Pavilion of Bridgeview, The

In the surveyor’s words

From the most serious findings on record at Pavilion of Bridgeview, The, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 14, 2025

  Based on interview and record review, the facility failed to provide a resident with adequate staff supervision during a shower for a resident who requires substantial maximal assistance with bathing/showering. This failure applies to one of three residents (R2) reviewed for accidents/supervision and resulted in R1 sustaining a femur fracture. Findings include: R2 has a diagnoses history of Paraplegia, Multiple Sclerosis, Morbid Obesity, and Cognitive Communication Deficit who was admitted to the facility 04/06/2024. […]

• Actual harm, isolatedF600Jun 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (R1) reviewed for abuse, was free from abuse from a staff member. This failure resulted in R1 suffering an abrasion to her face, sore ribs, and feeling angry and taken advantage of. Findings include: On 6/27/2023 at 11:45 AM, V1 (Administrator/Abuse Coordinator) states she reviewed tapes of the incident that occurred on 6/18/2023, resident was in and out of her room making noise. Resident attempted to leave and went downstairs at about 4:00 AM then went to her room. At around 6:15 AM, R1 came down again and got through the front doors. V5 (CNA) came downstairs and grabbed the back of R1's wheelchair and pulled R1 backwards, and V1 believes resident knocked her own glasses off her face. […]

• Actual harm, isolatedF689Jun 16, 2023

  Based on observation, interview, and record review the facility failed to safely provide incontinence care to a resident by not having two staff members provide the care. This failure resulted in a resident hitting his head which resulted in a five day hospitalization for a subdural hematoma. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 17. The findings include: R1's Admission Record dated 6/16/23 shows he is a [AGE] year old male and his diagnoses include, but are not limited to, Alzheimer's disease, severe protein calorie malnutrition, type 2 diabetes, acute respiratory failure, attention and concentration deficit following non-traumatic subarachnoid hemorrhage, anemia, heart disease, disorder of the brain, encephalopathy, cerebral… […]

• Actual harm, isolatedF689Apr 22, 2022

  Based on interview and record review the facility failed to ensure adequate supervision to resident (R58) who has multiple episodes of falls to prevent from future falls as indicated in his care plan. R58 was left unattended/unsupervised in the dining room and sustained a right [CONDITION(S)] requiring hospitalization . This deficiency affects one (R58) of 3 residents in a sample of 26 reviewed for Fall prevention management. Findings include: R58 is admitted on [DATE] with diagnosis to include Dementia, [CONDITION(S)], [CONDITION(S)] and Depression. R58 is at high risk of falls. He has a total of 10 episodes of multiple falls from 5/17/21 to 4/19/22. Most recent fall sustained right [CONDITION(S)] requiring hospitalization . […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observation, interview, and record review the facility failed to ensure that food kept in the refrigerator was labeled with open and use by date to prevent food borne illness and failed to ensure kitchen staff beards and hair were covered with required hair net and beard guard. This failure has the potential to affect 128 residents. Findings include:On 9/29/2025 between10:04am to 10:10am, during kitchen observation with V10, Dietary Manager, 2 quarter pans of pureed eggs dated 09/26/25 not specifying whether it is open date or used by date. V10 stated it is pureed eggs, and it does not have a used by date. I (V10) cannot see a used by date that must be the prepared date. V10 stated the cook should have put the used by date to show that this is the prepared date. […]