Bria of Chicago Heights

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe environment for one (R3) of one resident reviewed for abuse. R3 was allegedly hit in the nose by another resident R9 at the facility before the staff could separate them. The facility abuse coordinator investigated the incident but did not substantiate the event during the facility investigation. R3 was a [AGE] year-old male with Brief Interview of Mental Status (BIMS) score of 8, which would indicate moderate cognitive impairment. Diagnosis includes in part: diabetes Type 2, Dementia unspecified with mood disturbance. The complaint alleges that R3 was hit in the nose by his peer R9 and that he was not sent to the hospital, and that R3 was trying to snap his own nose back into place and that there was still bleeding, also that he was not sent out to the hospital, that he only hadx-rays. [...]

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures, failed to ensure that fall risk assessments were accurate, failed to utilize the falling star program for identified high risk residents, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, failed to provide supervision, and/or failed to ensure that responsible staff are aware of root cause of fall - to prevent additional falls for three of three residents (R1, R3, R4) reviewed for falls. These failures resulted in R1 sustaining an unwitnessed fall on 11/10/25 which resulted in facial injuries and anterior wedge compression fracture of L1 vertebral body.

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent a resident injury, and failed to determine the origin of the injury. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining left eye swelling and discoloration, discolorations to chest and right leg, scratches to face and chest area, and complaints of chest pain which were identified by the emergency room staff when R1 presented to the hospital for agitation.

Inspectors wroteBased on interview and record review the facility failed to prevent a resident to resident physical assault. This affected two of four (R48, R70) residents reviewed for physical abuse. This failure resulted in R48 assaulting R70 in the face with a shoe on 4/8/25. R70 sustained purple discoloration to the right eye lid and petechia above the eyebrow.

Inspectors wroteR94 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder, anxiety and conversion disorder with seizures or convulsions. R94's physician orders document monthly Tegretol(Carbamazepine) level dated 2/14/25. Carbamazepine extended release 100 mg. Give one tablet two times a day for conversion disorder with seizures. R94 carbamazepine level dated 2/19/25 was 5.3 normal. There was no level drawn for March. R94 carbamazepine level dated 4/11/25 documents 2.6 low. Reference range for carbamazepine is (4.0 -12). There were no carbamazepine levels for May. R94's Nurse Practitioner (NP) note dated 4/11/25 documents: Tegretol level 2.6. Conversion disorder with seizures or convulsions Give additional dose of Carbamazepine ER 100 mg x 1 Continue Zonisamide and current dose of Carbamazepine Seizure precautions. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to administer the influenza vaccine during influenza season, failed to screen residents for and offer the pneumococcal vaccine to residents. This failure affected 4 of 5 residents (R38, R68, R78, and R93) reviewed for influenza and pneumococcal vaccines in a sample of 48.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy and investigate an injury of unknown origin. This affected two of four residents (R48, R70) both reviewed for abuse policy and investigation. This resulted in a 44-day delay in investigating an injury of unknown origin to R70's face.

Inspectors wroteBased on interview and record review the facility failed to follow the abuse policy and procedures and immediately report an injury of unknown origin. This affected two of four residents (R48, R70) reviewed for reporting abuse and injury of unknown origin. This failure resulted in a 44 day delay in reporting an injury of unknown origin.

Inspectors wroteBased on record review and interviews, facility staff failed to accurately code a Minimum Data Set (MDS) for two of three residents (R75, R99) reviewed for accurate assessment. R75 was not being treated for a stage 3 pressure ulcer, and R99 was transferred to the community and not the hospital.

Inspectors wroteBased on interview and record review, the facility failed to refer one resident who was later identified with serious mental illness for a level II preadmission screening. This affected one of one resident (R66) reviewed preadmission screening.

Inspectors wroteBased on interviews and records reviewed the facility failed to review and revise the resident's wound care interventions. This affected one of three residents (R42) reviewed for care plan review and revisions.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its medication regimen review policy to ensure the outside pharmacist identified and reported the absence or inadequate indications for use of a medication. This failure affected 2 residents (R6 and R68) out of 3 residents reviewed for medication review in a sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to follow their transmission-based isolation policy by not relocating one resident's roommate after a resident was found to have Extended-Spectrum Beta-Lactamases (ESBL) in the urine and failed to discontinue the isolation order after treatment was completed. This affected two of two residents (R1, R38) reviewed for transmission-based precautions.

Inspectors wroteBased on interview and record review the facility failed to have an effective pest control policy/program, by not ensuring the facility was free of pest to include (rodents and flying insects). This affected two of two residents (R18, R15,) reviewed for pest control practices. This has the potential to affect the entire facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that the assigned staff, thoroughly assisted and documented the resident concerns and grievances during the monthly resident council meeting from 01/22/2025 to 5/21/2025. This has the potential to affect all 99 of the residents in the facility reviewed for grievance and resident concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor and supervise a newly admitted resident with a known history of falls, confusion, and assessed to be at risk for falls. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a laceration to her left eyebrow that required transfer to local hospital and treatment with sutures after a fall in the facility hallway.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for protecting residents from abuse by not ensuring staff were monitoring residents in the dining area who were at risk for abuse and with a history of aggression and by not ensuring adequate staff supervision was provided for residents involved in a physical altercation. This failure applied to two of five residents (R4 and R5) reviewed for abuse.

Inspectors wroteBased on interviews and records reviews the facility failed to prevent a cognitively impaired resident who requires supervision in the community that has a behavior of wandering from leaving the facility unauthorized without staff knowledge. This affected 1 of 3 (R6) residents reviewed for safety, supervision, and elopement. This failure resulted in R6 leaving through his bedroom window without staff knowledge. The Immediate Jeopardy began on 5/7/24. V1 Administrator was notified on 5/16/24 at 12:04PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 05/16/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interviews, record reviews, and observations the facility failed to have an effective pest control program to ensure the facility is free from pests. This failure affected five of five residents (R9-R13) reviewed for pest control.

Inspectors wroteBased on observation, interview, and record review the facility failed to have the State inspection survey results readily available and accessible to residents, family members and legal representatives. This deficient practice affects all ten (R3, R9, R17, R27, R52, R58, R60, R66, R85 and R94) residents reviewed for Resident rights to Survey results in a sample of 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label multi-dose medication for one of two medication rooms observed for medication storage and labeling. This failure has the potential to affect all 93 residents currently residing in the facility. The facility also failed to discard expired glucagon from their emergency medication box. This deficient practice has the potential to affect all 13 diabetic residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to follow their hypoglycemia protocol by not administering glucagon to a resident (R248) with a low blood sugar that was unresponsive for one (R248) out of three residents reviewed for change in condition in a total sample of 20. Findings Include: R248 is a [AGE] year old with the following diagnosis: type 2 diabetes, metabolic encephalopathy, and hemiplegia following a cerebral infarction. A Nursing note dated 1/23/24 documents R248 was observed unresponsive to verbal stimuli. Supplemental oxygen was placed on R248 at 3 L via nasal cannula. 911 was called and R248 was transported to the hospital. A Change in Condition dated 1/23/24 documents R248 was sent to the hospital for altered mental status. The most recent blood glucose test at 9:15AM was 45. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow R44's Fall care plan by not placing the call light within reach. This failure affected 1 resident (R44) of 2 reviewed for falls in a total sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment in resident rooms and bathrooms. This failure applied to nine of 22 residents (R1, R2, R3, R5, R6, R19, R20, R21, R22) reviewed for clean, comfortable, and homelike conditions in the sample of 22 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain air conditioners in resident rooms by not cleaning the filters prior to them becoming caked with dust and debris. This failure applied to six of 22 residents (R1, R13, R14, R15, R16 and R17) reviewed for resident equipment in the sample of 22 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and wear face masks properly in the kitchen and while preparing food. The facility also failed to wear facial hair restraints while in the kitchen. This failure effects all 89 residents in the facility who are served meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and modify the falls care plan of one resident (R73) out of six residents reviewed for falls in a sample 23. Findings Include: Review of the facility fall log dated 1/17/2023 documents that R73 had falls on 6/16/2022 and 12/25/2022. Review of R73's care plan revision documents an updated intervention for the fall on 6/16/2022, but no updated intervention for the fall on 12/25/2022. On 1/19/2022 at 2:40 PM, V28 (Restorative RN/Care Plan Coordinator) said that post fall care plans should be updated within 72 hours of the fall occurrence. R73 is a [AGE] year old male with a diagnosis not limited to schizophrenia, other abnormalities of gait and mobility, primary generalized (osteo) arthritis, other lack of coordination, muscle wasting and atrophy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medication errors below 5% for one resident (R20) of four residents reviewed for medication review in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard an inhaler more than thirty days after the opened date; and, the facility failed to discard single dose vials of medication in one of two medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions for one resident (R53) of one resident reviewed for gastric tube administration in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was accessible and functioning for 1 of 1 resident (R48) reviewed for call lights in a total sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the nursing staffing in a prominent place readily available to residents and visitors. This deficiency could potentially affect all residents of the facility.