Inspection·March 14, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 12:09PM, V2 (Social Service Director) stated V1 was R1's power of attorney. V2 reported V1 came to the facility around the time R1 expired and told V2 that the nurse didn't notify V1 that R1 went to the hospital. V2 stated normal procedure is that the nurse calls the family when a resident is sent to the hospital. V2 reported an in-service was done with staff about calling family when a resident goes to the hospital. V2 stated it does not matter if a resident is alert and orient that family still needs to be notified of where a resident is being sent. On [DATE] at 12:16PM, V3 (Nurse) stated R1 did not want to eat the morning of [DATE] so V3 took R1's blood sugar. V3 reported the glucose machine said HIGH which meant the blood sugar was too elevated for the machine to give an exact reading. V3 stated V3 gave insulin and called the nurse practitioner. V3 reported taking the blood sugar a second time after the insulin and go the same reading. V3 stated R1 was also saying things that did not make sense. V3 reported R1's baseline was no confusion. V3 reported when a resident has a change in condition the following people must be called the nurse practitioner/physician, the family, and the DON. V3 was unable to remember what number V3 called but stated V3 called R1's power of attorney (V1) and left a message. V3 reported all calls to family or physicians must be documented in a progress note. V3 stated V3 became too busy after sending R1 to the hospital and V3 forgot to document the call. V3 reported if you don't document a call then there is no evidence to prove you made the call. V3 stated a family member should always be called so they know where their loved one is being taken. On [DATE] at 12:37PM, V4 (Acting Administrator) stated the family came into the facility around the day R1 expired and was very heated. V4 reported V1 claimed the nurse never called V1 to say R1 was being transferred to the hospital for a change in condition. V4 stated after interviewing V3, V3 said V3 called and left a message for family but did not document the call due to being too busy. V4 reported information should be documented in a progress note on who was called, what phone number was called, and what time the family was called. V1 confirmed an in-service was done with staff on proper documentation of family notification. On [DATE] at 12:58PM, V5 (DON) stated V1 and other family members came to the facility on [DATE] to have a meeting and request medical records for R1. V5 reported V1 told facility staff that V1 was not called when R1 when to the hospital. V5 stated this was V5's first day on the job but the former DON did an in-service a couple weeks prior about what should be documented after updated family on a resident's condition. V5 reported the facility policy is that family should always be called for a resident's change in condition and the family needs to be aware where the resident is going. V5 stated the nurse needs to document who they spoke with, what time they called, what number was called, if a message was left, and if the voicemail box was full. The Illinois Statutory Short Form Power of Attorney for Healthcare dated [DATE] documents R1 listed V1 as the power of attorney. The SBAR Communication Form dated [DATE] documents R1 had a change in mental status that started on this day. When compared to baseline, R1 has other symptoms or signs or delirium. The form documents family was notified at 9:54AM but there is no documentation of a family name or number that was contacted. The Change in Condition Evaluation dated [DATE] documents R1 had altered mental status with uncontrolled diabetes. The nurse practitioner was notified during rounds. An order was placed to send R1 out to the hospital for medical evaluation. Again it is documented family was notified at 9:54AM but there is no documentation of a family name or number that was contacted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145735 If continuation sheet Page 2 of 3 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 145735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of River Oaks 14500 South Manistee Burnham, IL 60633 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 0580 Level of Harm - Minimal harm or potential for actual harm The Transfer Form dated [DATE] documents R1 was listed as the resident representative. The phone number listed on this form is the same phone number documented for R1's contact information on the face sheet. There is one number listed on the face sheet for V1. This number is a different number than what is documented on the Transfer Form. There is no documentation that the number documented for V1 on the face sheet was contacted when R1 went to the hospital on [DATE]. Residents Affected - Few The policy titled, Change In Resident Condition, dated 09/2024 documents, General: It is policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition .Policy: 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. The policy titled, Discharges, dated 09/2024 document, .Hospital Transfer: . 4. Inform the resident/patient and the resident's/patient's responsible party of the transfer. 5. Prepare an eINTERACT transfer form. 6. Document in the Progress Notes the condition of the resident/patient, who was notified of the transfer, where the resident/patient is going, mode of transportation, disposition of the resident/patient belongings and medications, and notification to all parties of the discharge. The Staff Education Attendance Record dated [DATE] documents nursing staff were educated on resident's change in condition and hospital transfer. Summary of the in-service includes: physician and family notification must be documented and the documentation needs to include the name of the family member contacted, the telephone number called, and the time the call was made. V3's signature is on the in-service sign in sheet as having received the education. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145735 If continuation sheet Page 3 of 3