Bria of Elmwood Park: Tube Feeding Stopped Without Notice - IL
The man, identified in inspection records as Resident 11, is dependent on staff for every aspect of daily life. His medical history includes anoxic brain damage, a stage 4 pressure ulcer on his sacral region, acute and chronic respiratory failure, a tracheostomy, a gastrostomy, and a personal history of sudden cardiac arrest. He has severely impaired memory. He cannot eat by mouth. The tube feeding discontinued on March 6, 2026, was his only source of nutrition.
When inspectors interviewed the dietitian, identified as V43, on March 26, she said the last time she had seen Resident 11 was March 3. He was on tube feeding then. On March 4 he was also receiving hydration therapy. She had no idea the feeding had been stopped.
"I was blindsided with this decision," she told inspectors. "No one notified her that resident's feeding was stopped." She said the floor nurse should have told her about any change to the resident's diet.
The nurse who received and acted on the discontinuation order was V7, a licensed practical nurse. His account, given to inspectors that same afternoon, was direct. He received an order to stop the feeding. He stopped it. He did not document it in the resident's record. He did not write a progress note. He did not notify the dietitian. He did not notify the doctor.
"He stated that he should have documented and notified the doctor and dietitian of the changes," inspectors wrote, summarizing what V7 told them.
The Director of Nursing, V2, was interviewed earlier that day. She described how the facility is supposed to work: hospice staff come in, carry out their orders, and the floor nurse collaborates with the physician and verifies anything unclear. "The floor nurse that received the feeding orders for R11 should have verified it with the physician, notify dietitian and document the order in resident's record," V2 said.
None of that happened.
The care plan for Resident 11, initiated April 1, 2025, listed him as NPO, meaning nothing by mouth, and documented that enteral feeding met all his nutrition needs. Interventions included adjusting the tube feeding as needed, monitoring his weight, labs, skin, and hydration, and referring to the dietitian as needed. The last active feeding order called for a continuous infusion of 1,200 milliliters daily. That order was discontinued March 6, 2026.
There is no documentation in the record of who authorized the discontinuation, whether a physician signed off, or what clinical reasoning supported stopping nutrition for a man with severe malnutrition listed in his own medical history.
The inspection report notes that the failure to properly document controlled substances, a separate but related concern flagged in the same citation, can be interpreted by the DEA and the Board of Pharmacy as negligence or misappropriation. The broader finding covers the facility's handling of medication and nutrition records across multiple residents.
But the starkest fact in the report is the simplest one: a man who cannot speak for himself, cannot advocate for a meal, cannot call down the hallway for a nurse, had his only source of nutrition removed without a single written word to explain why or who decided it was appropriate.
The dietitian who had been responsible for monitoring his weight and nutritional status found out from inspectors, not from the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Elmwood Park from 2026-03-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
BRIA OF ELMWOOD PARK in ELMWOOD PARK, IL was cited for violations during a health inspection on March 29, 2026.
The man, identified in inspection records as Resident 11, is dependent on staff for every aspect of daily life.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.