Bria of Elmwood Park: Resident Property Violations - IL
What she found when she checked: nothing. No vital signs documented, except oxygen saturation. No SBAR form. No physical assessment.
The resident died.
Federal inspectors who visited Bria of Elmwood Park on December 1, 2025, cited the facility for a deficiency causing actual harm, the second-most serious level of harm in the federal rating system, one step below immediate jeopardy. The citation covered the care provided to R2 on the night a change in condition was recorded at 10:35 p.m. What followed that notation, according to the inspection record, was a cascade of failures that the facility's own medical director said could increase the risk of death.
The nurse assigned to R2 that night is identified in inspection records as V7. When the surveyor later asked the Director of Nursing, identified as V2, whether V7 had documented vital signs during R2's change in condition, V2 reviewed the progress note and said: "Not in this note, she didn't have any vital signs in this particular note," adding the exception of oxygen saturation. When the surveyor asked whether V7 had completed an SBAR, the structured communication form used during patient handoffs and emergencies, V2 said: "I didn't see one." When the surveyor asked whether an SBAR was supposed to be completed for a resident change in condition, V2 said: "Yes, it is."
The Director of Nursing knew what was required. She acknowledged it, item by item, to the surveyor. The assessment. The vital signs. The SBAR. All of it was supposed to happen. None of it did.
The facility's Medical Director, identified as V8, was interviewed the following day. He described exactly what a nurse should do when a resident is experiencing respiratory distress: check oxygen saturation, heart rate, and blood pressure. Observe whether the resident is alert, whether they are diaphoretic, whether they are using accessory muscles to breathe. Listen to the lungs for wheezing, crackles, or the absence of sound altogether. "All of them," he said, when asked which vital signs should be obtained.
The surveyor then asked V8 a direct question: what is the potential harm to a resident if staff fail to obtain vital signs, fail to conduct a physical assessment, and fail to report actual changes in condition to EMS or a healthcare provider?
"I guess increased mortality and morbidity," V8 replied.
R2's certificate of death confirms the resident died.
The inspection record does not specify what caused R2's death or whether the care failures that night were the direct cause. What it does establish is that a resident in respiratory distress did not receive a complete assessment, did not have vital signs documented, and was not given the benefit of a properly completed handoff form before whatever happened next. EMS response time to the facility, according to V2, runs between five and ten minutes. Whether EMS was called that night, and what information they received if they were, is not detailed in the portion of the inspection record provided.
What the record does detail is what the facility's own policies required and what the facility's own leaders acknowledged was not done.
The facility's change-in-condition policy, as cited by inspectors, instructs nursing staff to notify the resident's physician or nurse practitioner when there is a significant change in physical, mental, or emotional status. The respiratory care monitoring policy, revised as recently as October 2024, states that any change in a resident's condition will be identified, and that if the change requires immediate intervention, including difficulty breathing or a resident in distress, the assessment will be completed and appropriate interventions implemented.
The policy was revised two months before R2.'s change in condition occurred. The assessment was not completed.
There is a particular quality to the Director of Nursing's answers in the inspection record. She is not evasive. She does not claim the nurse did everything correctly. She reviews the chart, finds what is missing, and confirms it is missing. She confirms that an SBAR was required. She confirms that vital signs should have been documented. She says, of the vital signs: "Not in this note." She says, of the SBAR: "I didn't see one."
The surveyor asked V2 how long EMS typically takes to arrive when 911 is called. V2 answered without apparent awareness of where the question was leading. "It takes em a couple of minutes to come here, between 5 and 10 minutes, they come rolling up," she said.
Five to ten minutes is a short window. It is also long enough that what a nurse documents, communicates, and hands off before that ambulance arrives can determine what paramedics know, what they treat, and how fast they move. An SBAR exists precisely because verbal handoffs in emergencies are incomplete. A nurse who does not fill one out leaves the next set of hands working from less information than they should have.
The medical director said the failures risked increased mortality. The death certificate confirms the resident died. The inspection record does not say whether anyone at the facility connected those two facts before federal surveyors arrived and began asking questions.
Bria of Elmwood Park is located at 7733 West Grand Avenue in Elmwood Park, a western suburb of Chicago. The December 1 inspection was a complaint survey, meaning it was triggered by a specific allegation rather than a routine annual review.
The facility received a deficiency tag of F0684, which covers the standard requiring that residents receive care that reflects current professional standards of practice. The level of harm was rated as actual harm, meaning inspectors determined that a resident suffered real injury or deterioration as a result of the deficiency, not merely that harm was possible. The number of residents affected was listed as few.
One of them did not survive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Elmwood Park from 2025-12-01 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: August 6, 2026 · Our methodology
BRIA OF ELMWOOD PARK in ELMWOOD PARK, IL was cited for violations during a health inspection on December 1, 2025.
What she found when she checked: nothing.
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.