Bria Of Elmwood Park
BRIA OF ELMWOOD PARK in ELMWOOD PARK, IL — inspection on December 24, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
medication have therapeutic laboratory level, have routine labs per doctor's order, following facility
jeopardy to resident health or action was initiated and was completed on [DATE] at 9:30pm)C.
The Medical Director, Administrator safety and DON reviewed the facility's policies which include but are not limited to:Policy of Critical Lab Result Reporting Critical Medications Requiring Laboratory MonitoringThis was initiated, reviewed
Designee.All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work.
The staff members will also be provided with the same educational materials. E.
The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift.
The Administrator/DON will send the same training materials to the staffing agency. (This immediate action was initiated and was completed on [DATE] at 9:30pm)Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first.F.
The DON/ADON/designee will conduct daily audits to identify any potential concerns related to this plan of removal. (This immediate action was initiated on [DATE], daily times 4 weeks then weekly times 8 weeks, then monthly x 3)G.
The DON/ADON/Designee will also conduct staff (nurses and agency) interview, with at least five employees, daily to gauge knowledge retention and determine if additional training is required. (This immediate action was initiated on [DATE], daily times 4 weeks then weekly times 8 weeks, then monthly x 3) H. I.
During the weekends, the assigned Nursing Supervisor/Designee will conduct the daily audit, ensuring time sensitive critical medication, recognizing therapeutic laboratory level, conduct routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
Any identified concern will be addressed immediately. (This immediate action was initiated on [DATE] daily for 4 weeks then weekly times 8 weeks, then monthly x 3) J. To ensure compliance, the results of the audit will be reviewed daily during the meeting which is attended by the clinical leadership which includes but is not limited to the: DON, ADON, MDS, IP, Restorative, and the Administrator/Designee. (This immediate action was initiated on [DATE] daily for 4 weeks then weekly times 8 weeks, then monthly x 3) K.
Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI.
The facility will reinforce the following process.L.
All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance. (This immediate action was initiated on [DATE], daily times 4 weeks then weekly times 8 weeks, then monthly x 3) M.
The Administrator, DON and Designee will monitor completion of this plan of removal.
Date Facility Asserts Likelihood for Serious Harm No Longer Exists: Completion Date: [DATE]
145419 12/24/2025
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
we need to recheck labs then that can play a role in the management as well. I have not been aware
particular. I would have definitely remembered a potassium of 2.0. I know she has called me before.
they need to call me or they can also call telehealth after hours. I recommended educating nursing to understand what is meaning of critical lab values. If we had been following her, we would have seen the potassium trending up and intervened.
The main concern with a potassium of 8.4 is the risk of arrhythmia (irregular or abnormal heart rhythm).
Record review showed that R1 was found unresponsive in the facility on [DATE], four days after the facility obtained the critically abnormal potassium result.R1's death certificate lists date of death as [DATE] and includes cause of death as cardiopulmonary arrest with other comorbidities.
Per the American Academy of Family Physicians: Treatment of Hyperkalemia: GENERAL PRINCIPLES: The goals of acute treatment are to prevent potentially life-threatening cardiac conduction and neuromuscular disturbances, shift potassium into cells, eliminate excess potassium, and resolve the underlying disturbance .Indications for prompt intervention are symptoms of hyperkalemia, changes on ECG, severe hyperkalemia (greater than 6.5 mEq per L), rapid-onset hyperkalemia, or underlying heart disease, cirrhosis, or kidney disease.24,30,33-35 Potassium should be monitored often because patients are at risk of redeveloping hyperkalemia until the underlying disorder is corrected and excess potassium is eliminated.Facility Policy, Critical Medications Requiring Laboratory Monitoring [DATE], reads: Purpose:To ensure resident safety by identifying medications that require ongoing laboratory monitoring, early detection of adverse effects, and timely clinical intervention to prevent deterioration, medication errors, and unplanned hospitalization.Definition: Critical MedicationA critical medication is any medication that:Has a narrow therapeutic rangeCan cause serious harm if levels are too high or too lowRequires scheduled or symptom-triggered lab monitoringHas a high risk for hospitalization if not monitored appropriatelyGeneral Monitoring Expectations (All Critical Medications)Baseline labs obtained prior to initiation (or verified on admission).Routine lab monitoring per Medical Provider order.PRN / symptom-triggered labs when change in condition occurs.Critical values reported immediately to provider.Nursing assessment documented with lab review.Care plan updated to reflect medication risk and monitoring needs.High-Risk Medications & Required Lab Monitoring but not limited to: 1.
Potassium (KCl oral)2.
Warfarin (Coumadin)3.
Digoxin4.
Vancomycin
145419 12/24/2025
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
and then the other thing I advised is if it's a critical lab they need to call me or they can also call
jeopardy to resident health or values.The main concern with a potassium of 8.4 is the risk of arrhythmia (irregular or abnormal heart safety rhythm).
Record review showed that R1 was found unresponsive in the facility on [DATE], four days after the facility obtained the critically abnormal potassium result.R1's death certificate lists date of
The National Institute of Health website, cites the following: Critical limits of laboratory results need urgent notification to the clinician because they are an indicator of a critical or even life-threatening condition of the patient.Facility policy for Critical Lab Result Reporting (Review Date 9/2022) reads:DEFINITIONS:Critical Test Results are those results that fall significantly outside the normal range and/or may represent life-threatening values, even from routine tests and that require rapid communication of results to the responsible licensed practitioner.Licensed Practitioners/Providers are Physicians, Physician Assistants, and Nurse Practitioners.RESPONSIBLE PARTY:DON, Nursing Supervisors, RN, LPNGUIDELINE:The facility will communicate the results of tests considered critical to patient care to the responsible licensed caregiver in a timely and reliable manner according to established guidelines.PROCEDURE:1.
The acceptable length of time between identifying the critical result and notification of a licensed practitioner will be within one hour unless:a.
The provider documents specific diagnostic notification range values in the medical record b.
The critical value is improved from a previous value and the provider is aware of the previous value.2.
Any critical Lab value will be communicated to facility nursing staff by the Laboratory via phone.3.
Critical Lab results will not be faxed to facility from the Laboratory.4.
Facility nursing staff will not communicate Critical Lab results to the responsible licensed practitioner using fax machine.5.
Facility nursing staff will communicate Critical Lab Results either in person or via telephone.6.
The nursing staff member who is notified by Laboratory of the critical lab result is accountable for communication to the responsible licensed practitioner.7. In the event that the patient's provider cannot be reached and/or does not respond to call/page, the call will be repeated every 15 minutes until one hour has been reached.8. If successful contact with the patient's licensed provider cannot be established, the medical director will be paged.
The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy. On [DATE], the survey team verified by observations, interviews, and record review, that the facility implemented the following to remove the immediacy.Actions Taken:Steps Taken to Remove the Immediacy1. On [DATE], DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to md for any abnormal labs and to escalate to medical director if md/p did not answer the call in- services are ongoing. V4 termed date was [DATE].2. On [DATE], DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to md for any abnormal labs and to escalate to medical director if md/np did not answer the call.
This was completed on [DATE].3.
All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation in- service is ongoing.4. On [DATE], DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.5.
The facility identified that all residents can be affected by the deficient practice, and none were identified as of [DATE].6. A QA tool was developed on [DATE] to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to md for any abnormal labs and to escalate to medical director if md/p did not answer the call and was completed on [DATE].7. A QA tool was developed on [DATE] to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order and was completed on [DATE].8, On [DATE], the Medical Director was made aware and in agreement with the abatement and on [DATE], an in-service was conducted with her Nurse practitioner regarding critical labs.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.