Health inspection·January 28, 2025

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** . Residents Affected - Few Based on observation, interview, and record review the facility failed to provide the necessary services to maintain good personal hygiene for 1 of 3 residents (R9) reviewed for activities of daily living in a sample of 3. Findings include: On 1/21/25 at 11:10 AM, observed R9 lying in a bariatric bed. R9 was alert, oriented x 3. R9 had disheveled hair, nails were overgrown in both hands and both feet and the nails had brownish debris underneath them. R9 stated, one day last week, no one provided her perineal care and she was left wet the whole shift. R9 could not remember the date. R9 stated, at the moment, her brief, bedsheet and her blanket were wet. R9 lifted her gown. Observed that R9 had a wet disposable brief. R9 stated, she had been wet for almost an hour. R9 stated, either she had to wait until someone comes in to check on her or she has to holler because her call light was not working. R9 stated, probably the CNAs (Certified Nursing Assistants) were on lunch break. R9's face-sheet showed she was admitted on [DATE] with diagnoses to include congestive heart failure, Parkinson's disease, bipolar disorder and anxiety. MDS (Minimum Data Set) dated 11/26/24 showed she was cognitively intact. R9 required moderate assistance with upper body functions and was totally dependent for lower body functions. Care-plan dated 11/26/24 addressed resident needs appropriately. On 1/21/25 at 10:00 AM, V11 (CNA) stated, she checks on her incontinent residents every 1-1.5 hours. On 1/21/25 at 11:35 AM, observed three CNAs (V10, V11 and V12) were sitting in the unit Dining Hall, chit-chatting. They stated, they were waiting for resident's lunch to arrive. On 1/21/25 at 12:15 PM, V12 (CNA) stated, she checks on her residents and changes them every couple hours. On 1/21/25 at 1:00 PM, observed that R9 still had a wet disposable brief. R9 stated, no-one had come to change her yet. On 1/21/25 at 2:15 PM, V10 (CNA) stated, she checks on her assigned residents every 1-2 hours and provides perineal care. Page 1 of 3 145420 145420 01/28/2025 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/22/25 at 3:00 PM, V3 (DON-Director of Nursing) stated, nursing staff are expected to check on their residents every 1-2 hours. V3 stated, the CNAs know who in their assignment are wet more frequently and heavily. They should make rounds on such residents more frequently and ensure they are kept clean and dry at all times. Policy for ADL Care revised in August 2008, does not indicate the frequency or when residents must be checked and provided perineal care. 145420 Page 2 of 3 145420 01/28/2025 Bridgeway Senior Living 111 East Washington Bensenville, IL 60106

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's call light was in working condition and the resident receives services within a reasonable timeframe. This applies to 1 of 3 residents (R9) reviewed for call lights in the sample of 9. Residents Affected - Few Findings include: On 1/21/25 at 11:10 AM, observed R9 lying in a bariatric bed. R9 was alert, oriented x 3. R9 stated, her brief, bedsheet and blanket were wet. R9 lifted her gown. Observed that R9 had a wet disposable brief. R9 stated, she had been wet for almost an hour. R9 stated, her call light was broken since the previous day. No one had fixed it. R9 stated, either she had to wait until someone comes in to check on her or she had to holler. Observed R9 press the call light and it didn't work. Observed that R9 did not have any other alternative method to call the nursing staff. On 1/22/25 at 9:00 AM, V16 (CNA) and V17 (CNA) were transferring R9 to her wheelchair. Asked them if R9's call light was working, and they stated it was working. V16 (CNA) pressed the call light and the light outside the door nor the light near the nurse's station flickered. Observed that call light was not working. R9's face-sheet showed she was admitted on [DATE] with diagnoses to include congestive heart failure, Parkinson's disease, bipolar disorder and anxiety. MDS (Minimum Data Set) dated 11/26/24 showed she was cognitively intact. R9 required moderate assistance with upper body functions and was totally dependent for lower body functions. Care-plan dated 11/26/24 addressed resident needs appropriately. On 1/22/25 at 3:00 PM, V3 (DON-Director of Nursing) stated, a call light must be answered as soon as it is noticed. V3 stated, whoever sees the call light must answer it. V3 stated, CNAs and maintenance personnel are expected to check resident's call lights every day. On 1/28/25, at 5:00 PM, V2 (Asst. Administrator) and V3 (DON) stated that on 1/21/25, V9 (LPN) was aware that R9's call light was not functional and that she placed a work-order for it to be repaired on 1/22/25. V2 stated, in the interim period, nothing was provided to R9 as an alternative method to call for help. Facility policy dated 1/1/2025 showed, ensure the call light is always plugged in and report all defective call lights to the maintenance department promptly. 145420 Page 3 of 3