Health inspection·September 12, 2024

F 0557 I can't find any of my clothes. I have to find clothes to wear every day. Level of Harm - Minimal harm or potential for actual harm On 9/10/24 AT 10:05 AM, V13 (R2's family) said, Me and my sister help to buy clothes for my aunt (R2). R2 is a big woman and it's hard to find clothes for her sometimes. I bought several outfits she can fit. I've also bought underwear several times as well and all of her items are missing. Her tops were all 3X- 4X and her pants were 5X. I sent an email to the social worker (V11) of the actual photos of the items I purchased for R2 because this is an on-going issue with her missing clothes. I sent pictures of: six pairs of underwear, five pairs of pants and five shirts. I sent this email on 06/18/2024. Prior to the June email, R2 always had clothes came up missing. I would bring in items and the staff would tell me they cannot locate an inventory list to inventory her items. They also say they don't have a marker to label her clothes. I have to label them myself. Every time I go to visit, I am arguing about her clothes. I have spoken with V4 (SSD/Social Service Director) several times about her clothes. I didn't like when he (V4) suggested my family should wash R2's clothes so they don't come up missing. He (V4) told me the facility would replace R2's items but they have not been replaced yet. Residents Affected - Some On 9/10/2024 at 10:30 AM, V4 (SSD) said, I told R2's niece (V13) if she gives me a receipt for R2's clothes, then we can reimburse her. V13 never brought a receipt. Surveyor inquired about inventory lists for R2, R3, R4 and R5. V4 (SSD) said, I don't have an inventory list for R2, R3, R4 or R5. I can't locate any inventory list for them. Surveyor inquired about the process and purpose of resident's inventory. On 9/10/2024 at 10:30 AM, V4 (SSD) said, Social Services is responsible for keeping inventory of resident's clothes and labeling them upon admission and whenever new items are brought to the facility. The purpose of keeping inventory of resident's items is to make sure we keep track of resident's personal belongings. On 9/9/24 at 11:20 AM, R3 said, The building got shut down and most of my belongings came up missing. I was given the run around about getting my belongings replaced, but they still only replaced about half of my items. They don't inventory or document everything, which is the problem. I'm not even sure what all is missing still. On 9/9/24 at 11:22 AM R4 said, I am still missing about a week work of clothes that have not been replaced as of today. I have never seen or signed any inventory list here. On 9/9/24 at 11:31 AM, R5 said, I had two loads of laundry that were lost back in December or January and never returned back to me. I complained to social services and my clothes are still missing. I don't recall signing an inventory list. On 9/10/2024 at 11:30 AM, V10 (Laundry Supervisor) said, We wash personal clothes in-house and the linen are sent out to another company to be cleaned. The issue with the laundry is a lot of times, clothes are sent down to the laundry room without names on them. When that happens, it is hard for us to determine who the clothes belong to. We just keep the unlabeled clothes in a bin for residents come to look for lost clothes. Laundry does not keep inventory or label clothes. I believe Social Services does. Surveyor noted a large bin filled with clothes. The clothes in the bin were not labeled with names on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 2 of 5 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 09/12/2024 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)

F 0557 Surveyor asked if R2 had any clothes in the laundry room. Level of Harm - Minimal harm or potential for actual harm On 9/10/2024 at 11:30 AM, V10 (Laundry Supervisor) said, R2 doesn't have any clothes down here that I know of, unless they are in the bin of un-labeled clothes. Residents Affected - Some On 9/10/2024 at 1:30 PM V11 (PRSC/ Psychiatric Rehabilitation Services Coordinator) said, I came to the facility in 2023, so I was not here when R2 was admitted . I am not sure what clothing items R2 had prior to the items her niece (V13) sent via email. As far as I know the only inventory list for R2 is the list I did on 04/05/2024. V13 had stated R2 had missing items in the past and sent me an email of the items were missing. The facility replaced the items and inventoried them. I am not able to locate any other inventory list for R2 besides the one for 04/05/2024. On 09/11/2024 at 12:20 PM, Surveyor observed R2 lying in bed with pants were too small and a portion of R2's buttocks were exposed. V12 (CNA/ Certified Nurse Assistant) conducted inventory of R2's belongings and was unable to locate any of the items listed in V13's email sent to V11 (PRSC). Surveyor noted several miscellaneous items such as: neck scarfs, size small pants, a medium size jacket, a coat and two medium size skirts; all items were not labeled with a name on them; all items were too small for R2 to wear. On 09/11/2024 at 12:25 PM, V6 (CNA) entered the room and said, All of R2's clothes were sent back up from laundry yesterday. Everything is in her room is what she has. On 09/11/2024 at 2:15 PM, V10 (Laundry Supervisor) said, All of the clothes from the sixth floor were washed and returned yesterday. R2's Personal belonging list dated 04/05/2024 documents: one 3x black blouse, one 3x peach blouse, one 6x black jogger and a six pack of underwear. Facility email dated 06/18/2024 from V13 (R2's family) documents, six shirts, eleven pairs of underwear and four pair of pants. Facility Census Report dated 09/09/2024 documents 200 residents in the facility. Facility policy titled Personal Belongings- Inventory documents, to record belongings brought to the facility by or for the resident; check and record all belongings brought to the facility on admission; have the resident or responsible party sign the inventory form on admission. Facility policy titled Resident Rights documents, residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 3 of 5 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 09/12/2024 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure a diagnostic appointment was scheduled for one resident (R5), who had an abnormal mammogram and doctor's order for a follow-up appointment. This failure affected one of three residents reviewed for nursing care. Residents Affected - Few Findings include: R5 is a [AGE] year old with diagnosis including but not limited to: Major depressive disorder, anxiety disorder, unspecified asthma, chronic obstructive pulmonary disease with acute exacerbation and essential hypertension. R5's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. During investigation on 09/10/2024 at 11:31 AM R5 said, I had a mammogram done in February (2024) that came back abnormal. I was supposed to return for a follow-up appointment and the appointment was never made. I have mentioned it a couple of times to several nurses. I don't know what is going on with my breast and I am concerned. On 09/11/2024 at 12:15 PM V3 (DON/Director of Nursing) said, I thought that R5's follow-up appointment was made, but I see that the appointment was not made. Surveyor inquired about the importance of follow-up appointments. At that time, V3 (DON) said, It is important to follow-up an abnormal mammogram because the situation can get worse. It is better to catch the issue early so that it may be treated. On 09/11/2024 at 1:30 PM, V9 APN (Advanced Practice Nurse) said, I am familiar with R5. I assessed her after her abnormal mammogram and noted that there were recommendations that she (R5) have a diagnostic mammogram and ultrasound scheduled. I did try to touch base with the scheduler to make the appointment. The order to schedule R5's appointment was entered into R5's orders. I was not aware that she (R5) did not have that appointment as of now. The importance of the diagnostic mammogram and ultrasound would be to make sure that there is not a delay in care or a delay in treatment should there be any life-threatening issues. R5's Mammogram report dated 02/02/2024 documents, bilateral focal asymmetries; recommend bilateral diagnostic mammogram and possible ultrasound. Facility document titled Hospital Radiology Department dated 02/02/2024 documents, R5 needs order for a bilateral diagnostic mammogram and bilateral breast ultrasound. Provider progress notes dated 02/19/2024, 03/18/2024, and 04/19/2024 written by V9 (APN) documents, R5 is concerned about her most recent mammogram and is requesting follow-up appointment. R5's Physician Order Sheet dated 09/09/2024 documents the following active order entered on 02/19/2024; bilateral diagnostic mammogram with ultrasound for diagnosis of abnormal mammogram. Facility policy titled Physician Orders documents, physician orders are followed as written; if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 4 of 5 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 09/12/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm there is a question about the order, contact physician for clarification; follow through with orders by making appropriate contact or notification. Facility policy titled Appointments documents, staff nurse or designee will call the place of the appointment to verify date, time and location. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 5 of 5