Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Pavilion Of Bridgeview, The during CMS and state inspections, most recent first.
A resident was transferred to a different room without prior notification to their power of attorney, as required by facility policy. The Social Service Director confirmed that the notification was not made, and there was no documentation in the resident's record to indicate that the representative had been informed.
Improper Food Labeling and Staff Hair Restraints in Kitchen: Kitchen observation found refrigerated eggs and pureed eggs labeled only with dates that did not identify an open date or use-by date, and a Dietary Aide with a long beard was observed without a beard guard or hair net. The Dietary Mgr stated hair should be covered, and facility policies required hair restraints, beard guards, and refrigerated foods to be labeled with a use-by date.
Dirty Dryer Lint Screens: During a tour of the laundry area, multiple dryers had lint compartments with loose lint on the floor and lint screens fully covered with lint. The Housekeeping Manager stated the compartments had not been cleaned recently, even though they are reportedly cleaned every 2 hours. Facility documents stated that laundry personnel should clean lint screens after every 2 to 3 loads, and the Laundry Aide is responsible for maintaining laundry equipment and reporting maintenance needs.
A facility failed to follow policy and federal requirements for PRN psychotropic meds for four residents. Records showed PRN Ativan and hydroxyzine orders without stop dates, and one resident on hospice had multiple PRN Ativan orders that were still being administered without stop-date clarification. Staff, including the RN case manager, psychotropic nurse, and DON, acknowledged that PRN psychotropics were supposed to be limited to 14 days and reevaluated, but the orders in the chart did not reflect that requirement.
Missing PASARR Screening for Residents With Mental Health Diagnoses: The facility failed to ensure required PASARR screening was completed or available for multiple residents with mental health diagnoses, including bipolar disorder, depression, anxiety, psychosis, PTSD, and dementia with behavioral disturbance. Records showed an outdated or inaccurate Level I screen for one resident, no Level II screening for another, and no Level I or II documentation for others, despite staff stating that PASARR screening should be triggered when mental health diagnoses are identified.
Unsafe Storage of Aerosol Chemicals in Resident Rooms: Staff observed disinfectant spray, odor neutralizer, air freshener, and insecticide stored at residents’ bedside or in room areas, including rooms occupied by residents with COPD, asthma, acute respiratory failure with hypoxia, and interstitial pulmonary disease. Residents and staff stated the products were being used or had been brought in by family, while the DON, ADON, and RNs stated the items should not be kept at bedside or used around residents with respiratory problems.
Controlled substance documentation was incomplete for several residents. An LPN and RNs failed to properly sign out administered doses on resident controlled drug records, one resident’s tramadol was tracked on a handwritten sheet instead of the required controlled substance record, and multiple shift-change narcotic count sheets had missing nurse initials. Facility policy required controlled substances to be counted on delivery, documented on resident records, and reconciled and signed by both nurses at each shift change.
Improper medication labeling and storage were identified during a medication cart review. A resident had Fluticasone propionate nasal spray at the bedside without a physician order for bedside storage or self-administration, and staff found an expired bottle of Loratadine plus two unlabeled, undated Fluticasone/Salmeterol Diskus in medication carts. The DON and nursing staff acknowledged the issues during the survey.
Failure to Provide Ordered Diabetic Medications and Admission Information: A resident with diabetes, hypertension, and other chronic conditions was admitted from the hospital with orders for multiple diabetic medications, but the facility did not obtain the needed admission information from the attending physician and did not administer any of the ordered medications before the resident expired. Staff said the medications were not yet available, but they did not notify the physician or DON, and the MAR showed all doses were marked unavailable. The resident was later documented as alert and oriented, then shortly afterward was found pale, cool, unresponsive, and in asystole.
Medication administration errors resulted in a 9% error rate after an LPN signed out meds before giving them, gave a resident 1 tablet instead of the ordered 2 tablets, and prepared another resident’s ordered fiber medication from house stock using an unmeasured amount and unmeasured water. The LPN also administered only 1 tablet of a constipation medication when 2 tablets were ordered. Interviews with the LPN and DON confirmed the need to verify the MAR and orders, measure accurately, and document after administration.
An LPN failed to follow infection control practices during medication administration and resident care. She did not perform hand hygiene after glove removal or before preparing medications, did not disinfect a glucometer or wrist BP machine between residents, used bare hands to dispense a stock powder medication, and handled a medication cup stored inside the medication container. The LPN also administered medications after touching resident equipment and completing resident care tasks without sanitizing her hands.
A resident with paraplegia, multiple sclerosis, and significant mobility limitations, who required extensive staff assistance for bathing and transfers, was left unsupervised in the shower after requesting privacy. During this time, the resident fell from the shower chair while attempting to retrieve a dropped towel, resulting in a femur fracture and hospitalization. Staff interviews and facility policy confirmed that residents requiring assistance should not be left unattended during bathing.
The facility failed to monitor residents during smoking times and improperly handled smoking materials. Two residents, one with a BIMS score of 13 and another with a score of 15, were involved. The male resident was observed smoking alone without supervision, and the female resident restarted smoking without staff assistance. Staff interviews revealed inconsistencies in monitoring and documentation, with no smokers' list available as required by policy.
The facility failed to provide timely incontinent care for two residents who required extensive assistance with toileting. One resident was left in a saturated incontinence brief for several hours, leading to a wet wound dressing, while another resident was found with a saturated and soiled brief after being left unattended for hours.
A resident with severe cognitive impairment and dementia did not receive a timely referral for a hearing aid request. Despite the family member's request in February 2024, the facility staff failed to follow the process for making audiology referrals, resulting in the resident not being evaluated until the issue was identified during a survey.
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. One resident was not repositioned as required, and her dressing became wet and fell off. Another resident's newly identified pressure injury was not properly assessed or documented. The facility's policies on pressure ulcer prevention and management were not followed.
Failure to Notify Resident's Representative of Room Transfer
Penalty
Summary
The facility failed to follow its room-to-room transfer policy by not notifying the resident's power of attorney prior to a room change. According to the facility's policy dated April 2014, the resident, their roommate, and the resident's representative are to be informed before any room transfer occurs. On September 16, 2025, a resident was moved to a different room, but there was no documentation in the electronic record that the resident's power of attorney was notified. This was confirmed by the Social Service Director, who stated that the notification did not occur, and by a review of the resident's power of attorney paperwork and the facility's records.
Improper Food Labeling and Staff Hair Restraints in Kitchen
Penalty
Summary
Food kept in the refrigerator was not labeled with an open date or use-by date. During kitchen observation on 9/29/2025 between 10:04 a.m. and 10:10 a.m., the Dietary Manager observed 2 quarter pans of pureed eggs dated 09/26/25 without specifying whether the date was an open date or a use-by date. The Dietary Manager stated it was pureed eggs and that there was no use-by date, then stated the cook should have put the use-by date to show that this was the prepared date. During the same observation, 1/2 quart of eggs dated 9/28/25 was also observed without specifying whether it was an open date or a use-by date. During the same kitchen observation, a Dietary Aide was observed with a long beard without a beard guard or hair net. The Dietary Manager stated that all hair should be covered with hair nets and beard guards. Facility policy on Hair Restraints/Jewelry/Nail Polish states that food and nutrition services staff shall wear hair restraints and beard guards, and the policy on Labeling and Dating Foods states that foods are labeled with the date by which the item should be discarded. The policy on Storage of Refrigerated Foods states that refrigerated food should be labeled with a use-by date.
Dirty Dryer Lint Screens
Penalty
Summary
The facility failed to clean and maintain the dryer lint screens thoroughly in the laundry area. During a tour of the laundry area with the Housekeeping Manager, four dryers were observed. Dryer #4 had a lint compartment floor with a large amount of loose lint and a lint screen that was fully covered with lint. Dryer #2 had loose lint on the lint compartment floor and a lint screen fully covered with lint. Dryer #1 also had a large amount of loose lint on the lint compartment floor and a lint screen fully covered with lint. Dryer #3 was identified as not working properly and was not in use. The Housekeeping Manager stated that the lint compartments had obviously not been cleaned recently and said they are cleaned out every 2 hours. When asked about the purpose of cleaning the lint compartments, the Housekeeping Manager stated that lint can cause a fire and burn the place. The facility’s written lint screen cleaning procedure stated that all laundry personnel should be trained to clean lint screens in dryers and that the screens must be cleaned after every 2 to 3 loads. The Laundry Aide job description stated that the aide maintains laundry equipment and informs the facility manager of maintenance needs.
PRN Psychotropic Orders Lacked Required Stop Dates and Reevaluation
Penalty
Summary
The facility failed to follow its policy and federal requirements for PRN psychotropic medications for four residents receiving these drugs. Survey review found that PRN orders for Ativan and hydroxyzine were written without stop dates or clear duration limits, and the facility continued to administer these medications without order clarification regarding stop dates. The affected residents included one resident on hospice with diagnoses including COPD, type 2 diabetes mellitus with ketoacidosis without coma, delusional disorder, restlessness and agitation, major depressive disorder, and urinary retention, and whose MDS showed a BIMS score of 03 indicating cognitive impairment. For the hospice resident, the record showed multiple PRN Ativan orders, including topical, oral, and IM formulations, each lacking a stop date. The MAR showed Ativan was being administered despite the absence of stop-date clarification. During interview, the hospice RN case manager stated that the hospice team did not use a stop date because they could not gauge the dying date or transition date, and that they did not renew PRN psychotropic medications every 14 days. The RN also stated that hospice staff managed symptoms weekly and that the hospice IDG did not include facility staff. For the other residents, the records showed PRN psychotropic orders without stop dates: one resident had Ativan 1 mg by mouth every 6 hours as needed for agitation; another had hydroxyzine pamoate 25 mg by mouth every 6 hours as needed for anxiety; and another had hydroxyzine HCl 25 mg by mouth every 8 hours as needed for anxiety. Facility staff, including the psychotropic nurse and DON, stated that PRN psychotropics were supposed to be ordered for 14 days and reevaluated, and that the purpose was to review whether the resident still needed the medication and to check behaviors. The psychotropic nurse also stated she did not know why staff were documenting zero behaviors and still giving the medication, and noted that one hydroxyzine order had been entered incorrectly and was later discontinued.
Missing PASARR Screening for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure pre-admission screening assessments were completed as required for residents identified as having mental illness. This deficiency affected four residents reviewed for pre-admission screening in a sample of 57 residents: R4, R5, R59, and R124. The report states that the facility did not have required PASARR documentation for these residents, and in some cases the screening information available in the record was inaccurate or outdated. R4 had diagnoses including post-traumatic stress disorder, bipolar disorder, and major depressive disorder, and the facility provided only an OBRA pre-admission screening dated 01/03/2021. The surveyor requested the resident’s PASARR screening from Maximus, and the Assistant Administrator stated that the facility did not have any screening from Maximus for the resident. R5’s face sheet listed multiple mental health diagnoses, including hypomanic bipolar disorder, depressed bipolar disorder, major depressive disorder, anxiety disorder, mood disorder, and unspecified mental disorder due to a known physiological condition, but the record did not show a completed Level II PASARR even though the Level I screen documented no Level II required and no SMI. R59’s record showed diagnoses including anxiety disorder, mood disorder, depressive disorder, and psychosis, yet the health record did not show that a Level I or Level II PASARR was completed. R124 had diagnoses including dementia with behavioral disturbance, depressive episodes, generalized anxiety disorder, and psychotic disorder not due to a substance or known physiological condition, and was documented as cognitively intact on assessment. When asked about PASARRs, the Assistant Administrator and Social Services Director described that admissions and social services were involved in identifying mental health diagnoses and requesting screenings, but the records reviewed for these residents still did not contain the required PASARR documentation.
Unsafe Storage of Aerosol Chemicals in Resident Rooms
Penalty
Summary
The facility failed to ensure that chemical sprays were safely locked up when not in use by authorized staff. Surveyors observed disinfectant spray on a dresser in a room shared by residents with respiratory diagnoses, including COPD and asthma, and the resident stated it was used whenever there was an odor in the room. A registered nurse stated the resident should not be spraying that in the room, and the DON stated staff rounds should include making sure hazardous chemicals in use are not stored inappropriately. Surveyors also observed an odor neutralizer aerosol on a bedside dresser in another resident’s room, with the can labeled as extremely flammable and instructing to keep out of reach of children. A nurse stated the family had brought it in and staff had repeatedly told them not to. The resident was documented as a hospice patient with COPD. An ADON was notified and stated that no chemical like aerosol should be used by the resident, especially if the resident has a roommate. Later, surveyors observed a can of air freshener and a can of insecticide on the windowsill in a room occupied by residents with respiratory conditions, including acute respiratory failure with hypoxia, COPD, and interstitial pulmonary disease; one resident was observed with oxygen in use. An RN stated the residents were not supposed to have those items at bedside, and one resident stated the items were theirs and that they used them. The DON stated the reason for not keeping air freshener products at bedside was to prevent aerosols in the air that could affect residents with respiratory problems such as asthma or COPD.
Controlled substance documentation and shift-count records were incomplete
Penalty
Summary
The facility failed to properly document administration of controlled medications on the controlled drug receipt/record/disposition forms for three residents and failed to properly document shift change accountability on the controlled substances check forms according to facility policy. During medication cart review, the shift change accountability record for controlled substances had missing nurse initials on multiple dates and shifts on the 2nd, 3rd, and 4th floor medication carts. The report states these documentation failures had the potential to affect 22 residents on the 2nd floor, 18 residents on the 3rd floor, and 15 residents on the 4th floor who received controlled medications reviewed during the storage review. For R140, the controlled drug receipt record/disposition form showed Hydrocodone-Acetaminophen 5-325 mg ordered every 8 hours as needed for pain with 15 tablets remaining, while the medication card count showed 14 tablets remaining. V12 stated the 9 AM dose had been given but not signed out. The same resident’s Alprazolam 0.25 mg daily for anxiety disorder showed 25 tablets remaining on the controlled drug record and 24 tablets on the medication card count, and V12 stated the dose had been given but not signed out. The MAR later documented both the Hydrocodone and Xanax doses as administered by V12 at 9:03 AM and 9 AM, respectively. For R32, Tramadol 50 mg every 8 hours as needed did not have a controlled drug receipt record/disposition form, and staff were using a handwritten paper to document the medication. V13 stated she was not sure what happened when it was delivered and that this was what everyone had been using; the last documented dose on the handwritten paper was 6/12/2025. For R63, Pregabalin 75 mg daily for other specified polyneuropathies showed 11 tablets remaining on the controlled drug record and 10 tablets on the medication card count, and V7 stated she had not signed for that dose. The report also includes facility policy stating controlled substances must be counted on delivery, documented on resident controlled substance records, and counted and signed by the oncoming and off-going nurses at each shift change.
Improper Medication Labeling, Storage, and Bedside Access
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted professional principles during medication storage review. The facility failed to ensure that a resident had a physician’s order to keep a prescribed inhaler at the bedside, and it also failed to remove expired stock Loratadine and two unlabeled Fluticasone/Salmeterol oral inhalation Diskus from medication storage areas. The report states that these findings had the potential to affect 43 residents receiving medication on the 2nd floor and 4 residents receiving Loratadine stock medication on the 4th floor. For one resident, Fluticasone propionate nasal spray was observed on the bedside table with no label, no name, and not in a manufacturer packet or pharmacy-labeled package. The resident stated the medication belonged to them and that they used it all the time, and the nurse stated she did not know whether the resident could keep it at bedside and would check the orders. Review of the EMAR and physician orders showed an order for Fluticasone propionate nasal spray to be administered once daily, but there was no order allowing bedside storage or self-administration. The DON later stated the resident should not have had the nasal spray at the bedside without a physician order. During medication cart review, an expired bottle of Loratadine 10 mg with an expiration date of 08/25 was found in the 4 [NAME] medication cart, and the LPN confirmed it was expired. In the 2 East medication cart, two unlabeled, undated, and unboxed Fluticasone/Salmeterol oral inhalation powder 500 mcg/50 mcg Diskus were found in the third drawer, and the staff member reviewing them stated she was not sure who they belonged to and said she would toss them. The facility policies cited in the report state that medications must be labeled properly, stored securely, and that outdated or improperly labeled medications are to be withdrawn from stock.
Failure to Provide Ordered Diabetic Medications and Admission Information
Penalty
Summary
The facility failed to follow its admission criteria policy and medication administration policy for a resident admitted from the hospital with a history that included type 2 diabetes with hyperglycemia, essential hypertension, hyperkalemia, mixed hyperlipidemia, and other diagnoses. The hospital record listed diabetes and hypertension-related medications to continue, and the physician order on admission included multiple diabetic medications with instructions to hold them if blood sugar was below 70. The resident’s record showed only one documented blood sugar of 210 on the evening of admission, and the medication administration record showed that none of the ordered medications were administered from admission until the resident expired the next day. Staff interviews showed that the admitting LPN reviewed the hospital record and texted the medication list to the physician, who said to keep the same medications, but she did not inform the physician that the resident was diabetic and did not receive blood glucose monitoring orders. She also stated that she did not give the resident medications because it was late, the medications had not yet arrived from the pharmacy, and she did not have access to the emergency medication box. She said she did not notify the physician or DON that the medications were not available. Another LPN later stated that the resident’s medications were not available and that she did not notify the physician or try to obtain them from the emergency box. On the following day, one LPN documented the resident as alert and oriented with stable vital signs and a blood sugar of 177, but later documented that the resident was pale, cool to touch, and unable to obtain vital signs or blood sugar, after which 911 was called and the physician notified. Fire department records documented the resident as unresponsive, pulseless, apneic, cold to touch, and in asystole, with time of death at 17:30. The attending physician stated he never saw the resident and was not contacted about medication reconciliation or unavailable medications, and the in-house NP stated she did not see the resident and was not notified that the diabetic medications were unavailable.
Medication Administration Errors and Inaccurate Dosing
Penalty
Summary
The facility failed to maintain a medication error rate at or below 5 percent. Surveyors identified 3 medication errors out of 33 medication opportunities, resulting in a 9% medication error rate during medication administration observations for 3 residents. The deficiency was based on observation, interview, and record review involving residents R70, R79, and R129. During medication administration, an LPN signed out medications as administered for R70 after preparing them before they were actually given. For R79, the LPN administered 1 tablet of Senokot S when the physician order directed 2 tablets by mouth one time a day for constipation. For R129, the LPN prepared Senexon-S 8.6-50 mg ordered as 2 tablets by mouth every 12 hours for constipation, but only prepared 1 tablet for administration, and later administered only 1 tablet instead of the ordered 2 tablets. The surveyor also observed the LPN preparing Metamucil 4 in 1 Fiber oral packet for R129 from a house stock container rather than an individual packet as ordered. The LPN removed a clear plastic medication cup from inside the container, used bare hands, scooped out an unmeasured amount, and adjusted the powder by eye until estimating 15 mL. The LPN then diluted the powder with an unmeasured amount of water and did not verify the ordered amount because the medication was taken from stock rather than a packet. Interviews with the LPN and the DON confirmed that MARs and physician orders should be checked before administration, measurements should be taken accurately at eye level, and medications should be signed out after administration. The facility's pharmacy medication administration policy and medication administration guidelines also state that the MAR should be reviewed, each order read entirely, and medications documented immediately after administration.
Infection Control Failures During Medication Administration
Penalty
Summary
The facility failed to follow its infection control policies during medication administration and resident care activities involving four residents. During the medication pass, an LPN prepared and administered medications while failing to perform hand hygiene after leaving one resident’s room and before preparing medications for the next resident. The same LPN also failed to perform hand hygiene after removing gloves and before continuing medication preparation and administration for another resident. The LPN performed blood glucose monitoring and blood pressure checks for a resident, then left the room without sanitizing her hands or disinfecting the glucometer or wrist blood pressure machine before placing the equipment back on the medication cart. The LPN later handled a dropped tablet by picking it up from the cart, placing it in the garbage, then removing it from the garbage with a glove and placing it into the sharps container, after which she removed the glove and did not perform hand hygiene before continuing medication preparation. The LPN also administered insulin with gloves, removed the gloves, and then administered oral medications without hand hygiene afterward. In another resident’s room, she adjusted the overbed table and bed position before giving medications, then left without sanitizing her hands. For a different resident, she took a blood pressure reading with the wrist machine and did not sanitize the machine afterward. When preparing a stock powder medication, she used bare hands to remove a medication cup stored inside the container, scooped out the powder, and adjusted the amount by pouring medication back and forth until she estimated the dose, while also diluting the powder with an unmeasured amount of water. The report also noted concern that a clear medication cup was stored inside the stock powder medication container.
Failure to Provide Adequate Supervision During Shower Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of paraplegia, multiple sclerosis, morbid obesity, and cognitive communication deficit, who required substantial to maximal assistance with bathing and transfers, was left unsupervised during a shower. The resident was known to be at high risk for falls, required a mechanical lift with two-person assistance for transfers, and had a care plan indicating the need for extensive staff assistance during bathing. Despite these documented needs, the resident was left alone in the shower room after requesting privacy, with the CNA stepping outside the room but remaining within arm's reach. During the unsupervised period, the resident dropped a towel and attempted to retrieve it, resulting in a fall from the shower chair. The incident was not witnessed, but staff responded to the resident's calls for help and found her on the floor in pain. The resident sustained a closed fracture of the left femur, requiring hospitalization and orthopedic evaluation. The call light was not activated at the time of the fall, and the resident reported that she thought she could reach the towel herself but lost access to the call light in the process. Interviews with staff revealed that the facility's policy required staff to remain with residents throughout bathing and never leave them unattended in the shower or tub. Staff members acknowledged the resident's need for assistance and the policy requirements, but the CNA involved believed she was honoring the resident's request for privacy. The Director of Nursing confirmed that, despite the resident's preference for privacy, staff should not have left her unattended due to her care needs and facility policy.
Inadequate Monitoring of Smoking Residents
Penalty
Summary
The facility failed to implement its smoking policy effectively, leading to inadequate monitoring of residents during smoking times and improper handling of smoking materials. Two residents, a female with a BIMS score of 13 and a male with a BIMS score of 15, were involved in the deficiency. The female resident, who had a history of benign neoplasm of meninge and other conditions, was observed smoking without proper documentation of smoking safety interventions. The male resident, with a history of type 2 diabetes mellitus and other conditions, was observed smoking independently despite not being listed as a smoker and having no smoking safety notes in his assessment. The facility's administrator provided a list of smokers that did not include the two residents in question. The male resident was observed smoking alone on the patio without supervision, and he reported keeping cigarettes and a lighter in his room, contrary to facility policy. The administrator acknowledged that the resident should not be smoking independently and should be monitored. The female resident reported restarting smoking without staff assistance and receiving cigarettes from an unknown individual. Interviews with facility staff revealed inconsistencies in the monitoring and documentation of smoking residents. The activity aid responsible for monitoring smokers stated that there was no existing smokers' list and that social services usually informed them of who was allowed to smoke. The social service director and director of nursing confirmed that all smoking residents require supervision, and there was no smokers' list at the front desk as required by the facility's smoking program details and safety policy.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for two residents who required extensive assistance with toileting. Resident R9, who has diagnoses including dementia, major depressive disorder, and diabetes, was observed in a reclining wheelchair for several hours without being changed. When finally attended to, R9's incontinence brief was found to be saturated with urine, and her wound dressing was wet and no longer adhering to her skin. The assigned CNA was unaware of R9's wound and had not changed her since the start of her shift. The wound care nurse and other staff confirmed the importance of checking and changing incontinence briefs every 2 hours, especially for residents with wounds. Resident R2, who has severe cognitive impairment and is always incontinent of bowel and bladder, was also not provided timely incontinent care. R2 was observed in the dining room for several hours before being taken to her room for a change. Upon changing, R2's incontinence brief was found to be saturated with urine and soiled with stool. The assigned CNA admitted this was the first time she had changed R2 since the start of her shift, and other staff confirmed that R2 should be toileted every 2 hours or as needed.
Failure to Make Audiology Referral for Resident
Penalty
Summary
The facility failed to ensure a referral was made for a hearing aid request for a resident with severe cognitive impairment and dementia. The resident's family member had initially requested hearing aids in February 2024, and the request was communicated to the Director of Nursing (DON) by the liaison. However, the DON was not aware of the request, and no order for an audiology evaluation was made. The Social Service Director, who started in March 2024, also did not receive any request for the resident to be seen by audiology and confirmed that the resident was not on the list for the upcoming audiologist visit. Interviews with the facility staff revealed that the process for handling such requests was not followed. The administrator stated that social services are responsible for making audiology referrals, but the Social Service Director did not have a list of residents needing evaluations. The DON and Social Service Director both confirmed that no referral was made for the resident, and the resident was only added to the list for the audiologist visit after the issue was identified during the survey. The facility's policy on the care of hearing-impaired residents requires arranging consultations with an otologist if needed, which was not done in this case.
Failure to Ensure Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. For one resident, the facility did not implement physician-ordered interventions such as turning and repositioning every two hours and offloading heels while in bed. The resident was observed in a reclining wheelchair for extended periods without repositioning, and her incontinence brief was found saturated with urine, causing her dressing to become wet and fall off. The staff were unaware of the resident's wound care needs, and the air mattress setting was incorrectly adjusted, further compromising her care. Another resident had a newly identified pressure injury on her heel that was not properly assessed or documented. The resident had severe cognitive impairment and required assistance with personal care. Despite a CNA noticing the sore and reporting it to a nurse, no formal assessment or treatment was documented. The wound was not reported to the wound care nurse, and the resident's record showed no indication of the injury prior to her discharge to the hospital. The facility's policies on pressure ulcer prevention and management were not followed, leading to inadequate care for the residents. The policies required regular skin inspections, proper fitting of shoes, and timely documentation and treatment of any skin impairments. The failure to adhere to these policies resulted in the residents' pressure injuries not being properly managed, increasing the risk of further complications.
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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 Bridgeview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Midway Neurological / Rehab Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Hickory Vlg Nrsg & Rhb | 1.7 mi | ★★★★★ | 0 | 0 |
| Aperion Care Oak Lawn | 1.9 mi | ★★★★★ | 17 | 0 |
| Aperion Care Burbank | 1.9 mi | ★★★★★ | 1 | 0 |
| Aliya Of Oak Lawn | 2.1 mi | ★★★★★ | 11 | 2 |
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