F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide comfortable and safe temperature
levels of 71-81 degrees for residents at the facility. This failure affected 8 residents R1 through R8, who
were reviewed for a safe, comfortable environment.
Findings Include:
On June 23, 2025, between 11:20 a.m. and 11:45 a.m., with V3 (Maintenance Director), several randomly
selected rooms were observed to ensure comfortable temperatures. Temperatures in the selected rooms on
the second floor where R1, R2, R7, and R8 reside are as follows:
room [ROOM NUMBER]-82 degrees; 208-87 degrees; 209-83 degrees; 223-81 degrees; 228-82 degrees.
R1 was in bed in the room and stated It's too hot here R1 added that it's been hot for a while. R2 was in the
room and stated he was hot, and that the air conditioner had been leaking water, and staff put a blanket
underneath it and promised to fix it. R7 was in bed and nodded that she was not comfortable. R8 stated that
it's been a few weeks, and they did not fix the air condition.
On 6/23/25 between 10:30am and 11:15 am, on the third floor where R3, R4, R5, and R6 reside, the
Temperatures are as follows:
room [ROOM NUMBER]-81 degrees; 303-83 degrees; 304-86 degrees; 307-84 degrees; 308-86 degrees;
327-82 degrees.
R3 was standing in front of the room in the hallway and stated, 'It's too hot,' and asked when the air
conditioner would be fixed. R4 stated that the room has been hot for almost a week. R5 was sitting in the
wheelchair in the room and stated he's feeling hot. R6 stated that the room was not comfortable.
On 6/23/25 at 11:08am, V3 stated that he started working at the facility about 2 months ago and he's been
working on some of the room air conditioners.
On 6/23/25 at 12:05 p.m., V10 (Corporate Maintenance Director) stated that the expectation is that the
temperatures should be between 68-78 degrees for the residents' rooms and that V3 is fairly new to the
facility. V10 added We do maintenance twice a year- in Spring before Summer and in the Fall before Winter.
V10 explained that he(V10) just heard about the issue of high temperatures in the building today, and that
V3 should have informed him(V10) earlier. At this time, V10 presented email
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145735
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
06/24/2025
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
documentation that shows that the servicing company told them a technician was on the way to fix the air
conditioners. V10 also presented some receipts of fans that were purchased.
On 6/24/25 at 1:45pm, V1(Assistant Administrator) presented the latest temperature readings of the above
listed rooms. Also, V3 stated that the Maintenance Staff continues to work to maintain acceptable
temperatures in the building.
Facility's policy titled Excessive Heat with revision date 10/2024 states #1: When a Heat Emergency is
declared, when temperatures are extreme, or when the heat index/apparent temperature inside the facility
exceeds 80°F, this facility will activate this policy. #2: The facility will take temperatures in the building
at least every 4 hours to ensure that they are within acceptable guidelines. #3: If they are running above the
accepted guidelines, then they will be taken at least every hour.
Facility's Policy titled Heat Emergencies with latest revision date 5/20/2024 states in part: The purpose of
this procedure is to provide precautionary and preventative measures for our residents during the hot and
humid weather conditions. Keep in mind that older adults are extremely vulnerable to heat related
disorders.
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
06/24/2025
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that air conditioners in the second and
third floor hallways and in some residents' rooms are in good repair to provide cool, comfortable and
functional environment for residents. This failure affected a total of 127 residents (59 residents on the
second and 68 residents on the third floor), that were reviewed for functional and comfortable environment.
Findings Include:
On 6/23/25 at 10:30am after the entrance conference, V2(Director of Nursing) presented the Facility's
Census that shows that 59 residents reside on the second floor while 68 residents reside on the third floor.
On 6/23/25 between 10:30am and 11:15am during observation with V3(Maintenance Director), the
second-floor hallway temperature was 84 Degrees Fahrenheit. Several randomly selected rooms (208, 207,
227, 228, 304, 308, and 310), were observed with air conditioner units that were not functioning properly
and blowing warm air.
On 6/23/25 between 11:30am and 11:45am, the third-floor hallway temperature was observed with V3 to be
85 degrees. Some randomly selected rooms were observed with air conditioner units that were blowing
warm air.
The air conditioner unit in room [ROOM NUMBER] was found with blanket underneath to soak up the water
dripping from the unit.
On 6/23/25 at 11:08am, V3 stated that he(V3) started working at the facility about 2 months ago and he's
been working on some of the room air conditioners.
On 6/23/25 at 12:05pm, V10(Corporate Maintenance Director) stated that the expectation is that the
temperatures should be between 68-78 degrees for the residents' rooms and that V3 is fairly new at the
facility. V10 added We do maintenance for the system twice a year- in Spring before Summer and in the Fall
before Winter. V10 explained that he(V10) just heard about the issue of high temperatures in the building
today, and that V3 should have informed him(V10) earlier. At this time, V10 presented email documentation
that shows that the servicing company told them a technician was on the way to fix the air conditioners. V10
also presented some receipts of fans that were purchased.
Facility's Job Description for Maintenance Director states: Ensure that supplies and equipment are
maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to
the administrator. Assist in establishing a preventive maintenance program.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145735
If continuation sheet
Page 3 of 3