Health inspection·December 24, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few results. This lab report was reviewed by V6 (Registered Nurse) on [DATE] 14:51. There is no documentation that V6 took any actions after reviewing this lab report in regard to the abnormal lab value. [DATE] at 2:02PM V6 (RN) was asked if she recalled caring for R1 and reviewing R1's lab values. While reviewing R1's EMR (electronic medical record) with surveyor present, V6 said yes, that she was the one who reviewed R1's labs on [DATE]. V6 confirmed that she would have documented in the progress notes if there were any new orders regarding the lab results. V6 was asked if she communicated this low potassium level to the nurse practitioner and V6 said that she recalled V5 (nurse practitioner) being in the building that morning and that they briefly talked about R1's labs but she didn't recall getting any new orders or instructions related to R1 and potassium levels. V6 also said that she took over that morning for V4 (LPN) because V4 was the overnight nurse but that she did not get report from V4 that morning because she thought that V4 had already left at the time that V6 got to work that morning. V6 was asked if she asked the nurse practitioner if there should be any new orders with the low potassium and V6 said she didn't since she assumed V5 was here and would have told her if she wanted any new orders. V6 confirmed that it is important to monitor potassium because of its relationship to the heart so it needs to be monitored closely.Review of physician orders for R1 show the following orders: - Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablets by mouth two times a day for hypokalemia (Order and Start Date [DATE] with no End Date noted)- Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ for 2 Days x 3 days (Order Date [DATE], Start Date [DATE], End Date [DATE])- Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ x 3 days (Order Date [DATE], Start Date [DATE], with no End Date noted)Medication Administration Record (MAR) for R1 [DATE] documents that R1 received Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablet by mouth two times a day for hypokalemia -Order Date- [DATE] 1435 -D/C Date-[DATE] 1002; MAR shows that R1 was administered this medication on [DATE] and then twice daily (at 0800 and 1600) from [DATE] thru [DATE] and then in the morning on [DATE]. In total, R1 received 34 doses of this medication. [DATE] at 5:10PM V7 (Regional Consultant) confirmed that the nurse entered the order incorrectly, the resident was only supposed to get the potassium for 3 days but instead they kept giving it. Despite continued potassium supplementation, there was no documentation that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice. There was no evidence that repeat potassium levels were obtained until [DATE], 13 days later. Record review further revealed that a laboratory result dated [DATE] indicated a critically elevated potassium level of 8.4 mEq/L (normal range 3.5-5.1); report flagged as critical. Under the potassium lab value, it also says, SPECIMEN WAS CHECKED AND RESULT VERIFIED BY REPEAT TESTING. This lab report was reviewed by V4 on [DATE] 20:56. Nurse progress note written by V4 [DATE] 20:59:49 reads: Lab relayed to NP (V5) via phone, awaiting return response. There is no other documentation that V4 took any actions after reviewing this lab report in regard to the abnormal lab value or that the provider was confirmed to be made aware of the critical lab value. Further, there was no evidence of nursing assessment or clinical intervention, and no initiation of emergent medical care in response to this critical potassium value.Employee disciplinary report for V4 documents - discharge: Date of Incident: 10/15: Description of what happened: Employee failed to contact MD regarding a critical lab. Employee should contact MD immediately for critical lab and receive respond [sic] before marking labs reviewed by Physician. Failure to adhere resulting in termination. V1 (Administrator) confirmed that V4 was terminated on [DATE].Job Description signed by V4 (LPN) on [DATE] include as part of Main Duties .P. Be responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 2 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few well-being and nursing care of all residents assigned to his/her unit while on duty. Contact families regarding significant decline in resident's status or transfer to hospital documenting contact in the EMR.R. At all times abide by policies of the facility and ascertain that employees under his/her supervision do the same.W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff.AF. Perform other related duties as directed by the DON, ADON, or Administrator.V4's Orientation Checklist signed on [DATE] documents that employee was instructed on reporting change of resident conditionXXX[DATE] at 1:52PM V9 (Licensed Practical Nurse/LPN) said that lab results come right to the dashboard (in the EMAR) and the nurse should print them out and notify the nurse practitioner (NP) right away. If it's in the evening after 6pm, the nurses can call telehealth and they will give orders or send the resident to the hospital. V9 said, if I call the provider and they don't respond and it's been an hour, depending on the resident assessment, I will call 911 and notify the director of nursing. I can also call the medical director. In the meantime, I would be monitoring the resident by checking vitals frequently and updating the manager. V9 added that when there is a critical lab value the lab will also call the facility in addition to uploading the reportXXX[DATE] at 12:42PM V10 (Registered Nurse) said that if there is a critical lab result, the lab will call and speak to the nurse and she would assess her patient and call the doctor right away. If it's after 5pm, she would call telehealth if she can't get a hold of the provider after 30 minutes. V10 added that for an elevated potassium, she would also hold any potassium supplements the resident is currently receiving and follow this up with the provider. V10 said that elevated potassium can cause arrythmias if it's over 5.0 and she would send the resident to the hospital due to the risk of fatal arrythmia. V10 added that the facility has recently provided in-service on reporting of critical lab values. [DATE] at 1:46pm V3 (Assistant Director of Nursing /ADON) said, after the resident coded, I was auditing the chart and I noticed that there was a critical lab and didn't see that there was any action or follow up done on that lab. I reported it to V2 (DON). After that, we talked to V4 and corporate did as well. She said that she text-ed or left a voicemail to the NP or the doctor but there was no response so she cleared it and then she left. As a nurse, if I see an 8.4 potassium, I understand that this is life threatening and something has to be done. By any means, I would have to reach the doctor. I would not leave without talking to the doctor. The NP said she didn't get any voice or text message. We also have telehealth. V4 used to work mornings and didn't normally work PM shift. Our afternoon nurses always know that after 5pm they can contact telehealth. They also know that they can contact the medical director. Just as a nurse, I would expect her to know that that was a serious lab value. On top of that she cleared it, so then no one else would have picked it up. They know that before the end of the shift they need to have all of their labs relayed and cleared so it's not left for the next shift. The expectation is that they will handle the complete action and document it. Since then, every week we go back to the labs and I check on a sample of labs. At least 3-4 times a week I go back and make sure that the full cycle has been completed with the labs. In the morning before morning meeting, I read the notes to see if they've documented that labs were relayed to the MD, etc. We in-service staff to know that they have to report critical labs immediately and if the doctor doesn't respond, they have been told to contact the medical directorXXX[DATE] at 1:15PM V2 (Director of Nursing) said, I first found out from the Assistant Director of Nursing (ADON). She said labs weren't being relayed. We immediately in-serviced the staff about relaying critical results and waiting for the provider response. I was told that V4 (LPN) relayed the lab. She (V4) told me that she took a screenshot of the lab and sent it to the NP (nurse practitioner V5). V5 (NP) used to be in the building but she's not here anymore. V4 said that she sent a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 3 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few screenshot to V5 and then forgot about it. I called V5 to confirm that and she said that she couldn't see it clearly. We get the labs via results in (electronic medical record). The providers all have access to the EMR to see the results as well. My expectation is that the nurses should call the provider and get a response and document it. If it's a critical lab I would expect them to get a response as soon as possible, at least by the end of their shift, or contact the medical director. The medical director's information is on the face sheet so the nurses know how to contact her. She is always available when we call her. The lab will call here directly when it's a critical lab value. All the lab values get automatically uploaded into (the EMAR). With a potassium of 8.4 I would have expected V4 to talk to someone to give her a directive of what to do - either send R1 out or something. She could have used her personal judgment to send the patient out because an 8.4 is a very high potassium. She could have contacted telehealth or the medical director because I don't think the NP works that late, it was night shift. With an 8.4 the resident was at risk of cardiac issues with a potassium that high. Since then, every week I am looking at everyone that is on potassium and making sure that labs get put in and ordered. I do a weekly audit to make sure that labs are being addressed and done timely. If critical, I make sure that labs are being relayed. I have not had any issues come up related since thenXXX[DATE] at 12:50PM V8 (Medical Director) said, they (facility) told me about the incident after (R1) passed. Then I found out from the DON that (R1)'s potassium was elevated. I guess the nurse said she notified the NP. If there are any concerns regarding critical patients or abnormal labs the NP will contact me. The problem is that sometimes our labs aren't accurate but they should repeat the labs. When correcting potassium, after treatment, I would have checked it the next day because potassium responds pretty quickly; or at least within a week or so. Potassium less than 2.5 would have been appropriate for hospitalization so they could administer IV. A value of 3.0 is reasonable to give oral potassium supplement and then recheck. I would have expected the NP to call me or send the patient to the hospital. When the NP ordered the supplement, I would have told her to recheck it the same day, a few hours after or at least the next day early morning. I did do a talk with the NP's after this happened and discussed what are critical labs and when to repeat. It also depends on the facility capabilities for labs, I don't know what the facility capabilities are some can give IV and some can't. If we need to recheck labs then that can play a role in the management as well. I have not been aware of this issue for any other residents. I don't remember if the NP called me about this resident in particular. I would have definitely remembered a potassium of 2.0. I know she has called me before. One of the problems is sending text messaging and then the other thing I advised is if it's a critical lab 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.Nurse Progress Note dated [DATE] 17:25:39 reads: @2:35pm Nurse is completing final rounds noted resident unresponsive. Code blue initiated with 911 being called and immediately begins CPR. With in minutes crash cart and live saving devices are utilized. @arouund 2:40pm Paramedics arrived and take control. @ around 3:30pm Paramedics pronounce resident as expired. Resident is clean and remain in room with door closed @ around 4pm Nurse place call to resident responsibility party (family). Nurse informs (family) that resident has expired. (Family) states that he has little to no money and they did not have a plan in place for this situation. Family does agree to have resident cremated. @ around 4:30pm Call placed to (Donor Services). Nurse speaks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 4 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few with (rep) who states they will give (family) a call and further assist in the process. Nurse informs on coming Nurse of situation who will await further instruction from (Donor Services).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: As with hypokalemia (low potassium), the immediate danger of hyperkalemia (high potassium) is its effect on cardiac conduction and muscle strength, and initial efforts should focus on determining the need for urgent intervention .The absence of symptoms does not exclude severe hyperkalemia, because hyperkalemia is often asymptomatic .Severe hyperkalemia (more than 6.5 mEq per L [6.5 mmol per L]) can cause muscle weakness, ascending paralysis, heart palpitations, and paresthesias. Chronic kidney disease, diabetes, heart failure, and liver disease all increase the risk of hyperkalemia.The physical examination should include assessment of blood pressure and intravascular volume status to identify potential causes of kidney hypoperfusion, which can lead to hyperkalemia. Neurologic signs of hypokalemia include generalized weakness and decreased deep tendon reflexes.LABORATORY ANALYSIS AND ECGRepeat measurement of serum potassium can help identify pseudohyperkalemia, which is common and typically results from potassium moving out of cells during or after sample collection. Other laboratory studies include measurement of serum blood urea nitrogen and creatinine, measurement of urine electrolytes and creatinine, and assessment of acid-base status. Further evaluation may include measurement of serum glucose to evaluate for hyperglycemia, and measurement of serum renin, aldosterone, and cortisol to further investigate kidney and adrenal function.ECG should be considered if the potassium level is greater than 6 mEq per L; if there are symptoms of hyperkalemia; if there is suspicion of rapid-onset hyperkalemia; or among patients with underlying kidney disease, heart disease, or cirrhosis who have a new case of hyperkalemia.Hyperkalemia-induced arrhythmias include sinus bradycardia, sinus arrest, ventricular tachycardia, ventricular fibrillation, and asystole.Treatment of HyperkalemiaGENERAL PRINCIPLESThe 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. 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 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 5 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 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:PLAN OF REMOVALPreparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. F684 Affected resident corrective actions.A. Resident R1 no longer resides in the facility. 2. Immediate Actions and Actions to prevent recurrence. (Initiated on [DATE] at 5:30PM and will continue until all staff are in-serviced and trained prior to the start of their shift) The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. The DON checked and verified all residents with time sensitive critical medication, recognizing therapeutic laboratory level, conducting routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. There was no concern identified. (This immediate action was initiated and was completed on [DATE] at 6:00pm)B. All Nurses staff were provided with education by the DON/ Designee. The training included but is not limited to ensuring time sensitive critical medication have therapeutic laboratory level, have routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. (This immediate action was initiated and was completed on [DATE] at 9:30pm)C. The Medical Director, Administrator 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 and completed on [DATE] at 6:05 pmD. New hires will be in-serviced by the DON, ADON or 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 6 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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] Event ID: Facility ID: 145419 If continuation sheet Page 7 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was provided with continued assessment and monitoring while receiving potassium supplementation. This failure applied to one resident (R1) who was being treated for low potassium of 2.5 mEq/L and then continued to receive the potassium supplement with no plan for monitoring or follow up labs scheduled, in order to confirm the continued need for treatment. As a result, R1 was found to have a critically high potassium level of 8.4 mEq/L (normal range 3.5-5.1) when labs were re-checked 13 days later. Findings include:R1 was a [AGE] year-old female admitted to the facility in [DATE]. R1 expired in the facility on [DATE]. R1 medical diagnoses included (but not limited to): chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, aneurysm of the descending thoracic aorta, without rupture, and aneurysm of the ascending aorta, without rupture.Review of R1's facility medical record show that R1 was being treated for low potassium levels (hypokalemia).R1 lab report dated [DATE] documents potassium level of 3.0 mEq/L (normal range 3.5 - 5.1); report flagged as containing abnormal results. Nurse progress note written by V4 dated [DATE] 12:36 reads: CBC and CMP reviewed by NP and new order given for Potassium 40 Meq p.o. 1 x, noted and carried out. Review of Medication Administration Record (MAR) for R1 for [DATE] does not include any documentation that this order was administered to R1. There is no documentation or order showing that labs were ordered to be repeated after this intervention nor was there any indication of monitoring to be done related to this order. R1 lab report dated [DATE] documents potassium level of 2.0 mEq/L (normal range 3.5 - 5.1); report flagged as critical. Nurse progress note written by V4 on [DATE] 23:53 reads: Spoke to V5 (Nurse Practitioner) to relay abnormal lab K+ 2.0, new orders given for Potassium 40 Meq p.o. x 3 days, repeat BMP in a.m., and give 5% dextrose 0.45% sodium chloride at 75ml/hr x 500ML. Noted and carried out. Supervisor is aware. R1 lab report dated [DATE] documents potassium level of 2.5 mEq/L (normal range 3.5 - 5.1); report flagged as containing abnormal results. There is no documentation that V6 took any actions after reviewing this lab report in regard to the abnormal lab value. There is no documentation or order showing that labs were ordered to be repeated at this time. [DATE] at 2:02PM V6 (RN) was asked if she recalled caring for R1 and reviewing R1's lab values. While reviewing R1's EMR (electronic medical record) with surveyor present, V6 said yes, that she was the one who reviewed R1's labs on [DATE]. V6 confirmed that she would have documented in the progress notes if there were any new orders regarding the lab results.V6 said that she recalled V5 (nurse practitioner) being in the building that morning and that they briefly talked about R1's labs but she didn't recall getting any new orders or instructions related to R1 and potassium levels .V6 was asked if she asked the nurse practitioner if there should be any new orders with the low potassium and V6 said she didn't since she assumed V5 was here and would have told her if she wanted any new orders. V6 confirmed that it is important to monitor potassium because of its relationship to the heart so it needs to be monitored closely.Review of physician orders for R1 show the following orders: - (Order and Start Date [DATE] with no End Date noted) Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablets by mouth two times a day for hypokalemia - (Order Date [DATE], Start Date [DATE], End Date [DATE]) Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ for 2 Days x 3 days - (Order Date [DATE], Start Date [DATE], with no End Date noted) Potassium Oral Tablet (Potassium) Give 40 mEq by mouth one time a day for low K+ x 3 days Medication Administration Record (MAR) for R1 [DATE] documents that R1 received Potassium Chloride Crys ER Oral Tablet Extended Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 8 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0757 Level of Harm - Actual harm Residents Affected - Few Release 20 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 2 tablet by mouth two times a day for hypokalemia -Order Date- [DATE] 1435 -D/C Date-[DATE] 1002; MAR shows that R1 was administered this medication on [DATE] and then twice daily (at 0800 and 1600) from [DATE] thru [DATE] and then in the morning on [DATE]. In total, R1 received 34 doses of this medication. [DATE] at 5:10PM V7 (Regional Consultant) confirmed that the nurse entered the order incorrectly, the resident was only supposed to get the potassium for 3 days but instead they kept giving it. Despite continued potassium supplementation, there was no documentation that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice or ongoing assessment for continued need based on assessment, monitoring, or consultation with the ordering provider in relation to potassium supplementation being administered from 10/2 - [DATE].There was no evidence that repeat potassium levels were obtained until [DATE], 13 days later. R1 laboratory result dated [DATE] indicated a critically elevated potassium level of 8.4 mEq/L (normal range 3.5-5.1); report flagged as critical. Under the potassium lab value, it also says, SPECIMEN WAS CHECKED AND RESULT VERIFIED BY REPEAT TESTING. This lab report was reviewed by V4 on [DATE] 20:56. Nurse progress note written by V4 [DATE] 20:59:49 reads: Lab relayed to NP (V5) via phone, awaiting return response. There is no other documentation that V4 took any actions after reviewing this lab report in regard to the abnormal lab value or that the provider was confirmed to be made aware of the critical lab value. Further, there was no evidence of nursing assessment or clinical intervention, and no initiation of emergent medical care in response to this critical potassium value.Job Description signed by V4 (LPN) on [DATE] include as part of Main Duties .P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Contact families regarding significant decline in resident's status or transfer to hospital documenting contact in the EMR.R. At all times abide by policies of the facility and ascertain that employees under his/her supervision do the same.W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff.AF. Perform other related duties as directed by the DON, ADON, or AdministratorXXX[DATE] at 12:42PM V10 (Registered Nurse) said that if there is a critical lab result, the lab will call and speak to the nurse and she would assess her patient and call the doctor right away. If it's after 5pm, she would call telehealth if she can't get a hold of the provider after 30 minutes. V10 added that for an elevated potassium, she would also hold any potassium supplements the resident is currently receiving and follow this up with the provider. V10 said that elevated potassium can cause arrythmias if it's over 5.0 and she would send the resident to the hospital due to the risk of fatal arrythmia. V10 added that the facility has recently provided in-service on reporting of critical lab values. [DATE] at 1:15PM V2 (Director of Nursing) said, I first found out from the Assistant Director of Nursing (ADON). She said labs weren't being relayed. We immediately in-serviced the staff about relaying critical results and waiting for the provider response.With a potassium of 8.4 I would have expected V4 (LPN) to talk to someone to give her a directive of what to do - either send R1 out or something. She could have used her personal judgment to send the patient out because an 8.4 is a very high potassium.Since then, every week I am looking at everyone that is on potassium and making sure that labs get put in and ordered. I do a weekly audit to make sure that labs are being addressed and done timely. If critical, I make sure that labs are being relayed. [DATE] at 12:50PM V8 (Medical Director) said, they (facility) told me about the incident after (R1) passed. Then I found out from the DON that (R1)'s potassium was elevated. I guess the nurse said she notified the NP. If there are any concerns regarding critical patients or abnormal labs the NP will contact me. The problem is that sometimes our labs aren't accurate but they should repeat the labs. When correcting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 9 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0757 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete potassium, after treatment, I would have checked it the next day because potassium responds pretty quickly; or at least within a week or so. Potassium less than 2.5 would have been appropriate for hospitalization so they could administer IV. A value of 3.0 is reasonable to give oral potassium supplement and then recheck. I would have expected the NP to call me or send the patient to the hospital. When the NP ordered the supplement, I would have told her to recheck it the same day, a few hours after or at least the next day early morning. I did do a talk with the NP's after this happened and discussed what are critical labs and when to repeat. It also depends on the facility capabilities for labs, I don't know what the facility capabilities are some can give IV and some can't. If we need to recheck labs then that can play a role in the management as well. I have not been aware of this issue for any other residents. I don't remember if the NP called me about this resident in particular. I would have definitely remembered a potassium of 2.0. I know she has called me before. One of the problems is sending text messaging and then the other thing I advised is if it's a critical lab 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 Event ID: Facility ID: 145419 If continuation sheet Page 10 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that laboratory results were communicated to the ordering provider in accordance with facility policy and procedures for notification. This failure applied to one (R1) of three residents reviewed for notification of laboratory results and resulted in no provider being notified that R1 had a critical potassium level of 8.4 mEq/L (normal range 3.5-5.1), putting R1 at risk of cardiac arrythmia (irregular or abnormal heart rhythm). R1 subsequently experienced cardiac arrest in the facility and expired four days after the laboratory result was obtained. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility was notified of R1's lab report that showed a critical potassium level of 8.4 mEq/L (normal range 3.5-5.1) and the facility failed to notify the provider of this critical value in order for it to be addressed. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12:00PM. The survey team confirmed by observation, interviews, and record reviews that the Immediate Jeopardy was removed on [DATE], when the facility initiated an audit process to verify code status and the deficient practice was corrected on [DATE]. This is being cited as past noncompliance.Findings include:R1 was a [AGE] year-old female admitted to the facility in [DATE]. R1 expired in the facility on [DATE]. R1 medical diagnoses included (but not limited to): chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, aneurysm of the descending thoracic aorta, without rupture, and aneurysm of the ascending aorta, without rupture.Record review for R1 revealed a laboratory result dated [DATE] which indicated a critically elevated potassium level of 8.4 mEq/L (normal range 3.5-5.1); report flagged as critical. Under the potassium lab value, it also says, SPECIMEN WAS CHECKED AND RESULT VERIFIED BY REPEAT TESTING. This lab report was reviewed by V4 on [DATE] 20:56. Nurse progress note written by V4 [DATE] 20:59:49 reads: Lab relayed to NP (V5) via phone, awaiting return response. There is no other documentation that V4 took any actions after reviewing this lab report in regard to the abnormal lab value nor was there confirmation that the provider was made aware of the critical lab value. Further, there was no evidence of nursing assessment or clinical intervention, and no initiation of emergent medical care in response to this critical potassium value.Employee disciplinary report for V4 documents - discharge: Date of Incident: 10/15: Description of what happened: Employee failed to contact MD regarding a critical lab. Employee should contact MD immediately for critical lab and receive respond [sic] before marking labs reviewed by Physician. Failure to adhere resulting in termination. V1 (Administrator) confirmed that V4 was terminated on [DATE].Job Description signed by V4 (LPN) on [DATE] include as part of Main Duties .P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Contact families regarding significant decline in resident's status or transfer to hospital documenting contact in the EMR.R. At all times abide by policies of the facility and ascertain that employees under his/her supervision do the same.W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff.AF. Perform other related duties as directed by the DON, ADON, or Administrator.V4's Orientation Checklist signed on [DATE] documents that employee was instructed on reporting change of resident conditionXXX[DATE] at 1:52PM V9 (Licensed Practical Nurse/LPN) said that lab results come right to the dashboard (in the EMAR) and the nurse should print them out and notify the nurse practitioner (NP) right away. If it's in the evening after 6pm, the nurses can call telehealth and they will give orders or send the resident to the hospital. V9 said, if I call the provider and they don't respond and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 11 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few it's been an hour, depending on the resident assessment, I will call 911 and notify the director of nursing. I can also call the medical director. In the meantime, I would be monitoring the resident by checking vitals frequently and updating the manager. V9 added that when there is a critical lab value the lab will also call the facility in addition to uploading the reportXXX[DATE] at 12:42PM V10 (Registered Nurse) said that if there is a critical lab result, the lab will call and speak to the nurse and she would assess her patient and call the doctor right away. If it's after 5pm, she would call telehealth if she can't get a hold of the provider after 30 minutes. V10 added that for an elevated potassium, she would also hold any potassium supplements the resident is currently receiving and follow this up with the provider. V10 said that elevated potassium can cause arrythmias if it's over 5.0 and she would send the resident to the hospital due to the risk of fatal arrythmia. V10 added that the facility has recently provided in-service on reporting of critical lab values. [DATE] at 1:46pm V3 (Assistant Director of Nursing /ADON) said, after the resident coded, I was auditing the chart and I noticed that there was a critical lab and didn't see that there was any action or follow up done on that lab. I reported it to V2 (DON). After that, we talked to V4 and corporate did as well. She said that she text-ed or left a voicemail to the NP or the doctor but there was no response so she cleared it and then she left. As a nurse, if I see an 8.4 potassium, I understand that this is life threatening and something has to be done. By any means, I would have to reach the doctor. I would not leave without talking to the doctor. The NP said she didn't get any voice or text message. We also have telehealth. V4 used to work mornings and didn't normally work PM shift. Our afternoon nurses always know that after 5pm they can contact telehealth. They also know that they can contact the medical director. Just as a nurse, I would expect her to know that that was a serious lab value. On top of that she cleared it, so then no one else would have picked it up. They know that before the end of the shift they need to have all of their labs relayed and cleared so it's not left for the next shift. The expectation is that they will handle the complete action and document it. Since then, every week we go back to the labs and I check on a sample of labs. At least 3-4 times a week I go back and make sure that the full cycle has been completed with the labs. In the morning before morning meeting, I read the notes to see if they've documented that labs were relayed to the MD, etc. We in-service staff to know that they have to report critical labs immediately and if the doctor doesn't respond, they have been told to contact the medical directorXXX[DATE] at 1:15PM V2 (Director of Nursing) said, I first found out from the Assistant Director of Nursing (ADON). She said labs weren't being relayed. We immediately in-serviced the staff about relaying critical results and waiting for the provider response. I was told that V4 (LPN) relayed the lab. She (V4) told me that she took a screenshot of the lab and sent it to the NP (nurse practitioner V5). V5 (NP) used to be in the building but she's not here anymore. V4 said that she sent a screenshot to V5 and then forgot about it. I called V5 to confirm that and she said that she couldn't see it clearly. We get the labs via results in (electronic medical record). The providers all have access to the EMR to see the results as well. My expectation is that the nurses should call the provider and get a response and document it. If it's a critical lab I would expect them to get a response as soon as possible, at least by the end of their shift, or contact the medical director. The medical director's information is on the face sheet so the nurses know how to contact her. She is always available when we call her. The lab will call here directly when it's a critical lab value. All the lab values get automatically uploaded into (the EMAR). With a potassium of 8.4 I would have expected V4 to talk to someone to give her a directive of what to do - either send R1 out or something. She could have used her personal judgment to send the patient out because an 8.4 is a very high potassium. She could have contacted telehealth or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 12 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the medical director because I don't think the NP works that late, it was night shift. With an 8.4 the resident was at risk of cardiac issues with a potassium that high. Since then, every week I am looking at everyone that is on potassium and making sure that labs get put in and ordered. I do a weekly audit to make sure that labs are being addressed and done timely. If critical, I make sure that labs are being relayed. I have not had any issues come up related since thenXXX[DATE] at 12:50PM V8 (Medical Director) said, they (facility) told me about the incident after (R1) passed. Then I found out from the DON that (R1)'s potassium was elevated. I guess the nurse said she notified the NP. If there are any concerns regarding critical patients or abnormal labs the NP will contact me. The problem is that sometimes our labs aren't accurate but they should repeat the labs.One of the problems is sending text messaging and then the other thing I advised is if it's a critical lab 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.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. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145419 If continuation sheet Page 13 of 14 Printed: 05/15/2026 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 145419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2025 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 145419 If continuation sheet Page 14 of 14