Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to follow the fall prevention and management policy to develop
and reevaluate individualized interventions to minimize the risk for falls with injuries. This affected one of
three residents (R1) reviewed for fall prevention. This failure resulted in R1 falling from bed, subsequently
noted with pain and a large red bruise to the right thigh. An Xray shows impacted [NAME]- cervical fracture
of femoral neck. R1 was sent to the local hospital for treatment.
Findings include:
R1's face sheet denotes diagnosis of muscle wasting, malaise, unsteadiness on feet, weakness,
unspecified dementia, age related nuclear cataract, lack of coordination, vitamin d deficiency, abnormality
of gait and mobility. R1 MDS dated [DATE] denotes BIMS score of 6 (cognitive impairments).
R1's follow-up investigation report denotes fall with injury, age [AGE], BIMS 6, mental status alertx1,
dementia, schizophrenia, unsteadiness of feet, anxiety, current location of victim- (hospital name). Resident
sustained subdural hematoma and impacted Basi-cervical fracture of the right femoral neck with varus.
Subdural hematoma and impacted Basi-cervical fracture as reported to V9 (physician) and POA. Resident
alert x1, able to state that he fell, however not able to elaborate on details. Summary of witness- Roommate
upon interview the resident roommate (R5) stated that he observed resident trying to transfer from bed to
wheelchair and that is when resident fell. (R5) stated resident got himself back on his bed. When R5 was
asked if he informed anyone of the fall, he stated no. R5 stated he thought resident (R1) was okay. R5 also
stated he does not remember the time or day of when the fall occurred. SC (LPN) writer states upon doing
rounds she noticed resident grimacing and in pain. Upon further assessment SC noticed a large red area
on inner right thigh and patient shook upon touch. Vitals assessment, ROM assessed with pain to touch on
right leg. PRN (as needed) Tylenol given, NP (Nurse practitioner) made aware with STAT Xray orders given
and ordered to start Keflex 500 mg (milligrams) PO (by mouth) TID x 7 days, and STAT labs, CBC, CMP for
next day. Bed positioned lowest to the floor with call light and floor mats in place at this time. STAT X ray
obtained, new orders to send patient to ER for further evaluation. V8 (LPN) stated resident slept throughout
the night upon her constant rounding on her shift. Follow up call placed to ER (emergency room) staff
informed our staff that the patient sustained a subdural hematoma and fracture, then was transferred to
(different hospital) hospital for further treatment. Resident is able to stand and pivot with and without
assistance. Per hospital report resident sustained subdural hematoma and impact basal cervical fracture of
the right femur neck with varus. Residents still at (different hospital) hospital at this time. After a thorough
investigation was conducted by reviewing of statements medical records and observation it is concluded
that it was an anticipated fall resulting in a subdural hematoma and or fracture. Per resident roommate
resident fell while attempting to transfer himself from bed to
(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:
145898
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
145898
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bria of Chicago Heights
120 West 26th Street
South Chicago Height, IL 60411
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 0689
Level of Harm - Actual harm
wheelchair. Root cause analysis; due to the residents diagnosis of unspecified dementia with behavior
disturbance resident gain a false sense of independence due to recently being on physical therapy. Care
plan updated rounding at a minimum of Q 2 hours and prompt assistance to change in positions toileting
offering fluids and ensure resident is warm and dry.
Residents Affected - Few
R1's incident report dated 7/11/23 denotes in-part resident noted in bed with redness to inner right thigh,
with shakes and facial grimacing. Resident states with confusing I fell and put myself back to bed. Making
AM rounds resident lying in bed seen with very large red bruise on inner right thigh and shakes with pain
when touched, notified NP (Nurse Practitioner) who ordered Xray of right leg and hip to r/o (rule out)
fracture, and for Keflex 500mg po TID (three times a day) for 7 days, also ordered a CBC and CMP for
tomorrow. Resident vitals 152/88 HR (heart rate)70, temp 97.2, 92% RA, 18 resp. Tylenol given for pain,
DON (Director of Nursing) also notified. (Radiology company) phoned for x-ray. Technician arrived in facility
for Xray at 930am. Resident was later sent out to (hospital name) or further evaluation. Phoned residents
responsible party to inform her that he was sent out for evaluation (phone number). Injury type, bruise, right
thigh. Pain ,6. Mental status, confused/forgetful. Predisposing factors confused incontinent.
R1's radiology report dated 7/11/23 denotes in-part right hip Xray, 2 views, findings right hip, Examination
reveals what appears to be an impact Basi-cervical fracture of the right femoral neck with varus deformity
and some demineralization degenerative arthritis changes.
R1's progress note dated 7/11/23 at 8:07am denotes in-part upon making AM rounds resident lying in bed
seen with very large red bruise on inner right thigh and shakes with pain when touched, notified NP (Nurse
Practitioner) whom ordered Xray of right leg and hip to r/o (rule out) fracture, and for Keflex 500mg po TID
(three times a day) for 7 days, also ordered a CBC and CMP for tomorrow. Resident vitals 152/88 HR (heart
rate) 70, temp 97.2, 92% RA (room air), 18 resp. Tylenol given for pain, DON (Director of Nursing) also
notified. (Radiology company) phoned for x-ray. Technician arrived in facility for Xray at 930am. Resident
was later sent out to (hospital name) or further evaluation. Phoned residents responsible party to inform her
that he was sent out for evaluation (phone number).
On 8/12/23 at 12:31pm V1 (Nurse) said she was the morning nurse caring for R1 when she was
summoned to the room to look at R1's thigh. V1 said she noticed a red bruise to R1's right thigh extending
down R1's leg. V1 said R1 was in a lot of pain, noticed with facial grimacing. V1 said she notified the Nurse
Practitioner who gave orders for Xray and antibiotics. V1 said she gave R1 Tylenol for pain. V1 said R1 had
increased pain, and that's when R1 was sent to the hospital for evaluation. V1 said the radiology company
came and did R1's X-ray but due to the increase pain, R1 was sent to the hospital before the results came
back. V1 said her shift originally started on another unit and she was moved to the unit that R1 was on. V1
said R1 was in severe pain, R1 was shaking and grimacing.
On 8/12/23 at 3:50pm V3 (DON-Director of Nursing) said R1 had a fall from his bed. V3 said R1's
roommate at that time saw R1 get himself up from the floor and get back in bed. V3 said the roommate was
coming from the bathroom and observed R1 pick himself from the floor. The roommate said she did not
know why he did not inform the nurse. V3 said she observed R1 with redness to the right inner thigh.
On 8/12/23 at 11:47am V6 (CNA-Certified Nursing Aide) said he did not work with R1 on 7/10/23, V6 said
he is familiar with R1, V6 said he has worked with R1 in the past and he's learned R1's behavior of trying to
get out of bed when he's wet, so he makes sure he keeps R1 dry when he works with him. V6 said R1 has
behaviors of trying to get out of bed when he's wet. V6 said he has seen R1 wheel
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 2 of 4
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
145898
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bria of Chicago Heights
120 West 26th Street
South Chicago Height, IL 60411
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 0689
himself out of his room in the mornings when he's getting ready to leave for his shift (11pm-7am). V6 said
he does not know if staff has gotten R1 up or not in the morning when he sees him up in his wheelchair.
Level of Harm - Actual harm
Residents Affected - Few
On 8/12/23 at 11:50am V2 (CNA- Certified Nursing Aide) said he worked with R1 on 7/10/23 during the
11PM -7AM shift, V2 said he did not see R1 fall, he did not pick R1 up from the floor. V2 said R1 does have
behaviors of trying to get out of bed. V2 said R1 is not on the morning get up list for the night shift. V2 said
he changed R1 at 5:00am and last saw R1 around 7:00am before his shift ended.
On 8/12/23 at 3:27pm V8 (Nurse) said she was the nurse responsible for R1's care on 7/10/23 on the
11:00pm-730am shift. V8 said she did not see R1 fall, she did not assist with picking R1 up from the floor.
V8 said R1 does try to get out of bed. V8 said she saw R1 sleeping that night, she saw R1 at 1am, 3am,
5am and before she left for her shift. V8 said R1 was sleeping every time except for the time she was
summoned in his room by V1. V8 said V1 summoned her to R1's room to look at R1's thigh on the morning
of 7/11/23. V8 said she noticed R1's right thigh with redness. V8 said she went home after making her
observation.
On 8/13/23 at 10:02am V4 (CNA- Certified Nursing Aide) said she worked with R1 on 7/10/23 during the
3-11pm shift. V4 said she did not witness R1 fall. V4 said R1 is a resident that like's to watch the news, eat
his meals, and lay in bed. V4 said R1 does have behaviors of trying to get out of bed. V4 said she put R1 to
bed after dinner on 7/10/23 and provided incontinence care to R1 around 930pm. V4 said that was the last
time she saw R1 for her shift.
On 8/12/23 at 2:28pm V7 (MDS Nurse) said she initiated the care plans for medical diagnosis, R1's plan of
care reviewed with V7 denoting alteration in hematological status related to vitamin D deficiency with
initiated date of 9/1/2022, interventions fall risk assessment and increase vigilance for falls. V7 said she
developed that intervention for R1 because R1 is at risk for falls. V7 said she don't do the fall care plans. V7
said vigilance for falls means checking on the resident as needed, V7 said she don't have a time frame, it's
just as needed.
On 8/12/23 at 2:56pm V5 (Restorative Nurse) said she was the restorative nurse, V5 said she initiates the
fall care plans, updates the fall care plans, she does the fall evaluations also. V5 said R1 was able to stand
and pivot with staff assist and cueing, V5 said there were days that R1 needed more assist from staff like
touching and guiding with transfers. V5 said R1 was able to sit at the bed side. V5 said R1 had poor safety
awareness that's why he needed assist with standing, pivoting, and transfers. V5 said she was not aware of
R1's behavior of trying to get out of bed. V5 said the Nurses and CNAs should make her aware of R1's
behaviors. V5 said R1 is a high fall risk now with a score of 13, and a prior score of 11. V5 said trying to get
out of bed is not the same as a fall. V5 said trying to get out of bed puts R1 at risk for falls. V5 said the
facility cannot physically restrain a resident to keep them in bed. V5 said if the staff would have made her
aware of R1 trying to get out of bed she would have implemented putting more eyes on R1. V5 said more
eyes on R1 means having someone in the room with him or having someone near his room. V5 said she
would have implemented checking on R1 every two hours. V5 was asked how they are checking on R1
every two hours different from the standard every two-hour check that the staff were doing before the fall?
V5 said she would have implemented every two-hour checks on R1. V5 said the interventions that were
initiated on 7/12/23 after R5 left the facility was to be put in place upon his return to the facility. R1 did not
return to the facility.
On 8/13/23 at 10:31am V9 (physician) said he was made aware of the incident regarding R1 sustaining
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 3 of 4
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
145898
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bria of Chicago Heights
120 West 26th Street
South Chicago Height, IL 60411
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 0689
Level of Harm - Actual harm
Residents Affected - Few
a hip fracture. V9 said the nurse observed R1 with a bruise to the thigh, the nurse practitioner was made
aware, the Nurse practitioner order Keflex and Xray. V9 said the Nurse practitioner initially thought it was
cellulitis based on what the nurse reported that's why Keflex was ordered. V9 said R1 received an Xray and
was sent to the hospital for further evaluation. V9 said a fracture is the result of trauma unless there's an
underling condition that the resident is not aware of. V9 said R1 was doing fine before this fracture. V9 said
initially the facility did not know what happened to R1's leg. V9 said during the facility investigation it was
determined that R1 had a fall. R1's roommate at that time saw R1 get up from the floor.
R1's fall risk assessment dated [DATE] denotes a score of 11, R1 has unsteady gait and/or use of
ambulatory device, R1 has confusion, R1 is 75 and above for age, R1 has medications drugs that have a
diuretic or increase GI mobility, Drugs that affect the thought process, Drugs that create a hypotensive
effect. R1 is incontinent. R1 fall risk assessment did not denote predisposing condition of hypertension.
R1's plan of care with initiation date of August 2022 denotes in part fall, resident is high risk for falls
cognitive deficits and use of psychotropic medications secondary to unspecified dementia with behavior
disturbance, the goal is to remain free from injury related to falls through the next review date, interventions
are to document signs and symptoms of adverse effects of medications on resident, encourage appropriate
use of assistive devices, position, keep frequently used items within reach, monitor for any changes in
condition, monitor resident for tolerance and endurance, scheduled task accordingly. Interventions with
initiation date of 7/12/2023 denotes falling star program, floor mats in place while in bed, keep bed in lowest
position R1 has a false sense of independence due to recently being on physical therapy, resident to be
educated on seeking staff for assistance, the importance of complying with safety measures and possible
complications of non-compliance, rounding at a minimum of Q (every) 2 hours and prompt or assist for
change in position, toileting, offer fluids and ensure resident is warm and dry. R1's care plan for alteration in
hematological status related to vitamin D deficiency with initiated date of 9/1/2022 denotes in-part,
interventions fall risk assessment and increase vigilance for falls.
R1 MDS dated [DATE] denotes BIMS score of 12 (cognitively intact).
Facility policy titled fall prevention and management with last review date 7/2022 denotes in-part this facility
is committed to maximizing each resident physical, mental and psychosocial well-being. While preventing
all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for
preventive strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the
resident existing plan of care shall be evaluated and modified as needed. Residents at risk for falls will have
fall risk identified on the interim plan of care and the ISP (individualized service plan) with interventions with
interventions implemented to minimize fall risk.
Facility policy titled comprehensive care plan with last review date 3/2023 denotes in-part the facility must
develop a comprehensive person-centered care plan for each resident. The care plan will include a focus,
measurable goal, and interventions specific to the residents medical, nursing, mental and psychosocial
needs. The comprehensive care plan should drive the care and services provided for the residents and
allow for highest level of physical, mental, and psychosocial function based on the comprehensive MDS
assessment. The comprehensive care plan should be reviewed with the residents and / or resident
representative and changes made as appropriate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the August 17, 2023 survey of BRIA OF CHICAGO HEIGHTS?
This was a inspection survey of BRIA OF CHICAGO HEIGHTS on August 17, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIA OF CHICAGO HEIGHTS on August 17, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.