Inspection Reports for
The Bridgeview Post Acute

The complaint investigation found that Resident 4 was left alone on a patio for 30 minutes by Restorative Nursing Assistant H, resulting in a fall and subdural hematoma. The injury was not reported timely by the facility. Interviews with staff including the Facility Administrator and Director of Nursing confirmed the failure to report and inadequate supervision. Resident 4 was hospitalized, placed on hospice care, and died 13 days after the fall.

The facility failed to report a major injury for Resident 4, who was left unsupervised on a patio for 30 minutes, fell, and sustained a subdural hematoma. This failure delayed investigation and resulted in Resident 4's decline and eventual death. Additionally, the facility failed to provide adequate supervision and activities consistent with Resident 4's care plan, and staff lacked appropriate competencies to care for Resident 4.

The complaint investigation found that the facility did not report an abuse incident involving Resident 4 being slapped by Resident 5 on 6/20/25. The facility staff misunderstood reporting requirements related to perpetrators with dementia. The complaint is substantiated.

The facility failed to report an abuse allegation involving Resident 4 being slapped by Resident 5 on 6/20/25. The incident was not reported to the state licensing/certification agency due to a misunderstanding that abuse involving a perpetrator with dementia did not require reporting.

The investigation focused on two residents (Resident 1 and Resident 2) with multiple falls. Resident 1 had eleven falls since admission with inadequate evaluation of interventions and supervision. Resident 2 had moderate fall risk with cognitive impairment and ineffective interventions such as reminders to use call light. The Director of Nursing confirmed ongoing issues with fall prevention, lack of CNA involvement in care planning, and insufficient evaluation of intervention effectiveness.

The facility failed to ensure residents were free from accidents and hazards by not adequately evaluating post-fall causes, not reassessing care plan interventions for effectiveness, and not developing new interventions to prevent further falls. Staff lacked knowledge on identifying high fall risk residents and their fall care plans, resulting in multiple repeated falls and potential risk to all residents.

The facility failed to maintain a safe and homelike environment by improperly storing construction materials, including laminate flooring and paint/adhesive cans, in a resident room. This created potential hazards and discomfort for residents, violating facility policies and OSHA standards.

The complaint investigation was triggered by multiple allegations including failure to provide privacy during personal care, staff speaking non-English languages in front of residents, loud night shifts, and abuse allegations involving physical and emotional mistreatment of residents. The investigation found substantiated issues of dignity violations, abuse, neglect, and failure to report and investigate abuse allegations.

The facility failed to ensure residents were treated with dignity and respect, including failure to provide privacy during personal care, staff speaking non-English languages in front of residents, and loud noise during night shifts. The facility also failed to protect residents from abuse, including physical abuse by staff and neglect, and failed to timely report and investigate allegations of abuse. Emotional distress and potential harm to residents were noted.

The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, failure to prevent and report abuse, inadequate investigation of abuse allegations, incomplete transfer documentation, failure to ensure non-skid footwear for fall prevention, improper gastrostomy tube care, incomplete physician progress notes, inadequate nursing competencies, failure to limit psychotropic medication use, improper medication storage and labeling, failure to provide timely dental care, failure to honor food preferences, poor food quality and temperature, inadequate social services, and unsanitary kitchen conditions.

The complaint investigation focused on Resident 1 who was administered psychotropic medication without informed consent or clinical indication, and whose physician-ordered BiPAP respiratory treatment was not implemented for 14 days, resulting in respiratory failure and hospitalization. The facility also failed to create accurate assessments and care plans, and nursing staff lacked training on BiPAP use.

The facility failed to ensure informed consent was obtained before administering psychotropic medication, failed to implement physician-ordered BiPAP respiratory treatment for 14 days resulting in emergent hospitalization, and failed to create accurate admission assessments and baseline care plans. The Medical Director did not adequately supervise care plans and medication use.

The complaint investigation was triggered by allegations of staff to resident abuse involving three residents (Resident 63, 74, and 86). The facility failed to report these allegations to mandated agencies and failed to investigate them properly.

The facility failed to timely report suspected abuse allegations for three residents, failed to provide accurate assessments and baseline care plans, did not ensure professional standards of care for skin conditions, failed to provide scheduled bathing and grooming assistance, and did not have physician orders for certain treatments applied.

The facility had multiple deficiencies including failure to provide dignified care, communication barriers, unresolved resident complaints, failure to notify physicians of significant weight loss, privacy issues, environmental maintenance problems, failure to timely report and investigate abuse allegations, incomplete care plans, inadequate assistance with activities of daily living, hearing aid maintenance issues, pressure ulcer care deficiencies, nutritional monitoring failures, pain management delays, insufficient staffing, inadequate staff competency evaluations, food service and safety violations, and ineffective quality assurance processes.

The complaint investigation found that the facility did not obtain informed consent before administering lorazepam, failed to conduct behavioral health evaluations or psychiatric referrals for Resident 1, and administered unnecessary psychotropic medication without clinical justification, resulting in potential harm and risk of falls.

The facility failed to obtain informed consent before administering lorazepam to Resident 1, did not provide necessary behavioral health evaluations or psychiatric services, and administered an unnecessary psychotropic medication without clinical justification, putting Resident 1 at risk for adverse effects and falls.

The facility failed to maintain a safe, clean, and homelike environment due to disrepair of tile and presence of dirty, standing water in two shower rooms. These conditions had the potential to promote disease spread and cause resident anxiety.

The facility failed to maintain two shower rooms in a safe and clean condition, with tile in disrepair and dirty standing water present, which could promote the growth and spread of disease-causing germs and cause resident anxiety.

The investigation was complaint-driven based on reports of a resident possessing a firearm in the facility and multiple complaints about food quality and meal delivery timeliness. The firearm incident was substantiated with policy violations noted. Food complaints were substantiated by resident interviews and observations.

The facility failed to follow its firearms policy when a resident brought a gun into the facility, creating a potential safety hazard. Additionally, multiple residents reported that meals were often late, unpalatable, and served at unsafe temperatures, resulting in dissatisfaction and potential health risks.

The complaint investigation focused on Resident 1, who experienced a significant change in condition including shortness of breath requiring oxygen, elevated blood sugars, and low blood pressure leading to holding of heart medications. The facility failed to update the care plan, notify the physician fully, and monitor the resident adequately. This resulted in Resident 1's condition worsening and requiring ICU admission for severe sepsis and pneumonia.

The facility failed to ensure that Resident 1's care plan was updated by the interdisciplinary team following a significant change in condition. This failure led to inadequate monitoring, lack of communication with the physician, and delayed interventions, resulting in Resident 1's condition deteriorating and requiring emergency hospital admission to the ICU with diagnoses including sepsis and pneumonia.

The complaint investigation focused on the facility's failure to obtain accurate code status and advance directives for residents, specifically Residents 212 and 106, which posed a risk of not honoring residents' healthcare decisions.

The facility failed to obtain accurate Physician Orders for Life-Sustaining Treatment (POLST) and advance directives reflecting residents' wishes for two residents, R212 and R106. Additional deficiencies included failure to assess significant changes in condition, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, lack of care planning for edentulous residents, failure to provide adequate incontinence care, inadequate hand hygiene during wound care, and unsafe environmental conditions such as hazardous decorations and broken faucet knobs.

The facility was found deficient in multiple areas including failure to obtain accurate code status and advance directives for residents, incomplete significant change assessments, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, lack of care planning for dental needs, failure to provide therapy for decline in activities of daily living, inadequate incontinence care, insufficient hand hygiene during wound care, and environmental safety hazards such as fire hazards and broken faucet knobs.