Inspection·August 16, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to affirm the right of the resident to be free from physical abuse. This failure has affected 1 (R6) of 6 residents reviewed for abuse. Findings Include: On 8/13/24 at 10:52 AM, R6 stated about a month ago R10 punched R6 in the face because R6 entered R10's bathroom without knocking while R10 was inside the bathroom. R6 stated R6 did not sustain any injury, but R6 was moved to another room and R10 was moved to the 3rd floor because of the incident. R6 told V18 (Certified Nursing Assistant/CNA)) and V36 (R6's Complainant) R6 was punched in the face by R10. R6 stated R6 has seen R10 since the incident, and R10 has threatened R6 with R10's walking cane. R10 stated R10 was transferred to the 3rd floor because of R6, but R6 always ignores R10, and R6 did not tell anyone. On 8/13/24 at 11:10 AM, V11 (Social Worker) stated the administrator is the abuse coordinator; therefore, V11 will report any abuse to the administrator immediately. The incident between R6 and R10 was not reported to V11, and there are several forms of abuse: physical, sexual, theft, and mental. Punching in the face is a form of physical abuse. On 8/13/24 at 11:35 AM, R10 stated R10 punched R6 in the face when R6 opened the washroom without knocking at the door when R10 was in the washroom. Surveyor asked if R10 has been threatening R6 with R10's walking cane. R10 denied threatening R6 with R10's cane. On 8/13/24 at 12:43 PM, surveyor notified V1 (Administrator) of R6's abuse allegation of being punched in the face by R10, and R10 has been threatening R6 with R10's cane. V1 stated V1 was not made aware of abuse allegation between R6 and R10 last month or that R10 has been threatening R6 since the incident. V1 stated V1 will investigate and follow up per policy and safety guidelines and in-service staff immediately. V1 stated it is V1's expectation staff would be reporting any abuse to V1 immediately for further investigation, and V1's phone number is available for all staff to call V1 24 hours 7 days a week to report any abuse or suspicion of potential abuse. On 8/14/24 at 12:28 PM, V18 (Rehab Aide/Certified Nursing Assistant/CNA) stated V18 worked with R6 on 7/20/24. R6 told V18 R6 was punched in the face by R10. V18 asked if R6 told the nurse. R6 stated R6 told the nurse and that was why R6 was moved to another room. V18 told V44 (Licensed Practical Nurse/LPN) on duty to make sure V44 was aware. V18 did not ask R6 why R6 was punched by R10. On 8/14/24 at 2:29 PM, through a telephone interview, V36 (R6's Complainant) stated R6 told V36 R6 (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 4 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 08/16/2024 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)