Health inspection·September 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and perform an assessment on a resident who exhibited a change in condition.This applies to 1of 3 residents (R5) reviewed for assessment in the sample of 7.The findings include:R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, diastolic congestive heart failure, gout, chronic kidney disease stage 3, and morbid obesity. R5's MDS (Minimum Data Set) dated July 29, 2025, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating and oral hygiene, supervision with personal hygiene, partial assistance with bed mobility, transfer and upper body dressing, substantial assistance with lower body dressing, toileting, and bathing and dependent on staff assistance with footwear.On September 11, 2025, at 3:40 PM, V16 (RN) stated she was R5's nurse on September 7, 2025, during the 7:00AM to 3:30 PM (day shift), V16 stated she received change of shift report from V15 (LPN) who stated R5 had a change in condition during the night shift. V16 stated R5 was receiving oxygen at 2 L(Liters) per NC (Nasal Cannula) when she first saw R5 during the day shift. V16 stated R5's daughter (V18) had visited earlier and requested V16 call the physician because R5 was lethargic. V16 stated she did not complete an assessment when she noted R5 had a change in condition around 12:50 PM. V16 stated she did not seek assistance from other nurses, and did not call an internal code blue, in response to R5 becoming lethargic and barely able to respond. V16 stated she called 911 and prepared the paperwork. R5's progress notes, by V16 on September 7, 2025, at 1:41 PM showed R5 was sent to the hospital, after 911 emergency services were called. There are no vital signs or further assessment of R5's condition documented in the progress note.R5's vital sign documentation showed the last documentation of vital signs were taken at 11:30 AM, on September 7, 2025.V16's progress note dated September 7, 2025, at 1:41 PM showed R5 became more lethargic and had a barely audible voice at 12:50 PM. There were no vital signs or further assessment documented at that time.On September 11, 2025, at 3:12 PM, V15 (LPN) stated R5 had been placed on oxygen during the night shift on September 6, 2025, when R5's oxygen saturation was 87%. V15 stated she was unable to contact the physician and placed R5 on Oxygen at 2L/NC and did not notify the Medical Director or Director of Nursing when unable to contact the physician. V15 did not document R5's progress note regarding the use of oxygen until September 10, 2025.R5's EMS (Emergency Medical Services) dated September 7, 2025, showed R5 was found by EMS lying supine and was receiving oxygen administered at 1.5 L via NC. The EMS report showed R5 was lethargic, cold, dry, and pale. The report showed facility staff reported R5 had been becoming more lethargic over the last 48 hours and that R5 was placed on oxygen due to oxygen saturation was 70% during the previous night. The record showed the first blood pressure obtained by paramedics was 90/52, pulse rate was 40, and a body temperature was unable to be obtained. The record showed R5 had rhonchi in both right and left lung during the EMS initial assessment.R5's hospital record in the emergency room dated September 7, 2025, showed R5's vital signs were blood pressure 98/65, pulse 56, respiration rate 28, and body temperature 87.1 F. R5 was admitted to the ICU (Intensive Care Unit) with a diagnosis of hypothermia, septic shock, thrombocytopenia, and hypernatremia.On September 11, 2025, at 11:26 AM, V2 (Director of Nursing) stated nurses should document their assessments when a resident has a change of condition in the nurses' progress note.The facility's policy titled Acute Condition Changes-Clinical Protocol dated August 2008, showed Assessment and Recognition . 1.individuals with significant risk for having acute changes of condition during their stay, the nurse shall assess and document /report the following a. vital signs b. neurological assessment, c. change in level of consciousness.f. onset, duration, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145420 If continuation sheet Page 2 of 3 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 09/14/2025 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 - Minimal harm or potential for actual harm and severity.4. Before contacting a physician about someone with an acute change in condition, the nursing staff will make pertinent observations and collect appropriate information to report to the Physician.Monitoring and Follow up.1.the staff will monitor and document the resident's progress and response to treatment.2.the nurse will monitor a resident with a recent change in condition until the problem or condition has resolved or stabilized. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145420 If continuation sheet Page 3 of 3