Health inspection·March 7, 2024

F 0677 continence status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145420 If continuation sheet Page 2 of 4 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 145420 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have fall prevention interventions in place for a resident at risk for falls. This failure resulted in R1 falling out of bed and sustaining a subdural hematoma. This applies to 1 of 3 residents (R1) reviewed for accidents. The findings include: The facility's [DATE], Final Serious Injury Incident and Communicable Disease Report documented the following: CNA [Certified Nurse Assistant] notified the nurse on duty that R1 was noted on the floor by her bed. R1 stated that she was trying to get something off her table when she tipped over and fell from the bed. R1 was observed with a hematoma and bleeding to the left side of the head. Report showed, Root Cause: Per R1, she was trying to get something from her table when she tipped over and fell from her bed. R1 possibly hit her head on the bedside table causing the hematoma to left side of head. The Report did not mention that a fall mat was in use at the time of R1's fall. The facility's [DATE], Post Fall Evaluation Assessment from 4:00 AM which includes questions and checkboxes showed, Floor mat on floor? No. It also showed Was fall witnessed? No. and Was Resident wearing oxygen as prescribed at time of fall? No. R1's [DATE], Risk for Falls Assessment showed R1 was at risk for falls. On [DATE], at 10:52 AM, V4 (LPN/Licensed Practical Nurse) said she worked the 11 PM to 7 AM shift on [DATE], and was the nurse caring for R1. V4 said she was called to the room by the CNA (V5) and upon entering the room, saw R1 on the floor. V4 said there was blood all over the floor and the fall mat was either standing up or against the wall. V4 said she did not believe the fall mat was in place because there was blood on the floor and not on the fall mat. On [DATE], at 11:08 AM, V5 (CNA) was called, and a voicemail left requesting a return call. As of [DATE], at 9 AM, V5 had not return the surveyor's call. On February 28, 2024, at 08:28 AM, V17 (R1's Family Member) said that on [DATE], around 4 AM, R1 fell out of bed and hit her head and went to the hospital. V17 said there were supposed to be mattresses alongside the bed and if there were, she would not have hit her head and had a brain bleed. V17 said R1 needed surgery and ended up becoming unconscious and died on February 1, 2024. V17 said R1 had prior falls and was dependent on the staff to get her out of bed as she was bedridden. R1's [DATE], care plan showed R1 was at risk for falls related to impaired functional mobility due to weakness and contractures to bilateral lower extremities. R1's care plan goal showed R1 would have no injuries from a fall. R1's fall prevention interventions include on February 4, 2023, and [DATE], place floor bed with floor mat when resident is in bed and on [DATE], to keep needed items, water, etc. in reach. On [DATE], staff were to frequently check resident at night and on [DATE], to have the call light within reach. On [DATE], at 02:48 PM, V6 (R1's Physician) said R1 was an elderly woman with dementia, who was generally deconditioned. V6 said R1 was at a high risk for falls and measures including low bed with the mattress on the floor were initiated. V6 said the floor mat should have been there as she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145420 If continuation sheet Page 3 of 4 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 145420 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 previously had a fall in November of 2023. V6 said if R1 was bed bound, she should have had a fall mattress. R1's progress note dated [DATE], at 07:24 AM showed, At approximately 2:30 am, the resident was noted on the floor. R1's face sheet showed R1 was admitted with diagnoses including multiple sclerosis, generalized muscle weakness, lack of coordination, cognitive communication deficit, contracture of muscle, left lower leg and right lower leg, unsteadiness on feet, need for assistance with personal care, and abnormal posture. R1's MDS (Minimum Data Set) dated [DATE], showed R1 had moderate cognitive impairment. R1 required partial assistance from staff for bed mobility and was dependent on staff transfers. R1's MDS also showed R1 had no impairment with her upper extremities. R1's [DATE] [History and Physical] CT Brain or Head showed .Conclusion: Large acute on chronic left frontal, parietal and temporal subdural hematoma measuring up to 2.1 [centimeters]. R1's [Emergency Department] Provider Notes showed [Computed Tomography of Head] performed. I personally interpreted the images- Large [Left Subdural Hematoma] with midline shift. On exam, [R1's] mental status is similar, though slightly slower to respond. [Left] pupil now lightly larger than the [Right] . The facility's Falls- Clinical Protocol policy (revised [DATE]) showed Based on the preceding assessment, the staff and physician will identity pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Causes refer to factors that are associated with or that directly result in a fall .Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145420 If continuation sheet Page 4 of 4