Health inspection·July 1, 2024

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to notify residents of their trust fund balances before they exceeded the $2000.00 resource limit for Social Security Administration (SSI) for an individual for 17 of 17 residents (R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20) who were reviewed for trust fund in the sample. This failure has the potential to affect the Medicaid and SSI eligibility for R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20 listed as having trust fund over the $2000 limit and has the potential to affect all the 189 residents residing at the facility. Residents Affected - Some Findings include: On 06/25/24 review of the facility Resident Fund Management Service Trial Balance dated 06/25/24 showed the following resident trust fund balances: R4 Trust fund balance as at 06/25/23 =$3752.49 R5 Trust fund balance as at 06/25/23 = $14,942.58 R6 Trust fund balance as at 06/25/23 =$2036.95 R7 Trust fund balance as at 06/25/23 =$2074.04 R8 Trust fund balance as at 06/25/23 =$3319.71 R9 Trust fund balance as at 06/25/23 =$2303.29 R10 Trust fund balance as at 06/25/23 =$2461.08 R11 Trust fund balance as at 06/25/23 =$2698.50 R12 Trust fund balance as at 06/25/23 =$2071.16 R13 Trust fund balance as at 06/25/23 =$2872.20 R14 Trust fund balance as at 06/25/23 =$3849.29 R15 Trust fund balance as at 06/25/23 =$2524.73 (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 2 Event ID: 145864 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 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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)