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Health Inspection Summary

Pavilion of Bridgeview, The

8100 South Harlem Avenue

Bridgeview, IL 60455

(708) 594-5440

Deficiency Category	Inspection Date: 10/3/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 7/14/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 4/22/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	1	2
Quality of Life and Care Deficiencies	3	9	5
Infection Control Deficiencies	0	1	2
Resident Assessment and Care Planning Deficiencies	0	4	0
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	0	2	2
Nutrition and Dietary Deficiencies	0	0	2
Pharmacy Service Deficiencies	0	0	1
Environmental Deficiencies	1	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 10/3/24

Date of last standard health inspection:	10/3/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	5/10/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	4
Average number of Health Deficiencies in Illinois:	12.2
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	5/10/24	5/20/24	2 - Minimal harm or potential for actual harm	Few
Assist a resident in gaining access to vision and hearing services.	5/10/24	5/20/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	5/10/24	5/20/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Have policies on smoking.	10/3/24	10/23/24	2 - Minimal harm or potential for actual harm	Few

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 7/14/23

Date of last standard health inspection:	7/14/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	12/1/23Read the full report (PDF) 9/20/23Read the full report (PDF) 6/30/23Read the full report (PDF) 6/16/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	17
Average number of Health Deficiencies in Illinois:	13
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	6/30/23	7/14/23	3 - Actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	12/1/23	12/6/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/1/23	12/6/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/20/23	10/3/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/20/23	10/3/23	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/16/23	6/20/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	6/16/23	6/20/23	3 - Actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/1/23	12/6/23	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Plan the resident's discharge to meet the resident's goals and needs.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Allow residents to self-administer drugs if determined clinically appropriate.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	7/14/23	7/18/23	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/22/22

Date of last standard health inspection:	4/22/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	11/19/22Read the full report (PDF) 7/8/22Read the full report (PDF) 6/3/22Read the full report (PDF) 5/9/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	14
Average number of Health Deficiencies in Illinois:	12.5
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	7/8/22	7/15/22	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/19/22	12/7/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	5/9/22	5/21/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	4/22/22	5/16/22	3 - Actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	5/9/22	5/21/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/3/22	6/4/22	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep residents' personal and medical records private and confidential.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	4/22/22	5/16/22	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	5/10/24	5/20/24	2 - Minimal harm or potential for actual harm	Few
Assist a resident in gaining access to vision and hearing services.	5/10/24	5/20/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	5/10/24	5/20/24	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	6/30/23	7/14/23	3 - Actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	12/1/23	12/6/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/1/23	12/6/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/20/23	10/3/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/20/23	10/3/23	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/16/23	6/20/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	6/16/23	6/20/23	3 - Actual harm	Few
Provide and implement an infection prevention and control program.	12/1/23	12/6/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	7/8/22	7/15/22	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/19/22	12/7/22	2 - Minimal harm or potential for actual harm	Few
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	5/9/22	5/21/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	5/9/22	5/21/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/3/22	6/4/22	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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