Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to identify a change in a resident condition, failed to provide
frequent monitoring, failed to provide accurate information to the physician, and failed to transfer R2 to the
hospital in a timely manner. This failure resulted in R2 experiencing a slow deterioration from the morning of
[DATE], until she was transferred to the hospital at 12:30 PM on [DATE], in critical condition. R2 died at the
hospital on [DATE] from septic shock. This applies to 1 of 3 residents (R2) reviewed for quality of care in the
sample of 11.
Residents Affected - Few
The Immediate Jeopardy began on [DATE] at 1:18 AM when V28 (LPN - Licensed Practical Nurse) failed to
identify R2's change in condition, complete an assessment, obtain vital signs, and notify R2's physician.
This failure continued when V19 (LPN) failed to provide frequent monitoring, provide accurate information to
the physician, and transfer R2 to the hospital in a timely manner. V3 (DON - Director of Nursing) was
notified of Immediate Jeopardy on [DATE] at 9:00 AM. The surveyor confirmed by interview and record
review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two
because additional time is needed to evaluate the implementation and effectiveness of the in-service
training.
The findings include:
On [DATE] at 9:19 AM, V16 and V17 (R2's family members) said they had attempted to call R2 the evening
of [DATE] and the morning of [DATE]. They said it was a routine for them to speak to R2 twice a day and it
wasn't normal that she wasn't answering her phone. They said they contacted V19 (LPN) and asked her to
check on R2. They said on [DATE] at 10:30 AM, V19 reported, that something was off and [R2] would
probably be sent to the hospital. They said V19 reported that R2 screamed whenever she tried to touch her.
V16 said she asked V19 if she was calling 911 and V19 replied, No I don't think so. V16 said she didn't
understand why R2 was not picked up by the ambulance until 12:30 PM. V16 said she arrived at the
emergency room to find R2 with an IV, indwelling catheter, and oxygen already on. V16 said R2 looked grey
and was screaming in pain. V16 said R2 was admitted to the ICU (Intensive Care Unit) and was receiving
IV blood pressure medications but was not doing well. V16 said R2 expired at the hospital on [DATE] due to
septic shock.
On [DATE] at 1:40 PM, V19 (LPN) said R2's wing was her regular assignment. V19 said she was familiar
with R2 and was the nurse that sent her out on [DATE]. V19 said R2 was alert and preferred to use the
bedpan and perform her own peri-care. V19 said R2 would usually turn on her call light when she needed
us to grab her something or empty the bedpan, but otherwise she didn't want us bothering her. V29 said the
night shift nurse did not report any issues with R2. V29 said on [DATE] R2 was a little confused, was having
diarrhea, looked tired, and couldn't clean herself up, like she usually did. V19 said she had to send the CNA
in to help R2 at least 2 times on [DATE]. V19 said that R2 wasn't
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
145420
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
07/01/2024
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
acting like herself and was very weak. V19 said she called her family, the physician, and sent her to the
hospital via non-emergent ambulance.
R2's Face sheet printed [DATE] showed R2 had diagnoses to include, but not limited to: COPD (chronic
obstructive pulmonary disease), heart failure, peripheral vascular disease, insomnia, atrial fibrillations,
major depressive disorder, anemia, non-pressure chronic ulcer to left foot, dementia, and osteoarthritis.
Residents Affected - Few
R2's facility assessment dated [DATE] showed R2 had moderate cognitive impairment; required partial to
moderate assistance for personal hygiene and rolling in bed; required substantial to maximal assistance for
toilet hygiene; and was always continent of stool.
R2's Vital Signs showed on [DATE] at 9:35 AM her blood pressure (BP) was 121/64, heart rate (HR) was
62, respirations were 18, and her oxygen saturation (Sp02) was 95% on room air. There were no vital signs
charted after [DATE] at 9:35 AM.
R2's [DATE] MAR showed R2 received Tylenol at 1:18 AM on [DATE] and R2's 11-7 vital signs were not
taken on [DATE].
R2 did not have progress notes from [DATE] until [DATE] at 11:58 AM. (R2's progress notes did not contain
an assessment or entry on [DATE] by V28 (LPN) regarding R2's increased weakness, change in behavior,
and complaints of vaginal pain. There were no vital signs taken on 11-7 shift and the physician was not
notified of R2's change in condition.) R2's Progress Note dated [DATE] at 11:58 AM, by V19 (LPN) showed,
Noticed resident weak and not doing her own peri-care as usual, said that she is weak and cannot do it and
kept on removing her diaper. Also, c/o (complained of) vaginal pain. Called [V34 - R2's Physician], order
given and carried out to - send resident to ER (emergency room to (local hospital) for eval and treat via
regular ambulance. Called (non-emergent ambulance service), said ETA (estimated time of arrival) 30
minutes . Vital signs stable. Resident left with 2 Paramedics around 12:35 PM. Resident was alert, verbally
responsive at the time of leaving. (This note does not contain any detail on the times the family or physician
were notified, nor does it contain ongoing assessments and vital signs of R2 between 9:35 AM
(identification of R2's change in condition) and 11:47 AM when the ambulance was notified.)
R2's Physician Order Sheet printed [DATE] showed an order on [DATE] to send R2 to the emergency room
via regular ambulance and an order to obtain vital signs every shift.
R2's SNF/NF to Hospital Transfer Form dated [DATE] showed vital signs obtained at 9:35 AM. This form
showed the date of transfer was [DATE] at 12:35 PM.
R2's Ambulance Patient Care Report dated [DATE] showed the time of injury was 9:30 AM, dispatch was
notified at 11:47 AM, and the ambulanced arrive to the patient at 12:23 PM. This report showed, Upon
arrival patient was alert and oriented x 1, on room air, laying in bed in a lethargic sate. Patient is currently
complaining of vaginal region pain and generalized weakness. (Nurse) on scene states they noticed patient
lethargic this morning at 9:30 AM. (Nurse) on scene states patient's normal mental status is alert and
oriented x 2-3. (Nurse) states (R2's) last known normal is [DATE] . Patient pale, cold, and dry . This report
showed initially R2's oxygen saturation was 86% on room air and she required hot packs on her hands and
100% oxygen, via a non-rebreather mask, to bring her oxygen level up. This report showed that R2's first
BP was 56/35 (critically low). R2 had low blood pressure readings, unsuccessful IV attempts and the crew
decided to divert to the closest hospital for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 2 of 8
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
07/01/2024
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 0684
critical care.
Level of Harm - Immediate
jeopardy to resident health or
safety
R2's Death Certificate dated [DATE] showed the cause of death was Septic Shock due to a UTI (Urinary
Tract Infection).
Residents Affected - Few
On [DATE] at 1:48 PM, V35 (Restorative Aide) said they worked R2's wing the weekend of Memorial Day.
V35 said on Saturday R2 complained of constipation and the nurse gave her a laxative. (R2's May MAR
showed MiraLAX was administered on [DATE] at 8:34 AM). V35 said R2 was going poop all day on Sunday,
she just kept going. V35 said R2 normally would clean herself up and rarely asked for help. V35 said on
Sunday ([DATE]) R2 had poop everywhere and was actually letting me help her. V35 said that wasn't like
R2, she was normally very independent with peri-care.
On [DATE] at 12:47 PM, V30 (CNA - Certified Nursing Assistant) said she was working the overnight shift
on [DATE]. V30 said R2 wasn't on her assignment, but she heard her screaming and went into her room.
V30 said V29 (CNA) was R2's assigned CNA, but she was busy on another hall. V30 said R2 was
screaming, so she went in to check on her. V30 said there was poop everywhere. V30 said R2 had spilled
the bedpan on the floor and poop was smeared on the mattress, linens, and R2. V30 said R2 was grabbing
at her vaginal area and yelling, It hurts! It burns! It itches! V30 said before she completed a full bed bath,
she notified V28 that R2 wasn't acting right and was complaining of vaginal pain. V30 said V28 went in the
room and gave R2 a Tylenol (R2's [DATE] MAR showed Tylenol was administered at 1:18 AM on [DATE]).
V30 said V28 (LPN) never directed her to take R2's vital signs. V30 said she reported to V29 (R2's assigned
CNA) that R2 wasn't acting like herself, and she would need to round on her. V30 said R2 can normally
change and toilet herself, but not that night.
On [DATE] at 3:06 PM, V29 (CNA) said normally R2 didn't want to be bothered at night. V29 said R2
wanted to do everything herself and usually used the bedpan and cleaned herself up. V29 said she didn't
recall providing any care to R2 on the 11-7 shift on [DATE].
On [DATE] at 2:45 PM, V28 (LPN) said she worked 3-11 and 11-7 on [DATE]. V28 said she was familiar with
R2. V28 said R2 was alert and oriented and able to make her needs known. V28 said R2 was very private
related to peri-care and was normally independent with use of the bedpan and cleaning herself up. V28
said she didn't know anything about R2 having diarrhea, requiring assistance with cleaning up, and
complaining of vaginal pain that night. The surveyor asked V28 why she gave Tylenol at 1:18 AM. V28
replied, Just to help her sleep or something. V28 said if R2 had weakness, required assistance with
bedpan/peri-care, and was complaining of vaginal pain, then that would be a change in condition for her.
V28 said with a change in condition she would complete an assessment, obtain vital signs, notify the
physician, and complete any orders given. V28 said she did not do any of that for R2 because she wasn't
aware there was an issue. V28 said frequent diarrhea causes dehydration and loss of electrolytes.
On [DATE] at 10:58 AM, V19 said she found R2 like that in the morning, after breakfast. V19 said it was
during morning medication pass when she did the assessment and took the vital signs. (Vital signs charted
at 9:35 AM, morning medications due at 9:00 AM). V19 said during that time R2 was talking to her, but
continued to have diarrhea, was complaining of vaginal pain, and kept removing her incontinence brief. The
surveyor asked V19 what time she called the family, physician, and ambulance. V19 said she couldn't recall
the exact times. The surveyor asked V19 if she took another set of vital signs before she called the
physician. V19 stated, I don't remember if I took another BP after 9:35 AM. She was weak when I did her
BP. The surveyor asked V19 to check her documentation in EMR and V19 replied, I don't see any more vital
signs charted. The surveyor asked V19 if there was any
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 3 of 8
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
07/01/2024
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
documentation to show continued assessments between 9:35 AM (when she noted R2's condition change)
and 11:47 AM (when the ambulance was notified, per Ambulance Patient Care Report). V19 said she didn't
see anything specific in R2's progress notes. V19 said they don't complete a SBAR form when notifying the
physician. V19 said the only form completed when she transfers a resident to the hospital is the Transfer
Form. V19 was unable to explain why she used the 9:35 AM vital signs for the Transfer form completed
dated [DATE] at 12:35 PM.
Residents Affected - Few
On [DATE] at 12:01 PM, V25 (Agency CNA) said she was working 7-3 shift on [DATE]. V25 said she didn't
recall the exact time, but she remembered R2 having diarrhea and not being able to clean herself up. V25
said she and the nurse thought something was up, and that she wasn't acting herself. V25 said R2 couldn't
use the bedpan and clean herself up like normal. V25 said R2 declined quick and had to be sent to the
hospital.
On [DATE] at 2:06 PM, V34 (R2's physician) said she didn't recall what time the facility called her about R2
on [DATE]. V34 stated, Most of the residents at the facility are old and frail, so I usually just send them out
911. I remember they called and said she (R2) was a little confused. I usually ask for vital signs and what is
going on. If the vital signs were stable, then I would follow the resident's wishes for transport. [R2's family
member] preferred to send her to a specific hospital. V34 said she would expect the nurses to provide all
pertinent information, regarding a resident's change in condition and a recent set of vital signs. V34 said
this information is pertinent in determining the appropriate mode of transportation (911 vs. non-emergent
transport). V34 said the vital signs were not stable, then she would have sent R2 out 911.
On [DATE] at 2:04 PM, V3 (DON) said if a resident had frequent diarrhea, change in normal
behavior/mentation, and complaints of vaginal pain that would be considered a change in condition. V3 said
when the nurse identifies a change in condition then they should do an assessment, check vital signs, and
discuss any concerns with the physician. The surveyor explained that R2 had frequent diarrhea, change in
behavior, increased weakness, and complaints of vaginal pain on 11-7 shift on [DATE]. V3 said she would
expect the nurse to notify the physician and document R2's vital signs, complaints, and pertinent
assessments. V3 said when the nurse calls the physician, she should provide recent vital signs and
accurate assessment information. V3 said it's important to provide the physician with an accurate picture of
the resident's condition, so they can determine proper mode of transportation.
The facility's Guidelines for Notifying Physicians of Clinical Problems (revised 4/07) showed, These
guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a
timely, efficient and effective manner and 2) all significant changes in resident status are assessed and
documented in the medial record . When contacting the practitioner, especially at night and on weekends
(when physician's not familiar with the residents may be on call), the nurse should have the following
information available: 1. Detailed description of current issue or problem, including vital signs, symptoms,
and results of physical assessment .
The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following
actions to remove the immediacy.
1. The corrective action(s) taken for the resident(s) found to have been affected by the deficient practice:
-V19 and V28 were in-serviced and educated on identification of a change in condition and continued
monitoring. In-service/Education included: to ensure that assessments, monitoring and documentation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 4 of 8
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
07/01/2024
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
is completed on residents with a change in condition, providing MD with accurate information regarding
change of condition and transferring to emergency department in a timely manner.
-Initiated in-service and education to nurses including agency nurses on identification of a change in
condition and continued monitoring, documentation of assessments, and monitoring is completed on
residents with a change in condition, providing MD with accurate information regarding change of condition
and transferring to emergency department in a timely manner. In-service will be completed by [DATE].
2. The corrective action(s) for other resident(s) having the potential to be affected by the same deficient
practice:
-All residents have the potential to be affected. None were identified.
3. The measures put into place and a systemic change made to ensure the deficient practice does not
reoccur:
-The Director of Nursing and MDS Coordinator in-serviced nurses on Identifying a Change of Condition in a
Resident - in particular, to ensure that assessments, monitoring and documentation is completed on
residents with a change of condition. In-servicing was [DATE]. V19 and V28 were already in-serviced and
educated. Anyone who had not been in-serviced will be in-serviced in person or over the phone prior to
their next shift by DON or designee prior to their next shift in this facility. This in-servicing includes nurses
on FMLA & PRN and agency nurses. All new hires will be in-serviced during their orientation on the
Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and
documentation is completed on residents with a change of condition.
4. To ensure the deficient practice does not reoccur, the corrective actions(s) will be monitored by:
-DON or designee will audit all residents with a change of condition daily x 6 weeks to ensure that all
residents with a change of condition were properly assessed, monitored, and documented on, MD was
notified with accurate information and transferred in a timely manner.
-QAPI Committee have met and discussed the measures that were put in place to ensure that deficient
practice does not occur. Medical Director is in agreement of the measures that were put in place and has
approved it.
5. Completion date systemic changes will be completed: [DATE]
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 5 of 8
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
07/01/2024
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to ensure the Quality Assessment and Assurance
committee met quarterly with the required members. This failure has effects all the residents in the facility.
Residents Affected - Many
The findings include:
The Facility Data Sheet dated 6/20/24 showed there were 163 residents residing in the facility.
On 7/1/24 at 10:00 AM, V3 (DON - Director of Nursing) provided a monthly QA (Quality Assurance)
Committee sign-in sheet dated 4/23/24. This form showed the meeting was attended by Restorative, MDS
Coordinator, Infection Control Preventionist, Business Office Manager, Admissions, Laundry/Housekeeping,
Human Resources, ADON, and DON. The Administrator and Medical Director were not in attendance.
(There were no monthly sign-in sheets for May or June 2024). The last QAPI (Quality Assurance and
Performance Improvement) sign-in sheet was 12/23/23. The Administrator, Medical Director, and other
required staff were present for this meeting. (There was no QAPI sign in sheet since 12/23/23 provided).
On 7/1/24 at 2:11 PM, V13 (Social Services Director) said she attends both the monthly QA meetings and
the quarterly QAPI meetings. V13 she was not sure when the last QAPI meeting was, but she would ask V3
(DON). V13 left the conference room and returned stating, The last monthly meeting was in April and the
last quarterly was in December (2023).
On 7/1/24 at 2:24 PM, V3 (DON) said the facility normally does monthly QA meetings and quarterly QAPI
meetings, but they were running behind. V3 said V1 (Administrator) was not in attendance at the April QA
meeting due to a religious holiday. V3 said the last QAPI meeting was held in December 2023. V3 said the
next meeting should have been in March/April 2024 and a second meeting should be June/July 2024. V3
said the facility was behind on those meetings. V3 said during the time the Quarter 4 QAPI would have
been done it was crazy. V3 said the facility just had their annual towards the end of January and everyone
was working on their POC (Plan of Correction). V3 said that's not an excuse, a meeting should have been
held. V3 said the facility discusses quality measures, quality improvement processes, and survey findings
during these meetings.
The facility's undated Quality Assurance Committee Policy showed, It is the policy of this facility to
systematically improve its performance by having an organized Quality Assurance Committee that assures
a quality assessment and improvement program is planned, systematic, ongoing and focused on those
important processes or outcomes related to resident care and organizational functions. The Committee
functions and programs shall be in accordance with the Quality Assessment and Improvement Standards of
the Joint Commission on Accreditation of Healthcare Organizations for Long Term Care and federal state
regulations and in coordination with the overall Quality Assurance Plan of this facility . Responsibility:
Administrator and all Committee Members. Membership: Administrator, Director of Nursing, Medical
Director, Pharmacist, Activity Director, Social Service Director, Food Service Supervisor, Maintenance
Director, and consultants as requested Standards: .2. The Administrator shall serve as the Chairperson. 3.
Committee shall meet monthly to assure activities are performed and identified problems promptly
corrected .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 6 of 8
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
07/01/2024
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observations, interview, and record review the facility failed to ensure the resident hallway was
safe, sanitary and comfortable for 7 residents (R12, R13, R14, R15, R16, R17, R18) reviewed for safe,
sanitary, comfortable environment in the sample of 18.
The findings include:
The facility census report dated 6/19/24 showed R12, R13, R14, R15, R16, R17, and R18 resident in the
rooms affected.
On 6/20/24 at 10:25 AM, near the B-wing nurses' station and the beginning of the 2401-2408 hallway there
were ceiling tiles missing and water steadily dripping. The carpet in a 5 foot radius of this area was
saturated and caused a sloshing sound when the surveyor attempted to walk past the area. There was a
large, gray, round, wheeled trash can under the missing tiles, but water was still dripping onto the carpet
and surrounding area. There were 4 pink, personal care basins at the base of the trash can and two towels,
with a light brown discoloration, spread out on the floor. The missing tiles exposed pluming and the air
ducts. The water appeared to be steadily dripping from the duct work. There was an adjacent tile, containing
a light fixture, that was saturated with water and bowing down. The round light, inside the saturated tile, was
on. A female visitor walked by this area and said, Welcome to the swamp. She said the area had looked like
this since Monday (6/17/24). There were no fans on the area in an attempt to dry the carpet and the water
was continuously dripping onto the floor.
On 6/20/24 at 10:37 AM, V3 (Director of Nursing - DON) said the water on B-wing had something to do with
an RTU (Air Conditioning Unit) that needed to be replaced. V3 said she would send Maintenance down to
explain the situation. V3 said the residents on that hall still have water, electricity, and air conditioning, but
they would have to pass through that area to go anywhere else in the facility. The surveyor requested to
speak with the Maintenance Director.
On 6/20/24 at 10:59 AM, V7 (Maintenance Assistant) said the B-wing air conditioning needs to be replaced.
V7 said there were complaints of warmer temperatures on Friday (6/14/24) and a local contractor was
called. V7 said they couldn't fix the unit that day but told us to run a slow trickle of water on the condenser
until the unit could be fixed or replaced. V7 said they found out there was a hole in the base of the air
conditioning unit on Monday (6/17/24) or Tuesday (6/18/24) when water started leaking through the ceiling.
V7 said that is what you are seeing, the water dripping in from the temporary fix. V7 said he wasn't sure
when the air conditioning would be fixed or replaced. V7 said V6 (Maintenance Director) was working on a
proposal to get the unit replaced. V7 said the facility had to replace two other air conditioning units in the
last two years. V7 said there are still residents residing on that hallway. V7 said the only way the residents
were affected was by the inconvenience of the water dripping onto the floor. The surveyor asked V7 if he
was aware that there was an adjacent ceiling tile, containing a light fixture, that was saturated in water. The
surveyor asked if water dripping onto an electrical source was a safety concern. V7 replied, No it's an LED
light.
On 6/20/24 at 12:57 PM, V5 (Maintenance Director) said there was an issue with the B-wing air
conditioning unit. V5 said the contractor instructed them to sprinkle water on the condenser to keep it
working, but then on Tuesday or Wednesday they noticed the leak in the ceiling tiles. V5 said the contractor
would be out tomorrow to repair the unit. The surveyor asked V5 if there was an issue with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 7 of 8
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
07/01/2024
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
water dripping onto a light fixture. V5 replied, Of course, we all know water and electricity don't mix. You
should never have water dripping over the light like that. I just had my guy (V7) fix that issue. He used a tarp
to create a drip edge. V5 said that was done for the residents' safety and the water will be contained better
now.
On 6/20/24 at 1:30 PM, on the B-wing, the adjacent tile and light fixture had been removed. There was a
black tarp, near missing tiles that was protruding slightly downward. There was a drainage spout at the
lowest portion and the water was dripping in a controlled fashion, into the gray, wheeled trash can.
On 6/20/24 at 1:32 PM, V8 (Agency LPN - Licensed Practical Nurse) said she didn't work yesterday and
wasn't sure when the leaking started. V8 said Maintenance was just over here working on it.
On 6/20/24 at 1:34 PM, V18 (CNA-Certified Nursing Assistant) said the floor was so soaked that her feet
were getting wet. V18 stated, That floor is going to stink once it dries. It's not safe for the residents to walk
through all that water. V18 said Maintenance was just over here putting that tarp up and it seems like that
might work better. The water was just everywhere before.
The facility provided a service ticket from the air conditioning contractor dated 6/14/24. This ticket showed
that there were issues with the air conditioning unit, parts were ordered, but some were delayed. The ticket
showed the unit was operational.
The surveyor requested a policy for Building Maintenance and Repair, but none was provided by the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145420
If continuation sheet
Page 8 of 8
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the July 1, 2024 survey of BRIDGEWAY SENIOR LIVING?
This was a inspection survey of BRIDGEWAY SENIOR LIVING on July 1, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIDGEWAY SENIOR LIVING on July 1, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.