Bria Of Cahokia

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8/20/25.1. Resident R5 returned to the facility and has been on 1:1 supervision since returning. Facility is looking for alternate placement for Resident R5. 8/13/25 Completed by V1, Administrator/V35 SSD (social services director) RNC (regional nurse consultant) in-serviced V2, Director of Nurses, (DON) and V1, Administrator on elopement policy 8/14/25 completed by V14, RN (registered nurse) RNC V2, DON/Designees to provide in-serving on elopement policy to all staff by 8/20/25 or prior to the start of their next shift. All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool completed 8/14/25.

Completed by DON/SSD All residents identified as at risk for elopements have had their care plans reviewed by the V36, MDS (minimum data set) nurses for resident specific interventions. Completed 8/14/25 The elopement binder was reviewed by the Regional Nurse Consultant, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. Completed 8/14/25. Facility has 24 Hour a day Receptionist from 8/13/25 revised by V1, Administrator/Lead Receptionist V1, Administrator/Designee In-Serviced All Receptionist on not leaving the Front Desk unattended 8/13/25. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion Date: 8/20/25 The DON/designee will in-service staff on facility elopement policy once a month for the next 3 months. The DON/designee will audit all new admissions and readmissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. A QAPI (Quality Assurance and Performance Improvement) PIP (performance improvement plan) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA (quality assurance and assessment) meeting. Monitoring/auditing and reporting will continue for a minimum of three months.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bria of Cahokia

3354 Jerome Lane Cahokia, IL 62206

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and observation the facility failed to assist with financial matters for 1 out of 1 residents (Resident R2) reviewed for social services in the sample of 8. Findings include:Resident R2's Face Sheet documented he was admitted to the facility on [DATE REDACTED] with diagnoses of, in part, metabolic encephalopathy, type two diabetes mellitus, artificial left eye, lack of coordination, dementia, and cognitive communication deficit.Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED] documented he was moderately cognitively impaired and required supervision or touching assistance with transfers and ambulation. Resident R2's Care Plan dated 6/2/25 documented

he required assistance with daily care needs related to safety concerns and has impaired vision related to his left eye prosthesis.On 8/14/25 at 11:45 AM, Resident R2 could not answer appropriately when asked if he every goes to the bank or if he wanted to close his bank account out. Resident R2 could not recall going to the bank.On 8/19/25 at 12:15 PM, V1, Administrator, stated Resident R2 had recently gone out to the bank and the teller called us and said she was going to call us into the state. V1 stated Resident R2 was brought to the bank by V15, Medical Records, and V17, Transportation, to get Resident R2's bank statements. V1 stated Resident R2 needed to get his bank statements because of a Medicaid Spend Down issue. V1 stated it was discovered during Resident R2's redetermination that he had too much money in his account for Medicaid to enroll him. V1 stated Resident R2's bank account statements were needed for this process in order for Resident R2 to be eligible for Medicaid. On 8/19/25 at 12:24 PM, V16, Regional Business of Manager, stated the State of Illinois was needing Resident R2's bank account statements for redetermination for Medicaid but he couldn't access his accounts when he went to the bank because he had no identification. V16 stated now we are in the process of getting him proper identification to be able to get his account information. On 8/19/25 at 12:30 PM, V15, Medical Record, stated V16 needed Resident R2 to go to the bank. V15 stated she went to Resident R2's room and explained everything that was going on and what was needed. V15 stated V17 was the one who took Resident R2 to the bank. V15 stated while Resident R2 was at

the bank, the bank teller called her and was concerned about what Resident R2 needed. V15 stated she explained everything about Medicaid and redetermination to the teller over the phone, but she had seemed questionable about what was going on and because Resident R2 didn't have identification, she wasn't able to do anything. V15 stated she's not sure how transportation handles taking residents to the bank, but she thinks if he was alert and ambulating then he went in by himself but V15 went in soon after.On 8/19/25 at 12:37 PM, V17, Transportation, stated he took Resident R2 to the bank but wasn't sure why, only that the business office needed him to go. V17 stated he got Resident R2 inside the bank with the teller and then waited in the van until he was flagged down by the teller because Resident R2 couldn't communication or articulate to them what he needed done. V17 stated Resident R2 used his walker to ambulate. V17 stated the bank called V15 for clarification but they were not able to complete anything due to Resident R2 not having proper identification on him. On 8/20/25 at 9:50 AM, V1, Administrator, stated she would have expected Resident R2 to be accompanied by a staff member at the bank with providing assistance and assumed that had taken place. The facility's Resident Rights Policy dated 8/1/22 documented the facility strives to consistently and fully comply with the various laws and regulations, including but not limited to the treatment, services and needs of residents to attain or maintain residents' highest practicable physical, mental and psychosocial well-being. The policy continued to document the facility shall safeguard residents' financial affairs.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet