Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
| Hickory Vlg Nrsg & Rhb | 1.7 mi | — | 0 | 0 |
| Aperion Care Oak Lawn | 1.9 mi | — | 16 | 0 |
| Aperion Care Burbank | 1.9 mi | — | 1 | 0 |
| Aliya Of Oak Lawn | 2.1 mi | — | 7 | 2 |
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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 August 2026) and official state health department websites.