Cycle 1
Health 2024-10-03 · Fire 2024-10-03
3 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Bridgeview, IL
Pavilion Of Bridgeview, The
4-star overall rating with 4-star inspections with $29,706 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
8100 South Harlem Avenue, Bridgeview, IL
(708) 594-5440
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
126
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pavilion Healthcare
Operator or chain grouping
Approved since
1969-07-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
2.36
CMS adjusted total nurse staffing hours
Case-mix index
1.87
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,809
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.55
Baseline 19.54% · Performance 19.79% · Measure score 3.55 · Achievement 3.55 · Improvement 0
Healthcare-associated infections
4.50
Baseline 10.52% · Performance 7.76% · Measure score 4.50 · Achievement 0 · Improvement 4.50
Total nurse turnover
5.94
Baseline 52.22% · Performance 39.42% · Measure score 5.94 · Achievement 5.94 · Improvement 4.18
Adjusted total nurse staffing
0
Baseline 2.30 hours · Performance 2.47 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.95% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 15.18% · Lower 95% interval 8.48% |
| Discharge to community | 31.38% |
50.57%
19.2 pts worse
|
Worse than the National Rate · Eligible stays 94 · Observed rate 21.28% · Lower 95% interval 23.75% |
| Medicare spending per beneficiary | 1.57 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 98.81% |
95.27%
3.5 pts better
|
Numerator 83 · Denominator 84 |
| Falls with major injury | 1.19% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 84 |
| Discharge self-care score | 24.49% |
53.69%
29.2 pts worse
|
Numerator 12 · Denominator 49 |
| Discharge mobility score | 22.45% |
50.94%
28.5 pts worse
|
Numerator 11 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 84 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 10.14% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 138 |
| Staff flu vaccination coverage | 15.19% |
42%
26.8 pts worse
|
Numerator 36 · Denominator 237 |
| Discharge function score | 26.53% |
56.45%
29.9 pts worse
|
Numerator 13 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 5 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.1% |
89.6%
15.5 pts worse
|
93.4%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.4% · Q2 66.9% · Q3 71.9% · Q4 76.0% · 4Q avg 74.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.7% |
91.6%
15.9 pts worse
|
95.5%
19.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.2% |
3.3%
3.1 pts better
|
3.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.7% |
50.3%
48.4 pts worse
|
11.4%
87.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
6.5%
0.7 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.7% · Q3 6.4% · Q4 7.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
18.5%
11.3 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.2% · Q3 6.2% · Q4 7.8% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
22.8%
0.1 pts better
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 22.4% · Q3 23.5% · Q4 25.0% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
17.2%
1.6 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
15.0%
4.1 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.4% · Q3 15.3% · Q4 4.7% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.5% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
21.3%
0.5 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 19.0% · Q3 26.1% · Q4 23.3% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.2%
2.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.7% · Q3 7.1% · Q4 7.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 6.3% |
68.8%
62.5 pts worse
|
81.7%
75.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 6.0% · Q3 3.6% · Q4 4.9% · 4Q avg 6.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
14.0%
6.2 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 8.1% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.3%
0.4 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.4% · Q3 2.1% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 14.1% |
63.0%
48.9 pts worse
|
79.7%
65.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 14.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.5% |
26.2%
10.3 pts worse
|
23.9%
12.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.5% · Observed 41.9% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-14 · Fire 2023-07-14
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-04-22 · Fire 2022-04-22
17 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-23
F · Potential for more than minimal harm
2023-07-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-07-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-08-10
F · Potential for more than minimal harm
2022-04-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-05-10
Inspection history
Recent health citations
C · Minimal harm
2025-12-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-21
G · Actual harm
2025-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-29
D · Potential for more than minimal harm
2024-10-03
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-05-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-05-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-05-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-20
D · Potential for more than minimal harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-07-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-14
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-07-18
G · Actual harm
2023-06-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-14
G · Actual harm
2023-06-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-06-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-20
G · Actual harm
2022-04-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-16
F · Potential for more than minimal harm
2022-04-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-16
E · Potential for more than minimal harm
2022-04-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-05-16
E · Potential for more than minimal harm
2022-04-22
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-05-16
E · Potential for more than minimal harm
2022-04-22
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-05-16
Penalties and ownership
What sits behind the stars
$8,938
2023-06-16
Fine
Fine · fine $8,938
Fine
$20,768
2023-06-16
Fine
Fine · fine $20,768
Fine
$0
2023-06-16
Payment Denial
Payment Denial · denial start 2023-07-14 · 4 days
4 day denial
Ownership
Aaron, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Stern Family Investment Tr
5% Or Greater Direct Ownership Interest · Organization
Todd A Stern 2015 Irrv Ins Tr
5% Or Greater Direct Ownership Interest · Organization
Ilana D Aaron Trust C/U Maurice Aaron 2014 Family Gift Trust
5% Or Greater Direct Ownership Interest · Organization
Ripstein, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Ilana D Aaron Trust C/U Maurice Aaron 2014 Legacy Gift Trust
5% Or Greater Direct Ownership Interest · Organization
Stern, Raphaela
5% Or Greater Direct Ownership Interest · Individual
Stern, Todd
5% Or Greater Direct Ownership Interest · Individual
Graf, Marcella
Corporate Officer · Individual
Graf, Marcella
W-2 Managing Employee · Individual
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