Bria of Elmwood Park: Care Plan Failures After Abuse - IL
That was not the only delay. Across three residents reviewed during a May 2026 complaint inspection, the facility's own care plan coordinator confirmed, one by one, that baseline care plans required within 48 hours of admission had not been completed on time, and in some cases had not been completed at all when inspectors arrived.
The care plan coordinator at Bria of Elmwood Park, identified in inspection records as V14, walked surveyors through the gaps herself. Each time an inspector asked whether a resident had a baseline care plan covering abuse or fall risk, V14 pulled up the electronic medical record and delivered the same answer. No. Or a date that told the story on its own.
The resident known in inspection records as R4 was admitted on March 19, 2026. Four days later, on March 23, the facility generated an incident report documenting her allegation: she had overheard two staff members talking to each other, saying they would choke her out. Her abuse and neglect care plan was not initiated until March 25, six days after she arrived and two days after the threat was reported.
When the surveyor asked V14 on May 21 whether R4's baseline care plan included abuse, V14 reviewed the electronic record and said no.
R1 had been admitted 18 days before anyone opened an abuse care plan. The surveyor asked V14 directly when R1's baseline care plan was initiated for abuse. V14 checked the record and said the date was April 27. R1 had been admitted earlier in April. The math left 18 days unaccounted for.
V14 described the facility's own standard to the surveyor before any of this came out. Within 72 hours of admission, she said, nurses on the floor should be opening a baseline care plan. It would be developed within 48 hours but in the system within 72. That was the expectation. The facility's written policy, revised as recently as September 2025, confirmed it: baseline care plans were to be completed within 48 hours and were required to include, at minimum, fall risk.
Then V14 looked up the records and found that none of the three residents had received what she had just described.
R6 arrived on May 5, 2026. Her admission fall risk evaluation was completed that same day and scored her an 11, placing her in the high-risk category. Eleven days later, on May 16, a staff member entered her room in response to a call light and found her on the floor beside her bed. The fall care plan that should have existed since May 7 was not initiated until May 18, thirteen days after admission and two days after she had already fallen.
There was more in R6's file. On May 14, two days before the fall, her husband reported that a nurse aide had yelled at her. The aide is identified in inspection records as V4, a certified nursing assistant. An abuse care plan was not started until May 17, twelve days after R6's admission and three days after her husband made the report.
When the surveyor asked V14 on May 21 about R6's baseline fall care plan, V14 said: "She doesn't have one." When asked about the abuse care plan, V14 said: "I only have 5/17 the comprehensive."
The comprehensive care plan is a longer, more detailed document developed after the baseline. The baseline is supposed to come first, within 48 hours, so that staff caring for a new resident in those early days know what they are dealing with. A resident scored as high fall risk on day one should have had a fall care plan in place before she ever reached for her call light on day eleven.
The inspection was a complaint survey, meaning someone had prompted regulators to take a closer look before the routine cycle would have brought them in. Inspectors reviewed four residents for abuse and falls. Three of the four had baseline care plan failures documented.
What the care plans are for, in practical terms, is communication. A new resident arrives. Nurses change shifts. Aides rotate. Without a care plan flagging that this particular person is at high risk of falling, or that an abuse allegation has been made and the situation requires monitoring, the information exists somewhere in the record but is not surfaced where it needs to be. The baseline plan is the mechanism that makes the concern visible to whoever walks into the room next.
R6 was assessed as high fall risk the day she arrived. That assessment existed. The care plan that should have translated it into active guidance for floor staff did not exist for nearly two weeks. In the gap, she ended up on the floor.
R4 reported what sounded like a direct threat from staff. The incident report was filed. The care plan meant to document the allegation and shape how staff interacted with her going forward was not opened for six days. In the meantime, the staff members she said had threatened her were presumably still working the floor.
V14's candor with surveyors was notable. She did not dispute the dates. She did not offer explanations for why the care plans had not been completed. She looked up the records and read back what was there, or what wasn't. The facility's own policy said 48 hours. The records said 6 days, 12 days, 13 days, 18 days.
CMS assigned this deficiency a harm level of minimal harm or potential for actual harm, the lower end of the scale. R6 had already fallen before her fall care plan existed. Whether the care plan's absence contributed to that outcome, the inspection record does not say. What it says is that a woman scored high risk for falls on the day she was admitted did not have a fall care plan when she hit the floor eleven days later.
R4's husband, if she has one, is not mentioned in the record. What is mentioned is that she told the facility she overheard staff say they would choke her out, and the facility took six days to formally document that in a care plan. Whatever conversations happened in her room during those six days, whatever staff came and went, they did so without a care plan in the system reflecting what she had reported.
The facility's policy on baseline care plans had been revised seven months before the inspection. The revision did not change what inspectors found when they arrived in May.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Elmwood Park from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
BRIA OF ELMWOOD PARK in ELMWOOD PARK, IL was cited for abuse-related violations during a health inspection on May 27, 2026.
The care plan coordinator at Bria of Elmwood Park, identified in inspection records as V14, walked surveyors through the gaps herself.
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.