order Summary (POS) shows a daily wound care to the sacrum. R11's Treatment Administration Record (TAR) administration history shows that R11 is scheduled for wound care daily at 9:00 AM. The same record shows that R11 received wound care on January 21, 2024, at 1:21 PM and on January 22, 2024, at 8:46 PM. R11's active wound care plan shows: R11 is at high risk for skin breakdown related to impaired mobility, incontinence of bowel and bladder. The same care plan shows multiple interventions which include keeping R11 clean and dry and to check and change for incontinence and repositioning every 2 hours and as needed. 145420 Page 11 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and provide interventions for R150's left hand contracture. This applies to 1 of 5 (R150) residents reviewed for range of motion and positioning in a sample of 34. R150's EMR (Electronic Medical Record) showed R150 was admitted to the facility on [DATE], with multiple diagnoses including spastic hemiplegia affecting left non dominant side, weakness, spinal stenosis lumber region, chronic viral hepatitis, vascular dementia, osteoarthritis of left, and contracture of muscle left forearm. R150's MDS (Minimum Data Set) dated October 17, 2023, showed R150 with moderate cognitive impairment and impairment of upper extremity range of motion on one side, and substantial assistance from staff for bathing, dressing, bed mobility, dependent on staff for transfer and assistance with eating. R150's care plan ADL (Activity of Daily Living) dated July 10, 2023, identifies limited ROM (Range of Motion), but does not include an intervention for positioning to prevent further contracture. R150's care plan for pain identifies there is a left-hand contracture but does not include an intervention for positioning. On January 22, 2024, at 09:43 AM, R150 was sitting in dining area, with her eyes closed, does not answer questions, only opens eyes to name and was leaning to the left side in the wheelchair, left hand and forearm were contracted in flexion being held against her chest, with no positioning device to the left hand. On January 23, 2024, at 12:09 PM, R150 was observed in the dining room, with her left arm and hand in a flexion contracture against her chest with no positioning device to the left hand. On January 23, 2024, at 12:09 PM, V3 (ADON/Assistant Director of Nursing) stated R150 is supposed to have a rolled washcloth in her left hand. R150's documentation of restorative nursing notes from January 13, 2024, December 12, 2023, October 18, 2023, and August 22, 2023, do not identify left hand contracture or use of a washcloth or palm protector as a positioning device. The intervention described was AROM (Active Range of Motion) to all extremities. The Occupational Therapy assessment dated [DATE], showed R150's left upper extremity required AAROM (Active Assisted Range of Motion) and PROM (Passive Range of Motion) within pain free tolerance for increased joint flexibility and reduced stiffness. On January 25, 2024, at 2:25 PM V3 (ADON) stated R150 should have a rolled washcloth for positioning in her left hand. V2 (DON) stated there is no facility policy regarding contractures and per V2 discussion with therapy staff, R150 should have PROM (Passive Range of Motion) to her left arm and hand and use a rolled washcloth or palm protector for her left hand for positioning. 145420 Page 12 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent urinary tract infection. In addition, the facility failed to ensure that an indwelling urinary catheter bag is not touching the floor. This applies to 5 of the 7 residents (R14, R38, R114, R160, R163) reviewed for peri-care and indwelling urinary care in the sample of 34. The findings include: 1. Face sheet shows that R14 is an [AGE] year-old who has multiple medical diagnoses which include Parkinson's disease, muscle weakness, and urinary tract infection (UTI). On January 22, 2024, at 11:13 AM, V16 (Certified Nursing Assistant/CNA) assisted R14 to the toilet who voided. After R14 voided, V16 assisted R14 to get up and cleaned R14's back perineum. Then V16 pulled the incontinence brief up and assisted R14 back to the bedroom without cleaning her frontal perineum. 2. Face sheet shows that R160 is 85 years-old with multiple medical diagnoses which include need assistance for personal care, lack of coordination, and weakness. Minimum Data Sheet (MDS) dated [DATE] shows that R160 is totally dependent on staff for toileting and hygiene. On January 23, 2024, at 11:20 AM, V16 (CNA) rendered incontinence care to R160 who was wet with urine. V16 wiped R160's frontal perineum in a downward stroke and proceeded to clean the back peri-area. V16 did not separate labia to clean the inner labia and did not clean R160's groins. 3. Face sheet shows that R38 is 95 years-old who has multiple medical diagnoses which include type 2 diabetes mellitus, disorder of kidney and ureter, muscle weakness, history of acute cystitis with hematuria, and history of sepsis due to Escherichia Coli (E. Coli). Minimum Data Set (MDS) dated [DATE] shows that R38 was dependent with toileting and hygiene. On January 23, 2024, at 1:29 PM, V16 (CNA) rendered incontinence care to R38 who had a bowel movement. V16 used wet wipes to clean R38's peri-area. V16 wiped the frontal perineum in a downward stroke but she did not separate R38's labia to clean the inner corners. V16 also did not clean R38's groins. V16 turned R38 on the left side to clean the back perineum. V16 used wet wipes to clean R38's buttocks and rectum and these same wet wipes were folded repeatedly to wipe the rectum. V16's gloved hands had a direct contact to R38's fecal matter. V16 took a no-rinse foaming cleanser to continue to clean R38. Wearing the same soiled gloves V16 went back to R38's frontal perineum to wipe the outer labia in downward stroke. Again, V16 did not separate the labia and did not clean the groins. On January 23, 2024, at 2:20 PM, V3 (Assistant Director of Nursing/ADON) stated that staff must clean from front to back, explain the procedure to the resident, clean the frontal area by using different clean wipes on each area, open the labia to clean the inner area of the labia, urethra, and the groins to prevent UTI. Facility's Perineal Care Policy and Procedure with revised date of August 2008 shows: Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent 145420 Page 13 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infections and skin irritations, and to observe the resident's skin condition. Procedure: 9. For female resident: b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward stroke. 4. R163's face sheet included diagnoses of acute cystitis with hematuria, obstructive and reflux uropathy, restlessness and agitation, dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R163's admission MDS (minimum data sheet) dated December 4, 2023, included that R163 was severely impaired in cognition. R163's POS (Physician Order Sheet) included that R163 has Foley (Urinary) catheter due to diagnosis of Obstructive Uropathy. On January 22, 2024, at 10:34 AM, R163 resting in bed with bed in lowest position. R163 had a catheter bag hooked on the left side of the bed frame towards the wall. The catheter bag was enclosed in a privacy bag, however, was touching the floor as the privacy bag was not enclosed at the bottom. V9 (Registered Nurse), who was in the room stated He just came back from the hospital for hematuria. The bed has to go up if the bag has to be off the floor. On January 23, 2024, at 9:50 AM, R163 resting in bed with bed in lowest position. R163's catheter bag was lying flat on the floor partially out of the privacy bag. This was relayed to V5 (Licensed Practical Nurse) who stated that the catheter bag should be hooked on to the bed (frame). On January 23, 2024, at 10:54 AM, R163's catheter bag and tubing was lying flat on floor with the catheter bag mostly out of the privacy bag and V5 was notified of the same. 5. R114's EMR showed R114 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy acute benign prostatic hyperplasia, and kidney failure. R114's MDS dated [DATE], showed R114 was cognitively intact. On January 22, 2024, at 10:04 AM R114's indwelling urinary catheter drainage bag was resting on the floor. The drainage bag was not in a privacy bag. On January 24, 2024, at 10:25 AM, V2 (DON/Director of Nursing) said the drainage bag should never rest on the floor. Facility provided their policy titled Catheter Care, Urinary, with a revision date of September 2005. This policy showed, The purpose of this procedure is to prevent infection of the resident's urinary tract Guideline 11. Be sure the catheter tubing and drainage bag are kept off the floor. 145420 Page 14 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R132's face sheet showed R132 has been in the facility January 2023 and has diagnoses including but not limited to Parkinson disease, chronic obstructive pulmonary disease, myasthenia gravis, rheumatoid arthritis, and other diagnoses. The most recent comprehensive assessment (MDS - minimum data set), dated October 24, 2023, shows R132 is cognitively intact with moderate deficits. Residents Affected - Few On January 22, 2024, at 10:02 AM, R132 stated she has pain in both knees that makes it very difficult to stand. R132 stated there is a prescription for lidocaine pain patches to be placed on each knee daily. R132 stated that sometimes the nurse does not put them on because they say they are out of stock. R132 added that today the nurse placed only one patch on the left knee and had none for the right knee. R132 stated the lidocaine patches help a lot with the pain. On January 22, 2023, at 2:52 PM, R132 stated there was still only one lidocaine pain patch on the left knee and none on the right knee. On January 22, 2023, at 3:14 PM, V31 (Registered Nurse) lifted R132's pant legs to visualize the knees. There was a lidocaine patch on left knee and no patch on the right knee. The POS (Physician's Order Sheet) for R132 showed an order for Lidocaine External Patch 4% (Lidocaine) Apply to both knees topically one time a day for Analgesic Remove previous patch before applying new one; document removal and remove per schedule. On January 22, 2023, at 3:16 PM, V31 (Registered Nurse) could not explain the missing patch but stated sometimes they run out of over-the-counter medications because the Agency Nurses don't always re-order items when they run out. The Care Plan for R132 contained no reference to pain management for R132. On January 24, 2024, at 11:01 AM, V2 (Director of Nurses) stated the Care Plan for R132 should include a care plan for pain management. Based on observation, interview, and record review the facility failed to ensure effective treatment and interventions for a resident's pain. The facility also failed to provide pain relief patches for one resident per physician orders. This applies to 2 of 6 residents (R102 and R132) reviewed for pain in the sample of 34. Findings include: 1. R102's face sheet documents a [AGE] year old female admitted to the facility last on May 19, 2022, with diagnoses that include Fracture of one rib, Fracture of shaft of Femur, Dementia, Anxiety, Depressive Disorder, History of falling, and Schizoaffective disorder. On January 22, 2024, at 10:41 AM, R102 stated she was scared and in pain. R102 stated her neck, legs, back and head hurt. R102 stated her pain level was an 8 out of 10. R102 stated she had pain medication about an hour ago and the nurse said she would give her more pain medication after 12:00 PM. R102 stated, I can't bear the pain. 145420 Page 15 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0697 Level of Harm - Minimal harm or potential for actual harm On January 22, 2024, at 10:47 AM, R102 told V4 (LPN/Licensed Practical Nurse) her pain level was 8 out of 10 and she had heart burn. V4 stated you have to wait 3 to 4 hours for pain medication. I can only give you ibuprofen and you are not due for that yet. R102 stated her neck, back and legs hurt, and it is always worse when she is in bed. V4 stated she heard R102 say her pain was 8 out of 10. V4 stated, I know her and how she is. Residents Affected - Few On January 22, 2024, at 11:32 AM, R102 told V4 her pain level was a 9 out of 10 as V4 was helping R102 to bed. R102 stated, Its hurts so bad, and I don't feel great. I feel terrible honey. On January 23, 2024, at 10:36 AM, R102 stated I'm doing terrible. R102 stated her pain was a 9 out of 10. R102 stated the nurse gave her some acetaminophen about 1/2 hour ago and it didn't work. R102 stated the generic acetaminophen doesn't work well. R102 stated she has a headache and is hurting all over. On January 23, 2024, at 10:39 AM, V4 (LPN) stated R102 is asking for acetaminophen every 15 minutes. V4 stated that R102 said her pain was a 7 out of 10 when she rechecked to see how effective the medication was. On January 23, 2024, at 11:45 AM, V4 stated R102 has complained of pain every day for a 1 year. V4 stated last week R102 was complaining of pain and asking for more acetaminophen after V4 had already given R102 acetaminophen. V4 said she told R102 she could not give her acetaminophen again, and R102 said well give me something different. V4 stated she told R102 she would call the doctor to get something more. V4 stated she called the V33 (Nurse Practitioner) last week and asked if she could give R102 something stronger because she complained of pain everywhere. V4 stated V33 said no, and to give R102 ibuprofen 400 Mg every 8 hours for pain. On January 23, 2024, at 12:17 PM, V35 (CNA) stated that R102 complained of pain and asking for acetaminophen constantly today and she told her she couldn't have it every 20 minutes because it was too soon. V35 stated she told the nurse about it. On January 24, 2024, at 3:27 PM, V34 (CNA) said, this week she's complaining of pain, and she is asking for more medication than she is allowed even after the nurse has given her medication. V34 stated, for 2 - 3 hours she calls for pain medication and she will keep doing it until she calls her children, and they will calm her down. V34 stated he always tells the nurse she is complaining of pain. V34 stated R102 says her back, or legs hurts and she says it's worse than it was before, and I asked her how bad, and she says, its bad honey, it's really hurting. This is conversation daily. V34 stated that R102's pain has been more noticeable since she came back from her children's house about a week and a half ago. V34 stated last week R102 came back from visiting her daughter and she had acetaminophen, ibuprofen, and antacid in a bag in her room and he gave it to the nurse. V34 stated since her over the counter medication she had was taken away, R102's pain is worse. Her family called and was upset that they took her pain medication away. On January 24, 224 02:45 PM, V2 (Director of Nursing) stated pain is subjective. V2 stated she expects the staff to assess pain, call the doctor and get medication orders if there is not as needed pain medications. V2 stated she expects the nurses to update the doctor about unrelieved pain. V2 stated she was not aware that R102 had any chronic pain and does not know the source of R102's pain. On January 25, 2024, at 9:11 AM, V13 (CNA) stated R102 is always looking for medication. V13 stated R102 always says she is in pain. V13 stated the resident says she has pain in her head and 145420 Page 16 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few everywhere. V13 stated she always tells the nurse when R102 complains of pain. V13 stated R102 has been saying she has pain for the last year. On January 25, 2024, at 12:16 PM, V33 (Nurse Practitioner) stated R102 was a hospice patient, off hospice for several months. V33 stated R102 is variable with pain. V33 stated when she sees her, she has no chronic pain. On January 25, 2024, at 2:24 PM V33 stated R102 generally says everything hurts, and needs more physical therapy. V33 stated now R102 is saying she has pain in her back today. V33 stated she believes she was called last week and did not order ibuprofen because the resident is allergic to Ibuprofen. V33 stated she increased R102's acetaminophen. V33 stated she does not recall ever getting a call to her know how effective the acetaminophen was for the resident. R102's electronic medication administration record shows Ibuprofen ordered from January 12, 2024, to January 18, 2024, but there are no administrations of the medication. R102 (MAR/Medication Administration Record) also showed Acetaminophen tablet 500 MG, give 2 tablets by mouth every 8 hours as needed for mild pain was given once on January 22, 2024, at 8:58 AM and once on January 23, 2024, at 9:49 AM. R102 did not have a care plan for pain, however pain care plan was created January 23, 2024, and shows: Check with R102 after pain mediation has been given and see if her number went down. Document in MAR what number pain R102 indicates, Identify and record previous pain history and management of that pain and impact on function. Notify physician if interventions are unsuccessful or if significant change from residents past experience of pain. The facility's Pain policy dated 2008 shows the following: 1) Identify individuals who have pain or who are at risk for pain. 2) Cause identification: The physician will help identify causes of pain by examining the resident directly, reviewing the resident's history, and having a sufficiently detailed discussion with the resident and staff. 3) Treatment: the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Evaluate and report how much and how often the individual asks for as need pain medication. 145420 Page 17 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 31 medication opportunities with 4 errors, resulting in an 12.9% medication error rate. This applies to 4 of 6 residents (R8, R13, R36, R39) reviewed for medication administration in the sample of 34. Residents Affected - Some The findings include: 1. On January 22, 2024, at 4:57 PM, V19 (Nurse) administered Ferrous Sulfate (Fe SO4) Elixir medication to R39. V19 poured the medication in the medicine cup and stated that she will administer the medication to R39. V19 also said that the order is to give 6.8 milliliter (ml) of the Fe SO4 Elixir. Upon inspection, it was noted that there was 7.5 ml of the Ferrous Sulfate in the medicine cup. V19 then re-check how much medication was in the cup, she poured some of the Ferrous Sulfate in the garbage can. It was noted that there was only 5ml of medication in the cup. The order is for 6.8 ml. R89's Medication Administration Record (MAR) dated January 2024, shows Ferrous Sulfate (Fe SO4) Elixir 220 milligram (mg)/5 ml. 2. On January 22, 2024, at 5:10 PM, V17 (Nurse) administered four drops of Dorzolamide HCL and Timolol Maleate 2%-0.5% Ophthalmic Solution in each eye of R13. This medication was in a small plastic ampule. R13's MAR shows to administer one drop of Dorzolamide HCL and Timolol Maleate 2%-0.5% Ophthalmic Solution in each eye. 3. On January 23, 2024, at 9:34 AM, V21 (Nurse) administered one tablet of Folic Acid 400 micrograms (mcg) to R36. R36's MAR shows Folic Acid Tablet 1 mg, to administer 1 tablet by mouth daily. On January 23, 2024, at 2:30 PM, V3 (Assistant Director of Nursing/ADON) stated that the nurse should administer medication as prescribed by the physician. V3 also stated that V17 should have given R13 one drop of Dorzolamide HCL and Timolol Maleate in each eye as prescribed. Whatever remained from the small plastic ampule should have been discarded. 4. R8's Physician's order showed insulin aspart solution 100 unit/ml Inject 10 units subcutaneously three times a day before meals related to type 2 diabetes mellitus with hyperglycemia. On January 22, 2024, at 5:00 PM, V28 obtained R8's blood glucose and it was 91. V28 did not administer R8's 4:00 PM scheduled dose of insulin aspart. Review of R8's Physician order summary on January 23, 2024, at 10:00 AM, did not contain an order to hold the January 22, 2024, 4:00 PM scheduled dose of insulin aspart and the order did not contain blood glucose parameters to indicate when the insulin should be held. Review of R8's progress notes on January 23, 2024, at 10:00 AM does not show what the blood glucose results were when V28 did not give the insulin nor indicate that blood glucose result was communicated to the prescriber. On January 23, 2024, at 10:41 AM, V2 (DON) stated If there are no parameters the nurse should call the prescriber after using their assessment skills and judgement, to obtain an order to hold any medications. 145420 Page 18 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label and date medications after opening to determine expiration dates. In addition, facility also failed to refrigerate an insulin that is unopened. This applies to 6 of 6 residents (R14, R15, R22, R31, R47, R151) reviewed for medication storage. The findings include: On [DATE], at 2:55 PM, the A-Unit Team 1 cart was observed with V27 (Nurse), and the following was noted: 1. R14's Arnuity Ellipta (fluticasone furoate inhalation powder) 100 mcg (micrograms) and Fluticasone Propionate and Salmeterol 250/50 mcg opened and not dated. 2. R47's Fluticasone Furoate 100 mcg/25 mcg opened and not dated. The Recommended Minimum Medication Storage Parameters based on manufacturer's guidance of the Fluticasone Furoate shows Date product when opened and discard in 6 weeks after opening the foil tray or when the counter reads 0. Whichever comes first. 3. R151's Breo Ellipta 200/25 opened and not dated. 4. R31's Breo Ellipta 200/25 open and not dated. The Recommended Minimum Medication Storage Parameters based on manufacturer's guidance of the Breo Ellipta shows Date the inhaler when removed from the pouch when opened and discard in 6 weeks after removal from the foil pouch or when the counter reads 0. Whichever comes first. On [DATE], at 5:19 PM, V2 (Director of Nursing/DON) stated that staff must label the inhalers when it was opened to determine expiration dates. Some medications have specific days of use after it was opened. The insulins that are sealed should be refrigerated. 5. On [DATE], at 2:54 PM, the medication carts in E wing was observed with V5 LPN (Licensed Practical Nurse). One of the medication carts had an unopened Levemir insulin 100 units ml/milliliter vial (10ml) labeled for R22. This insulin vial was noted to have a sticker that showed Refrigerate. V5 confirmed that the vial was unopened and stated that if unopened, it should have been refrigerated. On [DATE], at 3:33 PM, the same medication cart was monitored in presence of V29 (LPN) and V30 (LPN) and noted to have the same unopened 10 ml vial of Levemir insulin. V29 stated If it (insulin vial) is not open, we should leave it in the refrigerator. On [DATE], at 11:11 AM, V15 (Pharmacist) stated that unopened Levemir insulin should be refrigerated to prolong the shelf life. 6. On [DATE], at 11:51 AM with V4 (LPN) in medication cart A on the C unit in the active medication top drawer there was R15's insulin injection pen of Humalog/Lispro insulin. The insulin pen was 145420 Page 19 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0761 observed to have about half left in the vial and there was no written open date or expiration date on it. Level of Harm - Minimal harm or potential for actual harm 7. On [DATE], at 11:51 AM with V4 (LPN) the medication cart was observed and noted in the top drawer: Residents Affected - Some a) There was a used multi-dose vial of Lantus in the medication cart drawer with no resident name, and no written open date or expiration date on it. b) There was an opened multi-dose vial of Novolog Aspart insulin that had no resident name and no written open date or expiration date on it. c) There was a multi-dose vial of Levemir insulin with no resident name and an open date of 10/2023. The expiration day in 10/2023 is smeared and not legible. The written expired date on the Levemir shows [DATE]. V4 stated she is going to throw the Levemir away. V4 stated when they open insulin, they write the date the insulin is opened and the expiration date on it. V4 stated the insulin is good 28 days after it is opened. The Facility Storage of Medications policy dated [DATE] shows the following: C. Certain medications or package types, such as IV solutions, Multiples dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strip, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. E. When the original seal of manufacture's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. 145420 Page 20 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to provide fortified foods as ordered by the physician. Residents Affected - Some This applies to 5 of 5 (R27, R33, R137, R146, R152) residents reviewed for dining in the sample of 34. The findings include: On January 22, 2024, at 9:20 AM, during initial tour of the kitchen, V7 (Cook) stated that she is preparing barbecue pulled pork, carrots and mashed potato for the lunch meal service. On January 22, 2024, starting at 11:13 AM, V7 was platting the meal for the lunch service. V7 was noted to serve the mashed potatoes she had prepared for the meal to the residents that showed fortified mashed potato on the diet card. R27, R33, R137, R146, R152 received regular mashed potatoes instead of fortified potatoes. When asked, V7 stated that she used hot water and chicken base powder and a little butter to prepare the mashed potato. Recipe for Fortified Mashed Potatoes listed ingredients as Potato, Mashed Instant (complete); 2% milk; milk (nonfat dry); sour cream; margarine; iodized salt. On January 22, 2024, at 11:50 PM, V6 (Food Service Manager) stated that V7 should have followed the recipe to prepare the fortified mashed potato. On January 24, 2024, at 12:44 PM, V8 (Dietitian) stated that fortified foods are recommended for residents that have decreased intake or weight loss to provide extra nutritional supplementation of calories and protein. V8 stated that 1/2 cup serving of fortified mashed potatoes has 235 calories, 11 grams protein and 11 grams fat. V8 added that 1/2 cup serving of mashed potatoes has 137 calories, 4 grams protein and 0.5 grams fat. Physician order sheet diet orders included as follows: R33 fortified foods (revised 4/24/2023). R27 add fortified food (revised 1/10/2024). R137 fortified foods (revised 3/28/2023). R146 fortified diet (revised 7/12/2023). R152 fortified foods (revised 3/14/2023). 145420 Page 21 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard infection control processes in regards to hand hygiene and gloving during provisions of peri-care and medication administration. In addition, the facility failed to ensure that items were not stored under the medication room sink. This applies to 4 of the 34 residents (R13, R14, R38, R160) reviewed for infection control in the sample of 34. Residents Affected - Some The findings include: 1. On January 22, 2024, at 5:10 PM, V17 (Nurse) administered medications to R13. During the preparation of medications, V17 was wearing gloves. V17 popped each medication from the bingo card medication container to her gloved hands, then V17 would put the medications in the medicine cup. V17 opened the drawers of the medication cart to gather the additional items she needed for R13. When V17 completed the preparation of R13's medications, V17 proceeded to administer the medications to R13 including the Dorzolamide HCL and Timolol Maleate eye drops while wearing the same gloves and without hand hygiene. 2. On January 22, 2024, at 11:13 AM, V16 (Certified Nursing Assistant/CNA) assisted R14 to the toilet who voided. After R14 voided, V16 assisted R14 to get up and cleaned R14's back perineum, V16 pulled R14's incontinence brief back in place and assisted R14 back to the bedroom. V16 removed her gloves, without hand hygiene and with bare hands V16 continued to straighten R14's clothes, beddings, picked up the garbage, and left the R14's bedroom without hand hygiene. 3. On January 23, 2024, at 11:20 AM, V16 (CNA) rendered incontinence care to R160. V16 cleaned R160's peri-area from front to back and applied the clean incontinence brief while wearing the same gloves. V16 removed her gloves, without hand hygiene and with bare hands, V16 proceeded to help reposition R160, touched remote control of the bed, touched clean linen cart, placed clean pillow under R160's head, placed the linen sheet on top of R160, opened the drawer and closet door to return hygiene items back in placed, and left the room without hand hygiene. 4. On January 23, 2024, at 1:29 PM, V16 (CNA) rendered incontinence care to R38 who had a bowel movement. While V16 was providing peri-care, V16's gloved hands had a direct contact to R38's fecal matter. After V16 cleaned R38's perineum, V16 repositioned R38, straightened R38's clothing, and clean beddings, opened bedside drawer and closet door to return hygiene items in placed, while wearing same soiled gloves. On January 23, 2024, at 2:14 PM, V13 (Assistant Director of Nursing/ADON) stated that staff must perform hand hygiene and wear gloves prior to and after resident's care. The staff must change gloves and perform hand hygiene from dirty to clean task to prevent infection and to prevent cross contamination. When they touch surface area or other items, they must change gloves and sanitize hands prior to proceeding to clean task. 5. On January 23, 2024, at 2:45pm, in the medication room in the B unit, there were items stored in the cabinet beneath the sink. The floor of the cabinet showed signs of previous water damage. The items in the cabinet included a box of indwelling urinary catheters, a telephone, a suction pump, a space heater, and a plastic storage box containing extension cords and other items. On January 23, 2024, at 2:45pm, V28 (Registered Nurse) stated he didn't know there were items 145420 Page 22 of 23 145420 01/25/2024 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0880 stored beneath the sink. Level of Harm - Minimal harm or potential for actual harm Facility's Hand Washing/Hygiene Policy and Procedure date November 2013 shows: Policy: It is the policy of the facility to assure staff practice recognized hand washing/hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Policy Specifications:3. When hands are not visibly soiled, employees may use and alcohol-based hand rub containing 60-95% ethanol or isopropanol in all of the following situations: e. before preparing or handling medications. g. before moving from a contaminated body site to a clean body site during resident care. h. after handling used dressings, potentially contaminated equipment, etc. k. after removing gloves. 4. The use of gloves does not replace compliance with handwashing/hand hygiene procedures. Residents Affected - Some 145420 Page 23 of 23