Health inspection·September 3, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report and investigate mental abuse for one (R2) of three residents reviewed for mental abuse. Findings include: On 08/29/2024 at 10:51AM, R2 stated on the day of the altercation he was standing in the medication line to receive his medication. R2 stated the nurse (identified as V7/LPN) gave R2 his medication and noticed a pill was missing so R2 let V7 know. R2 stated V7 works at the facility periodically and V7 forgets his pill often. R2 stated this particular time after R2 reminded V7 to give him his pill, V7 told R2, I'm going to beat the $h!+ out of you. R2 stated he reported this to V5 (Psychiatric Rehabilitation Service Coordinator/PRSC) the next day. R2 stated he reported to V5 that V7 was being ignorant with him, giving him a hard time, and that V7 threatened to beat the $h!+ out of R2. On 08/29/2024 at 11:10AM, V5 (PRSC) stated R2 reported to her that V7 (Licensed Practical Nurse/LPN) yelled at him, V7 does not give R2 his medication, and R2 does not like getting his medication from V7. V5 stated R2 reported this to her last week sometime and she has been out of the facility for the last four days and just returned back to work today. V5 stated R2 did not report anything else to her but she cannot be certain of this. V5 stated the day R2 reported to her, V5 was located on the third floor of the facility at the end of the hallway by the stairs. V5 stated she was about to leave the facility and was on her way home for the day. V5 stated it is a possibility that R2 reported to her that V7 threatened R2 but V5 stated the only thing she remembers is R2 telling her that V7 yells at R2 and doesn't give R2 all of his medication. V5 reported this to her supervisor (identified as V6/Psychiatric Rehabilitation Service Director/PRSD). V5 stated she only reported to V6 what she remembered hearing, which is, that R2 does not feel comfortable receiving his medication from V7. V5 stated since she was leaving the facility for the day, it's possible that she did not comprehend what R2 was reporting to her. V5 stated she was in-serviced on abuse about 1.5 weeks ago and is able to verbalize different forms of abuse and who to report abuse to. V5 stated the importance of reporting abuse is to keep the residents safe and to protect them. V5 stated her conversation with R2 was very quick and it is a possibility that R2 reported abuse to her but V5 was not paying attention. V5 stated if abuse allegations are not addressed then R2 is at risk for experiencing more emotional abuse which could cause trauma and mental abuse because R2 was still in the presence of the V7 (LPN) and had to receive his medications from V7. V5 stated she has seen R1 receive his medication from V7 without any concerns. V5 stated she has never heard any complaints of V7 mistreating or abusing any of the residents in the facility. On 08/29/2024 at 1:03PM, V6 (PRSD) stated he has never had a conversation with V5 (PRSC) about Page 1 of 2 145864 145864 09/03/2024 Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anything pertaining to R2 and V7 (Nurse). V6 stated V5 did not report anything to him and a conversation with V5 about R2 and V7 never happened. V6 stated if anything is reported to him, then V6 documents it and then acts and does something about it. On 08/29/2024 at 3:17PM, V1 (Administrator) stated he has been the abuse coordinator since he started working at the facility about 3 months ago. V1 stated he is in charge of any abuse that is reported, and it is V1's responsibility to investigate every allegation that is brought to his attention. V1 stated he follows the abuse policies and protocols for reporting to the state agency. V1 stated he reports to the state agency within 2 hours of receiving an allegation and submits his final report within 5 days. V1 stated he has not received any allegations of abuse regarding R2. V1 stated this is the first time he is hearing of this. V1 stated if he had received a report of abuse, he would immediately follow the abuse investigating and reporting process. V1 stated he held an abuse in-service at the facility approximately 1 week ago. V1 stated the facility in-services address things such as the types of abuse, staff responsibilities regarding abuse, and who to report abuse to. V1 stated he reiterated to all of his staff that he is the abuse coordinator at the facility and all staff should report abuse to him. V1 stated it is his responsibility to remove a staff member from the facility pending an investigation if they are accused of abuse. V1 stated now that he is aware of R2's abuse allegations, he will start an investigation and report it to the state agency. R2's Face Sheet documents that R2 is a [AGE] year-old male with diagnoses not limited to: Chronic Obstructive Pulmonary Disease, Schizophrenia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety, Delusional Disorders, Hypertension, and Epilepsy. R2's Minimum Data Set/MDS dated [DATE] documents that R2 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R2 is cognitively intact. Facility incident reports reviewed for the past three months and does not document any allegation of abuse regarding R2. Facility in-service dated 08/21/2024 titled Abuse policy and procedure documents V5 (PRSC) was in-served on abuse. Facility policy dated 02/07/2017 documents in part, Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. 145864 Page 2 of 2