Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgeway Senior Living during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with multiple diagnoses, including dementia and aphasia, was care planned as totally dependent for bed mobility and requiring a two-person assist for turning and incontinence care. An RN provided peri care alone while the resident was positioned on her side in bed, and when the RN reached for a towel, the bed alarm sounded and the resident rolled out of bed onto the floor. The resident sustained a scalp laceration that required suturing in the emergency room. Staff interviews and records confirmed that the resident could not assist with bed mobility and was always to receive care with two staff present.
A resident admitted with multiple serious conditions, including infective endocarditis, had orders for IV antibiotics to be administered via a PICC line but no corresponding orders for PICC care, such as flushing or dressing changes. Staff, including an RN and the DON, stated that PICC care is usually done routinely and included in batch admission orders, but acknowledged that these orders were not entered for this resident, resulting in IV therapy being provided without documented PICC line maintenance orders.
A resident with multiple serious diagnoses, including infective endocarditis, was ordered IV Vancomycin every 12 hours for infection, but several scheduled doses were not administered and the physician was not notified of these missed doses. An LPN could not clearly explain why the antibiotic was not given on multiple occasions, despite pharmacy records showing more doses delivered than documented as administered on the MAR. A Vancomycin trough was reported as critically low, and a subsequent dose was given before pharmacy recommendations based on that lab were received, with no documented physician notification regarding the missed doses.
A resident with multiple medical and cognitive conditions was found living in a room with raised, uneven floor tiles, a window with rotting wood and a non-functioning crank that allowed cold air to enter, and a malfunctioning refrigerator unable to maintain safe temperatures. These environmental deficiencies were known to maintenance staff for months but were not adequately addressed, and facility leadership was unaware of the ongoing issues, despite policy requirements for preventive maintenance and communication.
A resident with multiple chronic conditions experienced a significant change in condition, including shortness of breath and low oxygen saturation, after being transferred to bed. The LPN assessed the resident and provided oxygen but did not notify the resident's family representative as required by facility policy, and there was no documentation of such notification or escalation to the DON or Medical Director.
A resident with multiple chronic conditions became lethargic and required oxygen, but nursing staff did not perform or document a thorough assessment, including vital signs and neurological status, as required by facility policy. The nurse did not seek additional help or notify the physician in a timely manner, and documentation of the resident's condition and interventions was incomplete prior to the resident's emergency transfer and subsequent hospital admission for serious medical issues.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident with cognitive intactness and multiple diagnoses, including congestive heart failure and Parkinson's disease, was found with disheveled hair, overgrown nails, and a wet brief. Despite a care plan addressing her needs, the resident reported being left wet for extended periods, with CNAs observed not attending to her needs. The facility's policy lacked specific guidelines on the frequency of perineal care checks.
A resident with multiple health conditions was left without a working call light for over a day, resulting in delayed assistance while she was wet and unable to call for help. Despite being aware of the issue, the facility did not provide an alternative method for the resident to contact staff, and the call light was not repaired promptly.
The facility failed to follow standardized recipes, resulting in substandard meal quality for residents. Observations revealed that meals did not adhere to prescribed recipes, with residents reporting issues such as overly salty food and unpleasant tastes. The kitchen staff deviated from recipes for items like pizza and strawberry shortcake, leading to meals lacking nutritional value and quality. The dietary manager confirmed the importance of following recipes to ensure proper nutrition and taste.
The facility's kitchen was found to have several deficiencies related to food safety and storage. The walk-in cooler was operating above the safe temperature, and food items were improperly stored, including staff lunches without labels. Staff members were not wearing required hair and beard restraints, and the kitchen lacked a garbage can near the handwashing sink. In dry storage, several food items were expired or improperly labeled. These issues indicate non-compliance with the facility's food safety policies.
The facility failed to maintain the kitchen walk-in cooler at a safe temperature, with readings of 58 and 55 degrees Fahrenheit observed, exceeding the safe range of 41 degrees Fahrenheit or below. Despite this, perishable food items were stored in the cooler, contrary to facility policy, which requires transferring food to another unit if temperatures exceed safe levels. This affected all residents receiving oral nutrition from the facility kitchen.
The facility failed to provide written notification to residents and their families or POA regarding hospital transfers and did not notify the ombudsman. This affected five residents transferred for conditions like acute cystitis, wound infection, sepsis, and respiratory distress. The ADON stated that written documentation was only given to alert residents and the ombudsman was notified only upon discharge, not during hospitalizations.
The facility failed to provide written notification of bed hold policies to residents and/or their POA at the time of hospital discharge. Five residents were transferred for various medical conditions without receiving the required documentation. The ADON admitted that the facility only verbally notified families and lacked a formal bed hold policy.
The facility failed to provide adequate ADL care for five residents dependent on staff for personal hygiene. Observations showed residents with unshaved facial hair, long nails with brown substances, and oily hair. Residents expressed dissatisfaction, indicating staff did not provide necessary assistance. The residents had various medical conditions requiring staff help, but the facility did not meet these needs, as evidenced by their unkempt appearances and reports of inadequate care.
The facility failed to secure medications during administration and did not obtain physician orders for over-the-counter medications, leading to unauthorized storage in residents' rooms. An RN left medications unattended, and several residents had medications without proper orders or assessments. The DON acknowledged the need for assessments and orders for self-administration or bedside storage, which were not followed.
The facility failed to maintain proper temperature logs and storage of food in residents' personal refrigerators, affecting five residents. Observations showed missing temperature logs and thermometers, with some refrigerators containing potentially spoiled food. The DON was unsure of staff responsibilities for temperature checks, later identifying housekeeping as responsible, but they were not consistently performing the task. Facility policies require food to be labeled, dated, and discarded per guidelines, with daily temperature checks recorded.
The facility failed to implement proper infection control practices, affecting all residents. Staff did not use Enhanced Barrier Precautions (EBP) as required, with missing signage and PPE for residents with wounds and catheters. Improper disposal of PPE and inadequate hand hygiene were observed. The facility also lacked updated infection control policies and had missing records for water testing to prevent legionella.
A resident with severe cognitive impairment was fed by a nurse in a demeaning manner, with the nurse standing over her and instructing her to eat in a demeaning tone. The Director of Nursing acknowledged that staff should sit at the same level as residents during feeding to maintain dignity, as per the facility's Resident Rights Statement.
A resident in a LTC facility was unable to reach her call light while sitting in a recliner, as it was attached to her bed across the room. The resident, who has moderately impaired cognition and is dependent on staff for hygiene, expressed frustration about the inaccessibility. The MDS Coordinator and DON confirmed that call lights should be within reach, aligning with the facility's policy to ensure communication means are accessible to residents.
A facility failed to invite a resident to care plan meetings, resulting in the resident being unaware of discharge goals. The Social Services Director confirmed the lack of documentation showing invitations to the resident or family, despite the facility's policy requiring their involvement in the care planning process.
The facility failed to properly monitor blood glucose levels and administer insulin according to physician orders for two residents. An RN administered insulin without aligning with meal times, and an LPN checked a resident's blood glucose while they were eating, contrary to orders. The DON acknowledged the need for pre-meal checks, but some nurses administered insulin with meal trays to avoid hypoglycemia.
A facility failed to implement a physician's order for a resident with dysphagia, leading to the use of a straw despite orders against it. The resident's care plan and physician's orders specified no straws and aspiration precautions, which were not followed by CNAs and an SLP. The facility lacked a policy for implementing physician's orders, as acknowledged by the ADON.
A resident with a history of hemiplegia and hemiparesis following a cerebral infarction did not receive restorative services as recommended. Despite being on programs for bed mobility, dressing, and active range of motion, there was no documentation of these services being provided over the past 30+ days. The resident expressed that he no longer receives therapy and is unable to get out of bed on his own, highlighting a lapse in the facility's adherence to its restorative nursing policy.
The facility failed to properly position catheter drainage bags for three residents during wound and incontinence care, leading to potential urine backflow. One resident's bag was placed above the bladder line, causing backflow, while another's was mishandled during care. A third resident was not switched to a larger collection bag when in bed, risking backflow. Staff acknowledged the improper handling, which could lead to UTIs.
The facility did not post current daily staffing information, affecting all 159 residents. The Daily Staff Posting was outdated, showing a previous date and census. The DON explained that the receptionist updates and posts staffing information after receiving the census email between 9:30 AM and 10:00 AM. However, the receptionist's schedule may cause delays. The facility's policy requires posting staffing data at the start of each shift, as per regulations.
A resident with a complex medical history experienced a slow deterioration due to the facility's failure to identify a change in condition, provide frequent monitoring, and communicate effectively with the physician. The resident was transferred to the hospital in critical condition and later died from septic shock. The facility did not take vital signs after the initial assessment and delayed notifying the physician, leading to a delay in hospital transfer.
The facility failed to conduct the required quarterly Quality Assessment and Assurance (QAA) meetings with the necessary members, impacting all residents. The last QAPI meeting was in December 2023, and subsequent meetings were missed. The April 2024 QA meeting lacked attendance from the Administrator and Medical Director, contrary to the facility's policy requiring their presence.
The facility failed to maintain a safe and sanitary environment in the B-wing hallway, affecting several residents. Observations showed missing ceiling tiles with water dripping from exposed plumbing, saturating the carpet. A malfunctioning air conditioning unit was identified as the cause, with temporary fixes leading to leaks. The Maintenance Director acknowledged the safety concern of water dripping onto an electrical source, but no immediate resolution was provided. The issue persisted for several days, impacting residents and staff.
Failure to Use Required Two-Person Assist During Peri Care Resulting in Resident Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a dependent resident during incontinence care, resulting in a fall from bed and injury. The resident had diagnoses including conversion disorder with seizures, dementia, aphasia, and dysphagia, and an assessment documented severe cognitive impairment with total dependence on staff for all care, including bed mobility. The care plan for activities of daily living identified the resident as totally dependent for bed mobility, requiring two staff to roll left and right. Despite this, on the afternoon in question, a single RN provided incontinence care while the resident was lying in bed on her right side. The RN reported that the resident’s daughter had requested the resident be cleaned, the daughter then left the room, and the RN proceeded to provide care alone. During the provision of perineal care, the RN had the resident positioned on her right side and reached to the left for a towel while stating she kept a hand on the resident. At that moment, the bed alarm sounded and the resident rolled out of the bed onto the floor. The fall report and staff interviews indicate the resident was totally dependent for movement in bed and was always to be assisted by two staff for care. Following the fall, the RN observed bleeding from a small cut on the back of the resident’s head, immediately assessed the resident, contacted the physician, and the resident was transferred to the emergency room, where a 1-centimeter scalp laceration requiring two staples was documented. The DON’s investigation concluded that the resident rolled off the bed during incontinence care while only one staff member was present, despite the resident’s documented need for two-person assistance for care and bed mobility.
Failure to Obtain PICC Line Care Orders for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to obtain and document provider orders for the care and management of a resident’s PICC (peripherally inserted central catheter) line despite ongoing IV antibiotic therapy. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder, and had admission orders for two IV antibiotics to be administered via the PICC line two to three times daily. However, the admission orders did not include any directives for PICC line care, such as flushing, dressing changes, or other maintenance. Nursing staff, including an RN and the DON, reported that routine PICC line care (flushes, weekly dressing changes, checking for a cap, measuring the line and arm circumference) is normally performed and is supposed to be included in batch orders entered at admission, but acknowledged that these orders were not entered for this resident. This omission resulted in the resident receiving IV medications through a PICC line without corresponding written orders for line care and maintenance, as confirmed by interview and record review.
Missed Vancomycin Doses and Lack of Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV Vancomycin doses were not administered as prescribed and the physician was not notified of the missed doses. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder. The February 2026 MAR shows that Vancomycin 1750 mg/350 ml every 12 hours for infection was not given on multiple scheduled administrations: 2/26 at 9:00 PM, 2/27 at 9:00 PM, 2/28 at 9:00 AM, and 2/28 at 9:00 PM. An LPN stated she did not know why the Vancomycin was not given on those days, speculating that on the admission date it was probably not available, that on one date the resident went to the hospital after calling 911, and that on another date the medication might have been on hold pending blood test results, but she did not provide a clear reason for each missed dose. Laboratory data show that a Vancomycin trough drawn on 2/28/26 was reported as an alert low value of 3.6 (normal 10–20), with the result communicated to facility staff on the same day at 2:52 PM. The facility’s process, as confirmed by staff, was to notify the pharmacy after receiving such results. The next progress note entry, dated 3/1/26 at 3:19 PM, documents a call from the pharmacy with instructions to continue the same Vancomycin dose and obtain additional labs, and staff confirmed that a Vancomycin dose was administered on 3/1/26 at approximately 9:30 AM before the pharmacy’s recommendations based on the 2/28/26 lab were received. Pharmacy packing slips show that a total of 8 Vancomycin doses were delivered between 2/26 and 3/3, while the MARs for February and March 2026 document administration of only 5 doses. Progress notes from 2/27 through 3/1 do not contain any documentation that the physician was notified of the missed Vancomycin doses.
Failure to Maintain Safe and Comfortable Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident with multiple diagnoses, including Parkinson's disease, bipolar disorder, paranoid schizophrenia, unspecified dementia, hypertension, and chronic diastolic heart failure. The resident was noted to have impaired cognition, impaired mobility, poor safety awareness, and an increased risk of falls. During observation, two floor tiles in the resident's room were found to be raised and uneven, creating an unstable surface that contributed to the instability of furniture, including a television stand. The Maintenance Director acknowledged awareness of the uneven tiles and stated they should have been repaired earlier. Additionally, the window in the resident's room had rotting wood, peeling paint, and a non-functioning crank, resulting in a gap that allowed cold air to enter the room. The window had been in this condition for several months, and work orders submitted to address the issue were either marked as completed without full resolution or left incomplete. The room temperature was measured at 67°F, and the in-room refrigerator provided by the facility was found to be malfunctioning, with an internal temperature of 48°F, water accumulation in the freezer, and moisture along the interior edges. Staff confirmed the refrigerator was unable to maintain appropriate temperature. The Assistant Administrator was unaware of the issues with the floor, window, or refrigerator, and acknowledged these conditions posed a safety concern. The facility's Safety Policy requires preventive inspections, maintenance, and a system for communicating and addressing repair needs, but these procedures were not effectively implemented in this case.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding prompt notification of a resident's representative after a significant change in the resident's condition. A resident with multiple diagnoses, including type 2 diabetes, congestive heart failure, gout, chronic kidney disease, and morbid obesity, experienced shortness of breath and a drop in oxygen saturation to 87% after being transferred to bed with the assistance of four staff members. The LPN on duty assessed the resident and applied oxygen via nasal cannula but did not notify the resident's family representative of this change in condition, as required by facility policy. Documentation in the resident's electronic medical record and progress notes did not indicate that the family representative was informed, nor was there evidence that the physician or the Medical Director or DON were contacted when the physician did not respond. The DON later confirmed that the family representative had not been notified and that the LPN stated it had not occurred to her to do so. The facility's policy specifically requires prompt notification and documentation of such events, which was not followed in this instance.
Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to follow its policy and perform a timely assessment on a resident who exhibited a change in condition. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, chronic kidney disease, and morbid obesity, was noted to be lethargic and required oxygen after a drop in oxygen saturation. Nursing staff did not complete or document a thorough assessment, including vital signs and neurological status, when the resident's condition changed. The nurse on duty did not seek assistance from other nurses, did not call an internal code, and only called 911 after the resident became barely responsive. Documentation of vital signs and the use of oxygen was incomplete, with the last recorded vital signs taken hours before the emergency transfer and delayed progress notes regarding oxygen administration. The facility's policy required staff to assess and document vital signs, neurological status, and changes in level of consciousness when a resident experiences an acute change in condition. Staff were also expected to notify the physician and monitor the resident's progress. In this case, the nurse did not collect or report the necessary information to the physician, and there was a lack of monitoring and documentation as required by facility policy. The resident was ultimately transferred to the hospital, where they were diagnosed with hypothermia, septic shock, thrombocytopenia, and hypernatremia.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident, identified as R9, who was reviewed for activities of daily living. On multiple occasions, R9 was observed with disheveled hair, overgrown nails with brownish debris, and a wet disposable brief. R9 reported that she had been left wet for almost an hour and had experienced a previous incident where no perineal care was provided, leaving her wet for an entire shift. R9 also mentioned that her call light was not functioning, requiring her to wait for staff to check on her or to call out for assistance. Despite the care plan addressing R9's needs appropriately, the CNAs were observed sitting in the dining hall and not attending to R9's needs. The CNAs stated they check on residents every 1-2 hours, but R9 remained in a wet brief for an extended period. The Director of Nursing confirmed that staff are expected to check on residents every 1-2 hours, especially those who are frequently wet. The facility's policy for ADL care, revised in 2008, does not specify the frequency for checking and providing perineal care, contributing to the deficiency in care provided to R9.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to ensure that a resident's call light was in working condition, resulting in the resident not receiving timely assistance. On January 21, 2025, a resident was observed lying in a bariatric bed with a wet disposable brief, bedsheet, and blanket. The resident, who was alert and oriented, reported that her call light had been broken since the previous day, and she had been wet for almost an hour without assistance. The resident had no alternative method to call for help, and the call light was confirmed to be non-functional by two CNAs the following day. The resident, who was admitted with diagnoses including congestive heart failure, Parkinson's disease, bipolar disorder, and anxiety, required moderate assistance with upper body functions and was totally dependent for lower body functions. Despite the facility's policy requiring daily checks of call lights by CNAs and maintenance personnel, the issue was not addressed promptly. The Director of Nursing stated that call lights must be answered as soon as they are noticed, but the resident's call light was not repaired until a work order was placed on January 22, 2025, leaving the resident without an alternative method to call for help in the interim.
Failure to Follow Standardized Recipes in Meal Preparation
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature, as evidenced by the failure to follow standardized recipes. Observations and interviews revealed that residents receiving regular diets, both regular and pureed textures, were served meals that did not adhere to the prescribed recipes. For instance, a resident reported that the food was consistently salty, leading her to rely on canned soup brought by her family. Another resident described the food as horrible and opted for simple sandwiches instead of the menu items. A third resident found a long black hair on her lunch tray and described the food as having an unpleasant taste, refusing to eat it. Further investigation showed that the kitchen staff did not follow the recipes for several menu items, including pizza, pureed pizza, strawberry shortcake, and side salad with dressing. The cook used red peppers instead of the specified green peppers and did not measure the vegetables as required. The strawberry shortcake was served with pound cake and half a strawberry instead of the specified biscuit and full portion of strawberries. The side salad lacked the required tomatoes and shredded cheese, consisting only of bagged lettuce. The dietary manager confirmed that recipes are designed to ensure nutritional value and quality, emphasizing the importance of following them. The facility's policy mandates the use of standardized recipes for all menu items, but this was not adhered to, resulting in substandard meal quality for the residents.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and storage protocols, as observed during a survey of the kitchen. The walk-in cooler was found to have a temperature of 58 degrees Fahrenheit, which is above the safe storage temperature of 41 degrees Fahrenheit. Despite being informed of the elevated temperature, food items such as bread and various vegetables were still stored in the cooler. Additionally, staff lunches were improperly stored in the walk-in cooler without labels or dates, contrary to facility policy. During the kitchen tour, it was noted that staff members, including the Dietary Manager and a Dietary Aide, were not wearing required hair and beard restraints while working in food preparation areas. This lack of compliance with the facility's policy on hair restraints poses a risk of cross-contamination. Furthermore, the kitchen lacked a garbage can near the handwashing sink, which is necessary for proper hygiene practices. In the dry storage area, several food items were found to be improperly stored or expired. An opened carton of Au Gratin potatoes was not sealed, and five boxes of muffin mix and two cartons of rainbow sprinkles were past their expiration dates. An opened bag of cake mix was also found without a label or date. These findings indicate a failure to follow the facility's policies on labeling, dating, and discarding expired food items, which are essential for maintaining food safety and preventing foodborne illnesses among residents.
Failure to Maintain Safe Temperature in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to maintain the kitchen walk-in cooler in a safe operating condition, affecting all residents receiving oral nutrition and foods prepared in the facility kitchen. During a kitchen tour, the walk-in cooler was observed to have a temperature of 58 degrees Fahrenheit, which is above the safe temperature range for food storage. The Dietary Manager confirmed that the cooler's temperature should be below 41 degrees Fahrenheit to prevent the growth of pathogens and bacteria. Despite this, food items such as bread, tomatoes, potatoes, onions, cabbage, and spinach were found stored in the cooler, with packaging indicating they should be kept between 33-38 degrees Fahrenheit. The facility's policy on refrigerator and freezer temperatures requires that all cold storage units maintain a temperature of 41 degrees Fahrenheit or below. If temperatures exceed this range, the policy mandates that food be transferred to another unit and the affected unit be locked out. However, the walk-in cooler continued to operate at unsafe temperatures, as confirmed by the Maintenance Director's infrared thermometer reading of 55 degrees Fahrenheit. This failure to adhere to established guidelines and procedures for food storage compromised the safety and quality of food provided to residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their families or Power of Attorney (POA) regarding the reasons for hospital transfers, as well as failing to notify the ombudsman of these transfers. This deficiency was identified in five residents who were transferred to the hospital for various medical conditions, including acute cystitis, wound infection, sepsis, acute on chronic abdominal pain, and acute chronic respiratory distress. The facility's Assistant Director of Nursing (ADON) admitted that written documentation of the bed hold policy was only provided to alert residents and that the ombudsman was only notified upon discharge from the facility, not during hospitalizations. The report highlights specific instances where residents were transferred to the hospital without proper written notification to their families or the ombudsman. For example, one resident was sent to the hospital due to elevated blood pressure and jerking movements, another for a wound infection requiring possible debridement, and another for respiratory distress. In each case, the facility failed to provide the necessary written documentation to the resident's family or representative, and the ombudsman was not informed of the hospital transfers, which is a requirement for compliance.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of bed hold policies to residents and/or their Power of Attorney (POA) at the time of discharge to the hospital. This deficiency was observed in five residents who were transferred to the hospital for various medical conditions, including acute cystitis, wound infection, sepsis, acute on chronic abdominal pain, and acute chronic respiratory distress. In each case, there was no documentation in the medical records indicating that the residents or their representatives were informed in writing about the bed hold policy, which is a requirement. The Assistant Director of Nursing (ADON) acknowledged that the facility only verbally notified residents' families of hospital transfers and did not provide written documentation of the bed hold policy. The facility's existing policy stated that a bed hold agreement should be provided to residents or their representatives at the time of transfer, but this was not adhered to. The facility also lacked a formal bed hold policy, further contributing to the deficiency.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate ADL care for five residents who are dependent on staff for personal hygiene. Observations revealed that residents had unshaved facial hair, long and jagged nails with brown substances underneath, and oily hair. These residents expressed dissatisfaction with their personal hygiene care, indicating that staff did not provide necessary assistance. For instance, one resident with multiple sclerosis and quadriplegia was observed with facial hair and stated that she was unaware of it because staff never offered her a mirror or assistance with shaving. Another resident with severe cognitive impairment and mobility issues reported that staff only shaved her once a month, which caused her discomfort. The residents involved had various medical conditions, including multiple sclerosis, osteoarthritis, parkinsonism, type 2 diabetes, Alzheimer's, dementia, chronic obstructive pulmonary disease, and hemiplegia. Their care plans indicated a need for staff assistance with personal hygiene due to their physical and cognitive limitations. Despite these documented needs, the facility did not provide the necessary care, as evidenced by the residents' unkempt appearances and their reports of inadequate assistance. The Director of Nursing acknowledged that personal nail care and hair washing should be provided as needed, but the facility was unable to provide an ADL policy, highlighting a gap in ensuring residents' rights to a dignified existence and quality of life.
Medication Security and Physician Order Deficiencies
Penalty
Summary
The facility failed to secure medications properly during administration and did not obtain physician orders for over-the-counter medications, leading to medications being stored in residents' rooms without authorization. In one instance, an agency RN left a medication cup with nine unlabeled pills on a resident's dresser while retrieving equipment, leaving the medication unsecured. The resident, who had multiple diagnoses including chronic kidney disease and schizoaffective disorder, had moderately impaired cognition, increasing the risk of medication mishandling. Another resident was found with a bottle of eye drops and a cup containing unlabeled pills, which the resident identified as ibuprofen for foot pain. The resident's medical record did not include a physician order for ibuprofen or permission to store medications in the room. Similarly, other residents were found with various medications, such as inhalers and eye drops, on their bedside tables without proper orders or assessments to self-administer or store medications at the bedside. Additionally, a medication cart was left unattended in a hallway with a cup of unlabeled pills, posing a risk of accidental ingestion by other residents. The Director of Nursing acknowledged that residents need an assessment and physician order to self-administer or store medications at the bedside, and that medications should not be left unattended. The facility's policy on medication storage was not followed, as evidenced by the lack of orders and assessments for residents to self-medicate or store medications in their rooms.
Failure to Maintain Proper Food Storage and Temperature Logs
Penalty
Summary
The facility failed to maintain proper temperature logs, storage, and labeling of food items in residents' personal refrigerators, affecting five residents. Observations revealed that several personal refrigerators lacked temperature logs and thermometers, with some containing potentially spoiled food items. For instance, one refrigerator contained liquid ice cream and sherbet, while another had an uncovered and unlabeled bowl of salad. Additionally, one refrigerator showed a temperature of 42°F, which is above the recommended range. The Director of Nursing (DON) acknowledged that temperatures should be checked and recorded daily, but was unsure which staff was responsible for this task. It was later discovered that housekeeping staff were supposed to manage the residents' personal refrigerators, but they were either not performing the task or doing so inconsistently. The facility's policy requires food to be labeled, dated, and discarded according to safe storage guidelines, and the temperature of refrigerators and freezers outside the kitchen to be checked daily and recorded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, affecting all 159 residents. Several instances were observed where Enhanced Barrier Precautions (EBP) were not implemented as required. For instance, a resident with a stage 4 sacral ulcer and an indwelling catheter did not have EBP signage or PPE outside her room. Staff members, including a Wound Care Coordinator and a CNA, were observed providing wound care and handling the resident's urinary catheter with only gloves, without using gowns or other necessary protective equipment. This occurred despite a physician's order for EBP isolation due to the resident's wounds and catheter. Another resident with cellulitis and venous insufficiency also lacked EBP signage and PPE outside his room. A registered nurse provided wound care without wearing a gown, and there was no physician order for EBP for this resident. Similarly, a resident with a PICC line and multiple infections did not have precaution signage or PPE outside her room. A registered nurse assisted with incontinence care without wearing a gown, despite a physician's order for EBP being issued during the survey. The facility's infection control practices were further compromised by improper disposal of contaminated PPE. A red garbage container meant for disposing of PPE was placed outside a resident's room instead of inside, contrary to the facility's policy. Additionally, hand hygiene practices were not followed, as staff members failed to change gloves and clean their hands between tasks, such as wound care and incontinence care. The facility also lacked updated infection control policies, including those related to COVID-19, and there were missing records for water testing to prevent legionella growth.
Failure to Provide Dignified Care During Feeding
Penalty
Summary
The facility failed to provide care with dignity to a resident, identified as R139, who was observed being fed by a nurse, V9, in a demeaning manner. During the observation, V9 stood over R139 and repeatedly instructed her to eat in a demeaning tone. R139 is an elderly female with severe cognitive impairment and requires substantial assistance for eating, as indicated in her Minimum Data Set (MDS) assessments. The Director of Nursing, V2, acknowledged that staff should not stand over residents while feeding them, as it compromises their dignity. The facility's Resident Rights Statement emphasizes the right of residents to a dignified existence and care that enhances their quality of life and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were accessible to dependent residents, specifically affecting one resident in the sample. During an observation, a resident was found sitting in a recliner chair in her room with the call light attached to her bed, which was by the window, while she was sitting closer to the door. The resident expressed frustration about not being able to reach the call light from her position, stating that she needed it for assistance. The MDS Coordinator confirmed that the call light should be within reach of residents at all times. The resident's MDS indicated moderately impaired cognition and dependence on staff for toileting and personal hygiene, with a care plan noting a risk for falls and the need to call for assistance. The Director of Nursing also acknowledged that call lights should be easily accessible to residents in their rooms. The facility's policy states that call lights should be within easy reach to meet residents' needs.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite a resident to care plan meetings, which is a requirement for developing and maintaining a comprehensive care plan. This deficiency was identified for one resident, who expressed a desire to know what was needed to be discharged home but was unaware of the care plan meetings. The resident reported never being informed about the goals or invited to participate in these meetings. The Social Services Director confirmed that there was no documentation or progress notes indicating that the resident or their family had been invited to the care plan meetings. The facility's policy requires the involvement of the resident and their family in the care planning process, but this was not adhered to in this case, as evidenced by the resident's Care Plan Meeting Attendance forms showing no attendance by the resident or family at any meetings.
Improper Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to obtain residents' blood glucose levels appropriately and did not follow physician orders for administering insulin, affecting two residents. For one resident, an agency RN checked the blood glucose level and administered insulin based on a sliding scale, but the timing was inconsistent with meal times, as the resident had breakfast hours earlier and lunch trays were served later. The RN was unaware of the meal schedule, which is crucial for accurate insulin administration. Another resident's blood glucose was checked by an LPN while the resident was already eating, which is contrary to the physician's order to check blood sugar before meals. Insulin was administered based on this reading. The DON confirmed that blood glucose checks should be done before meals to ensure accurate readings, but some nurses were administering insulin when they saw meal trays to prevent hypoglycemia, indicating a lack of adherence to proper procedures.
Failure to Implement Physician's Order for Aspiration Precautions
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with dysphagia, chronic obstructive pulmonary disease, and dementia. The resident, identified as R77, had a physician's order dated 6/28/23 that specified no straws every shift and aspiration precautions due to her condition. Despite this, on 12/10/24, a CNA provided R77 with a cup of water containing a straw, contrary to the physician's order and the resident's care plan. Additionally, on 12/12/24, another CNA placed a straw on R77's lunch tray, which was then taken by the SLP who conducted a bedside swallow study and confirmed that R77 should not use straws. The facility's failure to adhere to the physician's order was further highlighted by the absence of a policy for following or implementing such orders. The Assistant Director of Nursing acknowledged that staff should follow all physician's orders, including those for no straws and aspiration precautions. The resident's care plan, updated on 11/20/24, reiterated the need for aspiration precautions and no straws, aligning with the SLP's evaluation from 12/12/24 to 12/25/24, which also recommended no straw use.
Failure to Provide Restorative Services to Resident
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R128, as recommended by the ADL Restorative Assessment. R128 is a male resident with a history of hemiplegia and hemiparesis following a cerebral infarction, affecting his right dominant side, along with aphasia, dysphagia, and repeated falls. The resident's MDS indicated impairments on one side of both upper and lower extremities, and he uses a wheelchair for mobility. During an interview, R128 communicated that he no longer receives physical, occupational, or speech therapy, and he does not receive any restorative therapy, despite having weak right arm and leg due to his stroke. The Director of Nursing (DON) confirmed that R128 was on three restorative programs: bed mobility, dressing, and active range of motion for upper and lower extremities. However, there was no documentation to show that these programs had been carried out over the past 30+ days. The resident's care plan, last revised in March, outlined interventions for his deficits, including a bed mobility program and active range of motion exercises, but these were not documented as being implemented. The facility's policy on restorative nursing programs emphasizes the importance of assessing and implementing appropriate nursing measures to achieve maximum independence, but this was not adhered to in R128's case.
Improper Positioning of Catheter Bags Leads to Potential Backflow
Penalty
Summary
The facility failed to properly position the indwelling catheter drainage bags for three residents during wound care and incontinence care, leading to potential backflow of urine. For one resident, the catheter drainage bag was observed hanging on the armrest of a motorized wheelchair above the bladder line, causing backflow of urine. During wound care, the same resident's catheter bag was placed on the bed, again resulting in backflow. This resident had a history of urinary tract infections (UTIs) and was recently on antibiotics for a UTI. The facility's policy requires that the urinary drainage bag be positioned lower than the bladder to prevent backflow. Another resident's catheter bag was similarly mishandled during wound care, being lifted above the bladder level and placed on the bed, contrary to the facility's policy. This resident also had a history of UTIs. Additionally, a third resident, who was supposed to switch from a leg bag to a larger urine collection bag when in bed, was not provided with the appropriate bag, risking backflow due to the lack of gravity with the leg bag. The facility's staff, including the Director of Nursing and Assistant Director of Nursing, acknowledged the improper handling of catheter bags and the potential for backflow, which could lead to UTIs.
Failure to Post Current Daily Staffing Information
Penalty
Summary
The facility failed to post the current daily staffing information, affecting all 159 residents. On December 10, 2024, at 10:36 AM, the Daily Staff Posting at the reception desk displayed a date of December 9, 2024, with a census of 160, indicating outdated information. The Director of Nursing (DON) explained that the admission staff emails the current census between 9:30 AM and 10:00 AM to the front desk, herself, and all managers. The receptionist is responsible for updating the staffing information and posting it after receiving the email. However, the receptionist's work schedule from 8:00 AM to 1:30 PM suggests a delay in posting the updated information. The facility's policy, dated August 2008, requires posting the number of nursing personnel responsible for direct care at the beginning of each shift, as mandated by state and federal regulations.
Failure to Identify Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to identify a change in condition for a resident, R2, who experienced a slow deterioration from the morning until she was transferred to the hospital in critical condition. The failure began when an LPN did not recognize R2's change in condition, did not complete an assessment, obtain vital signs, or notify R2's physician. This oversight continued with another LPN who did not provide frequent monitoring, failed to provide accurate information to the physician, and delayed transferring R2 to the hospital. As a result, R2 was transferred to the hospital in critical condition and later died from septic shock. R2 had a medical history that included COPD, heart failure, peripheral vascular disease, insomnia, atrial fibrillations, major depressive disorder, anemia, a non-pressure chronic ulcer to the left foot, dementia, and osteoarthritis. On the day of the incident, R2 was noted to be confused, experiencing diarrhea, and unable to perform her usual self-care activities. Despite these changes, there were no vital signs taken after the initial assessment in the morning, and the physician was not notified of R2's deteriorating condition. The facility's failure to monitor R2's condition and communicate effectively with the physician led to a delay in transferring her to the hospital. The ambulance report indicated that R2 was in a lethargic state, with low oxygen saturation and critically low blood pressure upon arrival. The lack of timely intervention and accurate communication contributed to the severity of R2's condition, ultimately resulting in her death from septic shock.
Removal Plan
- 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 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.
- 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. 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.
- DON or designee will audit all residents with a change of condition daily 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.
Failure to Conduct Required QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met quarterly with the required members, affecting all residents in the facility. The facility's data sheet indicated there were 163 residents at the time of the survey. During an interview and record review, it was found that the last Quality Assurance and Performance Improvement (QAPI) meeting was held in December 2023, and the subsequent meetings that should have occurred in March/April 2024 and June/July 2024 did not take place. The Director of Nursing (DON) acknowledged that the facility was behind on these meetings, citing a busy period following their annual survey in January and the development of a Plan of Correction (POC) as contributing factors. The monthly QA meeting held in April 2024 was attended by various staff members, including the Restorative, MDS Coordinator, Infection Control Preventionist, and others, but notably absent were the Administrator and Medical Director. The facility's policy requires the Administrator to serve as the Chairperson of the QAA committee, and the committee is expected to meet monthly to address quality measures, improvement processes, and survey findings. The absence of key members and the failure to hold the required meetings indicate a lapse in the facility's adherence to its quality assurance policy.
Unsafe and Unsanitary Conditions in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents in the B-wing hallway, affecting seven residents. Observations revealed missing ceiling tiles with water steadily dripping from exposed plumbing and air ducts, saturating the carpet and creating a sloshing sound when walked upon. A large trash can and personal care basins were placed to catch the water, but the area remained wet, and a light fixture in an adjacent tile was saturated with water. The issue was reportedly due to a malfunctioning air conditioning unit, which had been temporarily fixed by running water on the condenser, leading to the leak. The Maintenance Assistant and Director confirmed the air conditioning unit needed replacement, and a contractor had been called but could not fix the unit immediately. The Maintenance Director acknowledged the safety concern of water dripping onto an electrical source, although the Maintenance Assistant initially dismissed it. The facility had not provided a policy for Building Maintenance and Repair when requested by the surveyor. The situation had persisted since the previous Monday, with residents and staff having to navigate the wet area, raising concerns about safety and sanitation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bensenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Of Elmhurst, The | 1.4 mi | ★★★★★ | 3 | 0 |
| Avenora Elmhurst | 2.5 mi | ★★★★★ | 3 | 0 |
| Citadel At Casa Scalabrini | 2.7 mi | ★★★★★ | 0 | 0 |
| Landmark Of Itasca Rehabilitation And Nursing Cent | 3.9 mi | ★★★★★ | 28 | 2 |
| Asbury Court Nursing & Rehab | 5.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.