Pavilion of Bridgeview, the

Inspectors wroteBased on interview and record review, the facility failed to treat a resident in a dignified manner and ensured that (R1) had on clothing attire when resting in bed. This affects one of three residents (R1) reviewed for improper nursing care. R1 face sheet shows R1 has dementia. R1 MDS shows R1 is dependent on staff assistance for activities of daily living for dressing. R1 observed resting in bed awake and alert, R1 was not interview able. R1 was dressed in a orange gown/dress. 6/17/26 at 11:47am V5 (R1 power of attorney) said on Mother's day when she visited R1, R1 was observed with no clothing on while resting in bed, only the linen was covering R1 body. V5 said she made V2 (DON) aware. V5 sent photos showing R1 without clothing and resting on soiled linen. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its room-to-room transfer policy for R1 by not notifying R1's power of attorney of a room change for one of three resident's review for transfers. Findings Include:On 12/18/25 at 11:27am, V3 (Social Service Director) said, we did not notify V11 (R1's Power of Attorney) for R1 room transfer on 9/16/25. R1 power of attorney paperwork dated 8/22/25 documents: V11. R1's electronic record did not document any notification on 9/16/25. Room to room transfer policy dated 4/2014 documents: Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean and maintain the dryer lint screens thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 131 residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow policy and procedure and failed to use and follow a valid PRN (as-needed) order for four residents (R9, R39, R122, and R147) receiving psychotropic medications, as required by federal regulations and facility policy. These failures affected 4 residents (R9, R39, R122, and R147) in a sample of 57 residents reviewed for psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure preadmission screening assessments were completed as required for residents identified that have a mental illness. This failure affected four residents (R4, R5, R59, and R124) reviewed for pre-admission screening in the sample list of 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that chemical sprays were safely locked up when not in use by authorized facility staff to prevent accidental use by residents with diagnosis that includes respiratory disease/compromise for five of five residents (R9, R21, R66, R70, R117) reviewed for hazards and supervision. This failure affected five of five residents (R9, R21, R66, R70, R117) and has the potential to affect all 43 residents residing on the 2nd floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly document medication administration of controlled medications on the controlled drug receipt/record/disposition form for three residents (R32, R63, and R140) and failed to properly document shift change accountability on the controlled substances check form per facility policy. These failures have the potential to affect 22 residents on 2nd, 18 residents on 3rd, and 15 residents on 4th floor that receive controlled medications reviewed during medication storage review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. ensure a resident had a physician's order to keep a prescribed inhaler at the bedside for one (R21) resident, 2. failed to remove expired stock Loratadine medication and two unlabeled prescription Fluticasone/Salmeterol oral inhalation Diskus from the medication cart. This failure has the potential to affect 43 residents receiving medication on the 2nd and 4 residents (R24, R91, R92, and R124) receiving Loratadine stock medication on the 4th floor during medication storage review. On [DATE] at 10:31am, R21 was sitting in their wheelchair with Fluticasone propionate nasal spray noted on the bedside table with no label no name and not in manufacturer packet and no pharmacy labeled package. R21 stated that it is mine and I (R21) use it all the time. The nurse gave it to me. It's mine. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their admission criteria policy by failing to ensure that staff obtained information needed for the care of one resident from the attending physician prior to admission, failed to ensure that staff follow their medication administration policy by failing to administer prescribed diabetic medications and failed to notify the physician that medication was not available. This failure affected one (R135) of one resident reviewed for quality of care. R135 was admitted to the facility from the hospital, alert and oriented and was found unresponsive and cold to touch at the facility the following day. Death certificate listed cause of death as hypertension and diabetes mellitus.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 33 medication opportunities resulting in a 9% medication error rate for 3 (R70, R79, and R129) residents reviewed during medication administration. This failure has the potential to affect all 131 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for infection control related to 1. Failed to clean glucometer after resident use, 2. failed to ensure that reusable equipment (blood pressure cuff/machine) was cleaned between use of residents, 3. failed to perform hand hygiene after removing gloves, and before preparing resident medications, 4. failed to put on gloves to dispense a powder stock medication (used bare hand to dispense), 5. Failed to remove a medication cup (not manufacturer provided) stored inside the stock powder medication. These failures applied to four (R5, R70, R79, and R129) of four residents reviewed during medication administration in the sample of 57 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement their policy to adequately monitor residents during smoking times, ensure residents' turn over their smoking materials, and determine who is an active smoker for 2 (R6 and R81) of 3 residents reviewed for smoking in the sample of 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who required extensive assist with toileting was provided incontinent care in a timely manner for 2 or 4 residents (R2, R9) reviewed for Activities of Daily Living (ADL) in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure a referral was made for a hearing aid request for 1 of 3 residents (R2) reviewed for resident rights in the sample of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure injury, failed to ensure a pressure injury dressing was kept clean and intact, and failed to assess and implement treatment for a resident with a newly identified pressure injury for 2 of 3 residents (R3, R9) reviewed for pressure injury in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to identify a vascular diabetic wound until it was necrotic for one of three residents (R2) reviewed for wounds in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls. This failure applied to one of three residents (R1) reviewed for safety in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was not housed in the same room as a resident that was placed on contact isolation to prevent the spread of infection for one of three residents (R5) reviewed for infection control in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to follow their practice of identifying the name of the resident with the transportation company to ensure that the correct resident was sent to the correct appointment for one of three residents (R5) reviewed for right resident This failure resulted in R5 being dropped off at a non-dialysis clinic. R5 was subsequently taken to hospital for evaluation

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to implement fall prevention interventions for two residents at high risk for falls. This failure affected two of three residents (R2 and R9) reviewed for fall prevention interventions

Inspectors wroteBased on observation, interview and record review, the facility failed to perform assessment to determine safe self-administration for one of one resident (R95) reviewed for self-administration of medication in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy in displaying prominently in the medical record whether a resident has executed an advance directive for one resident (R2) reviewed for code status in a sample of 26 residents.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess at the time of the required comprehensive assessment for one of six residents (R9) reviewed for resident assessment in a sample of 26.

Inspectors wroteBased observation, interview, and record review the facility failed to provide ongoing assessment and revise care plan for a resident who has hearing impairment. This deficiency affects one (R8) of one resident in the sample of 26 reviewed for Sensory impairment.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Providers Orders for Infusion Therapy policy by not obtaining intravenous flush orders at the time intravenous medication is ordered. This failure effects 1 of 2 residents (R112) reviewed for Intravenous administration in a sample of 26. Findings Include: On 7/11/2023 at 12:00 pm, V20 (Nurse) was observed flushing intravenously, 10 milliliters of normal saline, administering R112 intravenous antibiotic therapy, flushing with 10 milliliters of normal saline in the left antecubital by (peripherally inserted central catheter-PICC) line. R112 did not have an order for intravenous flushes. V20 said I thought it was an order for flushing. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing - ADON) said the intravenous flush orders should be obtained when the antibiotic orders where given. [...]

Inspectors wroteBased on interview and record reviewed, the facility failed to follow its policy in developing a post-discharge plan with the resident's family for one resident (R130) reviewed for discharge planning in a sample of 26 residents.

Inspectors wroteBased on observation interview and record review the facility failed to ensure residents who were dependent on staff for shaving and fingernail care received those services for 1 of 5 residents (R112) reviewed for (Activities of Daily Living- ADL) assistance in a sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to follow orders per their Order Summary Report to off load heels while in bed. This failure effects 1 of 8 residents (R112) reviewed for prevention of pressure ulcers in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide range of motion (ROM) exercises to one resident (R34) out of eight residents reviewed for ROM in a sample of 26.