Bria Of Elmwood Park
Inspection Findings
F-Tag F0725
F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Based on interview and record review, the facility failed to ensure adequate staffing of certified nursing aides and implement an effective system in place for call-offs on the night shift. This failure has the potential to affect all residents residing on the first floor.Findings Include:Based on Facility Census Report dated 9/30/2025, there were 38 residents residing on the first floor.Facility Assessment Tool dated 8/1/2025 with
review date of 10/1/2025 shows the facility will staff 10 CNAs in total on the night shift.Facility Staffing Sheets dated 9/9/2025-9/28/2025, showed 6 night shifts out of 20 reviewed, were staffed with less than 10 CNA's.On 9/29/2025 at 11:45AM, Resident R3 said at nighttime he has to wait a long time for his call light to be answered.At 11:50AM, V5 (Registered Nurse) said she works both night and day shift. V5 said on the night shift there are sometimes not enough CNA's, and there are times where they work on the first floor with only two CNA's. V5 said she feels as if that is not enough staff to adequately care for all the residents. Staff have expressed concern to management.At 12:48PM, V6 (Certified Nursing Aide) said I typically work the first floor on the night shift. V6 said we are scheduled to have three CNA's but on multiple occasions we only work with two on the floor. I do not believe the residents receive adequate care. The first floor residents are high maintenance and require a higher level of care. When we have call-offs the management staff do not try hard to find a replacement or give us acceptable coverage for this shift.At 12:57PM, V8 (Licensed Practical Nurse) said I typically work on the first floor at night. We have a lot of residents who require a higher level of care on the first floor and they do not adequately staff this floor at night. At times there are approximately 20 residents that are dependent on staff for their ADL's (Activities of Daily Living) and require total care. These residents require more assistance than only two CNA's can provide, and it is not fair to
these residents.At 1:15PM, V7 (Certified Nursing Assistant) said we frequently work on night shift on the first floor with only two CNA's. They continue to schedule staff and they do not show up to their shift. They provide us with no coverage when a CNA calls off or a CNA is pulled off the first floor to go to another floor causing the first floor to be short staffed.At 1:23PM, V9 (Licensed Practical Nurse) said I work the night shift
on the first floor often. V9 said when there is a call off at night, the management team will pull our third CNA to go to another floor causing the first floor to be short staffed. The first floor residents are dependent on staff and some even require two person assistance. It is very difficult to provide adequate care to all the residents with only two CNA's at night. The night staffing issue has been a problem for months and it feels like at least 1-2 days a week we are short staffed.At 1:45PM, V3 (Director of Scheduling) said I am responsible for scheduling for the nursing department. We schedule 10 CNA's in total at night time. I am also responsible to provide coverage when a call-off occurs. I will reach out to staff but typically no one answers. V3 said we can work with two CNA's on each floor and we do the best we can. I do not feel as if
the first floor can provide the same amount of care to the residents as they can if they had three CNA's.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BRIA OF ELMWOOD PARK in ELMWOOD PARK, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ELMWOOD PARK, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRIA OF ELMWOOD PARK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.