Bria Of Elmwood Park

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

he did a reportable for missing snap benefits for her (Resident R4), he (V1) said no. On 12/1/25 at 2:07pm, surveyor inquired about the facility policy for reported theft of funds. V1 (Administrator) stated, If someone reported missing funds, we (staff) would have to do an investigation and report it, to IDPH. Surveyor inquired if Resident R4's alleged stolen SNAP benefits was investigated. V1 responded, The way it was explained at the time was that she (Resident R4) wasn't a resident when they were missing and when she moved in here (facility) her (Resident R4) benefits would have been canceled. So, no we (facility) did not report it because the way it was explained is that it happened prior to moving in the building. Surveyor inquired why Resident R4's theft allegation was not reported to IDPH. V1 responded, Again, what was reported to me (V1) is 1) her (Resident R4) benefits would have stopped already when she was admitted here and 2) it was reported that this happened prior to coming here. Surveyor inquired if V1 spoke with Resident R4 about the stolen SNAP benefits. V1 replied, No, I was going on

the information that was brought to me that this was something that happened prior to being a resident here. Considering reasonable person concept, Resident R4's (2/11/25) progress note, and resident/staff statements

the facility was made aware of Resident R4's link card concerns/theft of SNAP benefits - reported roughly 6 weeks

after admission (not when she first admitted - as alleged). The facility abuse prevention policy (reviewed 9/2017) includes misappropriation of resident property: the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent.

Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to

the administrator immediately. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Reports will be documented and a record kept of the documentation. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. The results of the investigation will be forwarded to the Illinois Department of Public Health within seven working days of the reported incident. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken.

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If continuation sheet

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

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bria of Elmwood Park

7733 West Grand Avenue Elmwood Park, IL 60707

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 0684 Level of Harm - Actual harm Residents Affected - Few

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

documented (Resident R2's change in condition occurred at 10:35pm). On [DATE REDACTED] at 1:50pm, surveyor inquired about staff requirements for resident change in condition. V2 (Director of Nursing) stated, They (staff) need to do an assessment and notify the doctor. Surveyor inquired what an assessment entails. V2 responded, A head to toe assessment and vitals. Surveyor inquired where resident vital signs are documented. V2 replied, In the chart. Surveyor inquired if V7 charted Resident R2's vital signs on ([DATE REDACTED]) V2 stated I'm not really sure I do have to go back into the notes to see. V2 subsequently reviewed Resident R2's ([DATE REDACTED]) progress note and responded, Not in this note, she (V7) didn't have any vital signs in this particular note (except oxygen saturation). Surveyor inquired how many minutes it usually takes for EMS to arrive to the facility when 911 is called V2 replied It take em a couple of minutes to come here between 5 and 10 minutes they come rolling up. Surveyor inquired if V7 filled out an SBAR (which provides a structured framework for healthcare professionals to quickly and clearly share critical information about a patient, especially during handoffs) for Resident R2's ([DATE REDACTED]) change in condition V2 stated I (V2) didn't see one. Surveyor inquired if an SBAR is supposed to be filled out for resident change in condition V2 responded Yes, it is. On [DATE REDACTED] at 11:13am, surveyor inquired about facility staff requirements for resident change in condition. V8 (Medical Director) stated, I would expect them (staff) to get vitals and then contact the provider. Surveyor inquired which vital signs should be obtained for a resident experiencing respiratory distress. V8 responded, The oxygen saturation, heart rate, blood pressure, all of them. Surveyor inquired if a resident is in respiratory distress which assessments should be conducted V8 replied I would expect them to see if they're alert, diaphoretic, are they struggling using accessory muscles, listen to their lungs to see if they have wheezing, crackles, or no sounds at all. Surveyor inquired about potential harm to a resident if staff fail to obtain vital signs, fail to conduct a physical assessment and/or fail to report actual changes in condition to EMS and/or healthcare provider. V8 stated, I guess increased mortality and morbidity. Resident R1's Certificate of Death affirms death occurred on [DATE REDACTED]. The ([DATE REDACTED]) facility change in resident condition policy states nursing will notify the resident's physician or nurse practitioner when: there is a significant change in the resident's physical, mental or emotional status [Physical Assessment, Vital Signs, and SBAR are excluded]. The facility Respiratory Care Monitoring policy (revised 10/2024) states any change in the resident's condition will be identified such as difficulty breathing, changes in color, change in mental status, or other changes that my signal further evaluation is needed. If the change requires immediate intervention (resident is in distress, having difficulty breathing) the assessment will be completed and appropriate interventions implemented.

Event ID:

Facility ID:

If continuation sheet

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

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bria of Elmwood Park

7733 West Grand Avenue Elmwood Park, IL 60707

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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

first I'm hearing of it. On 12/1/25 at 12:17pm, V11 inspected the (4th floor) North tub/shower door (as requested) and affirmed it did not latch when the door was closed. V11 subsequently inspected the door and stated Somebody flipped this around, this is the wrong way. Somebody put the throw on wrong. I will have that fixed today. On 12/1/25 at approximately 12:30pm, V11 stated that the facility does not have a policy for maintaining equipment therefore surveyor requested the facility maintenance policy. The (10/2024) facility preventive maintenance plan states proof of inspections will be record in the electronic system or on paper trackers provided. Monthly inspections: check door contacts. Surveyor requested documentation of facility door inspections on 12/1/25 however V11 affirmed that only the fire doors are inspected, documentation was not received.

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If continuation sheet