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Inspection visit

Inspection

BRIA OF RIVER OAKSCMS #1457352 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

2 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0921GeneralS&S Epotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the June 24, 2025 survey of BRIA OF RIVER OAKS?

This was a inspection survey of BRIA OF RIVER OAKS on June 24, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BRIA OF RIVER OAKS on June 24, 2025?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.