Bria Of Elmwood Park
BRIA OF ELMWOOD PARK in ELMWOOD PARK, IL — inspection on May 27, 2026.
Found 6 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
authorities.
submit a facility reported incident to IDPH (Illinois Department of Public Health) within regulatory
(Illinois Department of Public Health) received an abuse allegation perpetrated by facility staff.On 5/18/26 at 11:10am, surveyor inquired about the facility abuse protocol V1 (Administrator) stated If there's an abuse allegation, they (staff) report it to me (V1). If the perpetrator is a staff member they are suspended, a police report is made, I (V1) interview the resident or the person making the allegation and send the State a report within 2 hours. I have 5 working days to investigate and submit a final.
Surveyor requested R6's (5/14/26) facility reported incident/investigation at this time.On 5/18/26 at 11:34am, V1 presented an email (not a facility reported incident form) sent from a Gmail account which includes subject: alleged verbal abuse preliminary report.
The email states Please accept this email as a preliminary report of alleged verbal abuse. I (V1) was called at 5:54pm today and told that there was an allegation of alleged abuse.
The alleged incident happened on May 14th at approximately 4:30pm. CNA/Certified Nursing Assistant (V4's Name) was answering a call light.
The resident is [R6's first name].
Resident's husband reported that he witnessed (V4) yell at resident to not sit up. (V4) has been suspended pending the investigation.
Police were called and a report has been filed.
The resident's physician had been notified.
Resident's husband has been notified. No injuries reported.
The email was submitted to IDPH on 5/15/26 at 7:46pm - however required information (R6's last name, age, diagnosis, and mental status) and facility reported incident form were excluded.On 5/19/26 at 11:37am, surveyor inquired if R6's (5/14/26) abuse allegation was reported to IDPH within 2 hours V1 responded Yes.
Surveyor inquired why a Facility Reported Incident Form was not submitted to IDPH on 5/15/26 - when staff were notified of alleged abuse V1 replied I (V1) don't have a laptop yet.
That's why I put on there (referring to email) I hope you'll accept this initial.
Surveyor inquired if the (5/14/26) initial Facility Reported Incident was submitted to IDPH yet V1 replied Yesterday (5/18/28) I started putting it on an official form but when I submit the final, I'll submit the real form with all the data transferred over.
Surveyor inquired why R6's last name was excluded from the email submitted to IDPH on 5/15/26 V1 stated I used my Gmail and there was HIPAA (Health Insurance Portability Accountability Act), I don't know if it was encrypted and didn't want to break any HIPAA laws. R6's (initial) facility reported incident form was submitted to IDPH (via email) on 5/20/26 (5 days after staff was made aware of alleged abuse).The facility Abuse policy (reviewed 9/2017) states that 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 report shall include the following information, if known at the time of the report: Name, age, diagnosis of mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated.
Date, time, location and circumstances of the alleged incident.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145419 05/27/2026
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
(V5) saying that's disrespectful and said she (RT) saw the CNA leave. I think that was it.
Surveyor
across the hall, there's' an office there and the 2 residents next door are non-verbal.
Surveyor
investigation in an extremely long time and I followed a template, I haven't done one in 20 years.
Surveyor inquired if the facility policy was followed V1 stated I haven't read the policy, I went according to the template (referring to the facility reported incident form) and some guidance of regional.The facility Abuse policy (reviewed 9/2017) includes investigation procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview able.
Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed.
145419 05/27/2026
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
being admitted
interview and record review the facility failed to follow policy procedures and failed to develop a
abuse and falls.
Findings include:R1 was admitted on [DATE]. R1's potential for abuse care plan was initiated on 4/27/26 - (18 days after admission). On 5/21/26 at 10:13am, surveyor inquired about baseline care plan requirements V14 (Care Plan Coordinator) replied Within 72 hours upon admission the nurses on the floor should be opening up a baseline care plan. It would be developed within 48 hours but would be in there within 72 hours.
Surveyor inquired if R1's baseline care plan includes abuse V14 reviewed R1's EMR (Electronic Medical Records) and stated No, no abuse is in there.
Surveyor inquired when R1's abuse care plan was initiated, V14 responded 4/27.R4 was admitted on [DATE].R4's (3/23/26) facility reported incident states (R4) alleged she overheard two staff members talking to each other saying that they will choke her out. R4's abuse/neglect care plan was initiated on 3/25/26 - after 3/23/26 abuse allegation (6 days after admission). On 5/21/26 at 10:25am, surveyor inquired when R4 was admitted V14 Care Plan Coordinator) stated 3/19 of 2026.
Surveyor inquired if R4's baseline care plan includes abuse V14 reviewed R4's EMR and responded No.
Surveyor inquired when R4's abuse care plan was initiated V14 replied 3/25.R6 was admitted on [DATE].R6's 5/5/26 (admission) fall risk evaluation determined a score of 11 (high risk).R6's (5/16/26) incident report states upon staff entering room to answer call light, resident was observed on the floor on the side of her bed. R6's fall care plan was initiated on 5/18/26 - after 5/16/26 fall (13 days after admission).R6's (5/14/26) initial facility reported incident states (R6's) husband stated the nurse aide (V4/Certified Nursing Assistant) allegedly yelled at resident. R6's abuse care plan was initiated on 5/17/26 - after 5/14/26 abuse allegation (12 days after admission). On 5/21/26 at 10:28am, surveyor inquired when R6's admission fall risk assessment was conducted V14 stated She (R6) has a 5/5 fall risk assessment.
Surveyor inquired if R6 has a baseline fall care plan V14 responded She doesn't have one.
Surveyor inquired when R6's fall care plan was initiated V14 replied 5/18.
Surveyor inquired if R6 has a baseline abuse care plan V14 stated I (V14) only have 5/17 the comprehensive.The baseline care plan policy (revised 09/2025) states the baseline care plan will be developed within 48 hours of a resident's admission into the facility.
The baseline care plan will include at minimum the following necessary information to properly care for a resident: fall risk.
145419 05/27/2026
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
Vancomycin, they ran out of it. I (R3) finally got it today.R3's (5/15/26) POS (Physician Order Sheets)
at midnight, 6am, 12pm, and 6pm. 9 was also documented on 5/18 at midnight and 6am. R3's
delivered with delivery today. 9:31pm, Vancomycin: awaiting pharmacy delivery. On 5/21/26 at 12:57pm, surveyor inquired what 9 indicates on the MAR. V2 (Director of Nursing) stated, Other, see nurses note.
Surveyor inquired about R3's 5/17/26-5/18/26 Vancomycin administration V2 reviewed R3's (May 2026) MAR and responded On the 17th, he (R3) has a 9 for midnight, 6am, 12pm, and 6pm.
On the 18th he has a 9 for 12 midnight and 6am.
Surveyor inquired if R3's Vancomycin was unavailable V2 reviewed R3's progress notes and replied, This says at 9:31pm on 5/17 the nurse signed out that she was awaiting pharmacy to deliver. On 5/17 at 1:35pm, she (Nurse) did not have the medication available.
Surveyor inquired how many doses of Vancomycin R3 didn't receive. V2 stated, I'm (V2) seeing 6 doses.
The medication administration policy (revised 10/2025) states verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.
If medication is not given as ordered, document the reason on the MAR.
The staffing policy (reviewed 9/2025) states staffing is based on the IDPH formula for determining numbers and levels of staff.
Staffing is then increased based on the needs of the resident population. A schedule is made on a monthly basis and reviewed on an ongoing basis.
145419 05/27/2026
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
services of a licensed pharmacist.
reorder medication, and failed to ensure that prescribed medication was available for one of four
Department of Public Health) received allegations regarding medication administration.R3's diagnoses include sepsis. R3's (5/15/26) physician orders include Vancomycin 25mg (milligrams)/ml (milliliter) give 5 ml every 6 hours. R3's (4/10/26) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact).On 5/18/26 at 12:52pm, surveyor inquired about medication administration concerns at the facility R3 stated They (facility) didn't have my (R3) Vancomycin, they ran out of it. I (R3) finally got it today.R3's (May 2026) MAR (Medication Administration Record) affirms 9 (See Nurses Note) was documented on 5/17 at midnight, 6am, 12pm, and 6pm. 9 was also documented on 5/18 at midnight and 6am. R3's (5/17/26) progress notes state 1:35pm, Vancomycin: spoke with pharmacy, medication will be delivered with delivery today. 9:31pm, Vancomycin: awaiting pharmacy delivery. On 5/21/26 at 12:57pm, surveyor inquired about requirements for drug reordering V2 (Director of Nursing) responded With the antibiotic, we (staff) have to make sure the medication is on hand.
You should reorder, call and alert the pharmacy when the medication is running low.
Surveyor inquired what 9 indicates on the MAR V2 stated Other, see nurses note.
Surveyor inquired about R3's 5/17/26-5/18/26 Vancomycin administration V2 reviewed R3's (May 2026) MAR and responded On the 17th, he (R3) has a 9 for midnight, 6am, 12pm, and 6pm. On the 18th he has a 9 for 12 midnight and 6am.
Surveyor inquired if R3's Vancomycin was unavailable V2 reviewed R3's progress notes and replied This says at 9:31pm on 5/17 the nurse signed out that she was awaiting pharmacy to deliver.
On 5/17 at 1:35pm, she did not have the medication available.
Surveyor inquired how many doses of Vancomycin R3 didn't receive V2 stated I'm seeing 6 doses. On 5/26/26 at 11:21am, surveyor inquired what a blank entry on the MAR indicates V2 responded If it's not documented, it wasn't done.The medication administration policy (reviewed 10/2025) states if medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication.The (January 2026) medication ordering and receiving from pharmacy policy states the refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy.
When available and legible, the pharmacy label is pulled and transmitted to the pharmacy, when electronic ordering is unavailable.
145419 05/27/2026
Bria of Elmwood Park 7733 West Grand Avenue Elmwood Park, IL 60707
administered safely and appropriately to aid residents to overcome illness, relieve and prevent
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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.