Inspection visit
Inspection
37 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 37 deficiencies, 2 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 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Potential for
minimal harm
Based on interview and record review the facility failed to ensure that the assigned staff, thoroughly
assisted and documented the resident concerns and grievances during the monthly resident council
meeting from 01/22/2025 to 5/21/2025. This has the potential to affect all 99 of the residents in the facility
reviewed for grievance and resident concerns.
Residents Affected - Many
Findings include:
According to the CMS 671 dated 05.28.25, there were 99 residents residing in the facility.
On 5/28/25 request and approval was given to review resident council meeting minutes. There were no
documented concerns noted on the records for the meetings from 01/19/2025 to 05/23/2025.
During the hosted resident council meeting R83 (President) reviewed the documents presented by V2
(Administrator) and stated that the documents were not correct and the residents in fact mentioned
concerns during the March, April and May meetings, and the concerns were not listed on the documents.
R83 said this is an issue and that V27 (Activity Director) should be writing down the concerns for the
meetings.
R83 said one concern that was mentioned was about one particular Nursing staff's behavior of waking
other residents up when giving medications to the room mates, talking loudly at night and leaving resident
room lights on during the overnight shift. R83 said the facility did address that matter right away, however it
should have been documented in the minutes. R83 said residents made suggestions related to food.
Review of the facility concerns and grievances from 01/01/2025 to 5/27/2025, there was a total of three
listed concerns. The concerns that were listed were not related to what was mentioned by R83.
R83, R69, R89, and R44 asked what are their rights as a resident living in the long term care, all said the
resident rights are not being reviewed.
Using a reasonable person concept the facility failed to document all the resident concerns.
On 5/30/25 at 12:12pm V27 (Activity Director) said the residents did mention concerns in the last resident
council meeting, V27 said she can't recall what they were. V27 said she is responsible for typing the
meeting minutes, she removes the concerns and gives them to Social Services. V27 was made aware that
the minutes were requested for review on 5/27/25. V27 said she thinks the resident rights are reviewed
during the resident council meetings, but she can't be certain. V27 was asked how are repeated concerns
being monitored if the minutes are not being documented. V27 was made aware that
(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 18
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
05/30/2025
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 0565
the presented minutes appear as if the residents are not having concerns.
Level of Harm - Potential for
minimal harm
Facility policy tilted Grievance/concerns last review date denotes in-part, it is the policy of the facility to
allow and encourage residents and their representative to express grievances and concerns they may have
regarding the facility, services and staff. Any staff member in the facility may receive a grievance or concern
from a resident or family member. If possible, upon receiving the grievance or concern, attempt to resolve
the grievance, or direct the resident or family member to the appropriate department head or the
administrator. If the administrator or appropriate department-head are not available, the staff member will
gather as much information as possible about the grievance or concern and complete a facility concern
form. The staff member will submit the concern form to the appropriate department head designee for
resolution. The department head is responsible for investigating the grievance or concern and speaking
with the resident or family member who made the complaint regarding both the concern and possible
resolution. The administrator will be the designated grievance officer will review and complete form and
action taken and do any follow up necessary. Grievances and concerns will be discussed at the monthly
QAPI meeting.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 2 of 18
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
05/30/2025
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 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
Based on interview and record review the facility failed to prevent a resident to resident physical assault.
This affected two of four (R48, R70) residents reviewed for physical abuse. This failure resulted in R48
assaulting R70 in the face with a shoe on 4/8/25. R70 sustained purple discoloration to the right eye lid and
petechia above the eyebrow.
Findings include:
On 5/28/25 at 1:15pm R70 observed alert to person, place, time and situation. R70 stopped surveyor and
stated the facility has mixed residents with mental illness with residents that have medical problems. R70
said R48 hit her in the face with a shoe and she sustained a bruise to the eye. R70 said this was last
month. R70 showed surveyor a picture on her cellular phone. The image was of R70's face, there was a
dark purple discoloration to the right eye lid and petechia above the eyebrow. R70 said V1 (Assistant
Administrator) was aware, and she told her son about it. R70 said this happened the day the rooms were
changed.
Review of R70's progress notes noted that R70 and R48 had a verbal altercation and R48 was relocated to
another room.
On 5/28/25, R48 is not interview-able.
The data information on R70 phone denotes that image was taken on 4/14/2025 at 9:33am.
On 5/28/25 at 2:59pm V26 (R70's son) said that R70 did report to him that a resident hit her in the face with
a shoe. V26 said that matter should be investigated.
On 5/28/25 at 3:30pm V1 (Assistant Administrator) said R70 did inform him that R48 hit her in the face with
a shoe. V1 said how does a bruise come a week later. V1 said he did see the bruise to R70's right eye, and
when he asked R70 about it, R70 replied I told you what happened. V1 restated that R70 said R48 hit her
with a shoe. V1 said he is not a medical professional. V1 said R70 also fabricates stories. V1 said he does
not know how R70 sustained the bruise to the right eye and petechia to forehead. V1 said he did not report
the injury of unknown origin to the State Department. V1 said he did not reach out to the Administrator for
guidance regarding the bruise to R70's eye and reported injuries. V1 said he thought the matter was
resolved with he separated R70 and R48's room. V1 said the injury of unknown origin should have been
reported to the State Department. V1 said he did not investigate R70's allegation of physical assault when
alleged. V1 said the allegation was not investigated.
On 5/28/25 at 4:20pm V2 (Administrator) said she was not aware of the bruise to R70's right eye. V2 said
there is nothing documented in R70's medical records about the bruise to the right eye. V2 agreed that V1
should have reported the injury to the State Department.
Facility policy for abuse with last review date 9/2024 denotes in-part the facility affirms the right of our
residents to be free from abuse, neglect, mistreatment or misappropriation of resident property or
mistreatment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 3 of 18
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
05/30/2025
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 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to follow their abuse policy and investigate an injury
of unknown origin. This affected two of four residents (R48, R70) both reviewed for abuse policy and
investigation. This resulted in a 44-day delay in investigating an injury of unknown origin to R70's face.
Residents Affected - Few
Findings include:
On 5/28/25 at 1:15pm R70 observed alert to person, place, time and situation. R70 stopped surveyor and
stated the facility mixed residents with mental illness with residents that have medical problems. R70 said
R48 hit her in the face with a shoe and she sustained a bruise to the eye. R70 said this was last month. R70
showed surveyor a picture in her cellular phone. The image was of R70's face, there was a dark purple
discoloration to the right eye lid and petechia above the eyebrow. R70 said V1 (Assistant Administrator) was
aware, and she told her son about it. R70 said this happened the day the rooms were changed.
Review of R70 progress notes noted that R70 and R48 had a verbal altercation and R48 was relocated to
another room.
On 5/28/25 R48 is not interview-able.
The data information on R70's phone notes that the image was taken on 4/14/2025 at 9:33am.
On 5/28/25 at 2:59pm V26 (R70's son) said R70 did report to him that a resident hit her in the face with a
shoe, V26 said that matter should be investigated.
On 5/28/25 at 3:30pm V1 (Assistant Administrator) said R70 did inform him that R48 hit her in the face with
a shoe. V1 said how does a bruise comes a week later. V1 said he did see the bruise to R70 right eye, and
when he asked R70 about it, R70 replied I told you what happened. V1 restated that R70 said R48 hit her
with a shoe. V1 said he is not a medical professional. V1 said R70 also fabricate stories. V1 said he does
not know how R70 sustain the bruise to the right eye and petechia on the forehead. V1 said he did not
report the injury of unknown origin to the State Department. V1 said he did not reach out to the
Administrator for guidance regarding the bruise to 's eye and reported injuries. V1 said he thought the
matter was resolved with he separated R70 and R48's room. V1 said the injury of unknown origin should
have been reported to the State Department. V1 said he did not investigate R70's allegation of physical
assault when alleged. V1 said the allegation was not investigated.
5/28/25 at 4:20pm V2 (Administrator) said she was not aware of the bruise to R70's right eye, V2 said there
is nothing documented in R70's medical records about the bruise to the right eye. V2 was agreeable that V1
should have reported the injury to the State Department.
Facility policy for abuse with last review date denotes in-part external reporting, when an allegation of
abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the
administrator or designee shall notify Department of Public Health regional office immediately by telephone
or fax. Public health shall be informed that an occurrence of potential abuse, neglect, mistreatment or
misappropriation of resident property has been reported to the administrator and is being investigated. The
report shall include the following information, if known at the time
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 4 of 18
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
05/30/2025
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 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
of the report: name, type of abuse, date time location and circumstances of allegation. This report shall be
made immediately. As used herein the term immediately in relation to reporting abuse, neglect,
mistreatment or misappropriation of resident property and suspicious of a crime shall be defined as
following management of the immediate risk to the resident or residents, including the administration of
necessary medical attention, and establishing the safety of the resident or residents involved or not later
than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily
injury or not later than 24 hours if the event caused suspicion do not result in serious injury.
Event ID:
Facility ID:
145898
If continuation sheet
Page 5 of 18
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
05/30/2025
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 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.
Based on interview and record review the facility failed to follow the abuse policy and procedures and
immediately report an injury of unknown origin. This affected two of four residents (R48, R70) reviewed for
reporting abuse and injury of unknown origin. This failure resulted in a 44 day delay in reporting an injury of
unknown origin.
Findings include:
On 5/28/25 at 1:15pm R70 observed alert to person, place, time and situation. R70 stopped surveyor and
stated the facility mixed residents with mental illness with residents that have medical problems. R70 said
R48 hit her in the face with a shoe and she sustained a bruise to the eye. R70 said this was last month. R70
showed surveyor a picture in her cellular phone. The image was of R70's face, there was a dark purple
discoloration to the right eye lid and petechia above the eyebrow. R70 said V1 (Assistant Administrator) was
aware, and she told her son about it.
Review of R70's progress notes noted that R70 and R48 had a verbal altercation and R48 was relocated to
another room.
On 5/28/25 R48 is not interview-able.
The data information on R70's phone denotes that image was taken on 4/14/2025 at 9:33am.
On 5/28/25 at 2:59pm V26 (R70's son) said R70 did report to him that a resident hit her in the face with a
shoe, V26 said that matter should be investigated.
On 5/28/25 at 3:30pm V1 (Assistant Administrator) said R70 did inform him that R48 hit her in the face with
a shoe. V1 said how does a bruise come a week later. V1 said he did see the bruise to R70's right eye, and
when he asked R70 about it, R70 replied I told you what happened. V1 restated that R70 said R48 hit her
with a shoe. V1 said he is not a medical professional. V1 said R70 also fabricate stories. V1 said he does
not know how R70 sustain the bruise to the right eye and petechia on forehead. V1 said he did not report
the injury of unknown origin to the State Department. V1 said he did not reach out to the Administrator for
guidance regarding the bruise to R70's eye and reported injuries. V1 said he thought the matter was
resolved with he separated R70 and R48's room. V1 said the injury of unknown origin should have been
reported to the State Department. V1 said he did not investigate R70's allegation of physical assault when
alleged. V1 said the allegation was not investigated.
On 5/28/25 at 4:20pm V2 (Administrator) said she was not aware of the bruise to R70's right eye, V2 said
there is nothing documented in R70's medical records about the bruise to the right eye. V2 was agreeable
that V1 should have reported the injury to the state department.
Facility policy for abuse with last review date denotes in-part external reporting, when an allegation of
abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the
administrator or designee shall notify Department of Public Health regional office immediately by telephone
or fax. Public health shall be informed that an occurrence of potential abuse, neglect, mistreatment or
misappropriation of resident property has been reported to the administrator and is being investigated. The
report shall include the following information, if known at the time
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 6 of 18
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
05/30/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
of the report: name, type of abuse, date time location and circumstances of allegation. This report shall be
made immediately. As used herein the term immediately in relation to reporting abuse, neglect,
mistreatment or misappropriation of resident property and suspicious od a crime shall be defined as
following management of the immediate risk to the resident or residents, including the administration of
necessary medical attention, and establishing the safety of the resident or residents involved or not later
than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily
injury or not later than 24 hours if the event caused suspicion do not result in serious injury.
Event ID:
Facility ID:
145898
If continuation sheet
Page 7 of 18
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
05/30/2025
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interviews, facility staff failed to accurately code a Minimum Data Set (MDS) for two of
three residents (R75, R99) reviewed for accurate assessment. R75 was not being treated for a stage 3
pressure ulcer, and R99 was transferred to the community and not the hospital.
Residents Affected - Few
Findings include:
1. On 5/28/25 at 12:45pm during an interview R75 said he does not have any pressure ulcers, R75 said he
has never had a pressure ulcer while a resident at the [NAME] Chicago Heights.
On 5/28/25 at 12:51pm V7 (Wound Care Coordinator) said R75 has never been diagnosed or treated for a
stage 3 pressure ulcer while a resident of the [NAME] Chicago Heights facility. V7 said R75 has never had
any pressure ulcers while a resident at the facility. V7 said she does not have any documents to present to
surveyor noting that R75 does not have pressure ulcers and R75 has not been treated for a stage 3
pressure ulcer.
Review of R75 MDS dated [DATE] section M for skin, number of unhealed pressure ulcers, it is documented
that R75 has one unhealed pressure ulcer, number of stage 3 pressure ulcers- one is documented.
Review of R75 current physician order sheet, and April 2025 physician order sheet, there are no wound
treatments orders noted.
05/30/25 12:43 PM V11 (MDS Coordinator) said MDS assessments should be accurate, it should reflect
the care that the facility is providing.
2. On initial review of the R99's MDS dated [DATE], it statesR99 was a planned discharge to the hospital.
Progress notes for R99 dated 4/17/25 state R99 expressed intent to leave the facility against medical
advice (AMA). At 1:26PM R99 verbalized understanding of what AMA is and signed the form.
On 5/29/25 at 10:36am V1, Assistant Administrator, said R99 left the facility AMA. V1 said I spoke with him,
and he had said he wanted to leave. V1 said I spoke with R99 regarding his need for medication. V1 said
R99 said he did not want to be here. V1 said we advised R99 about AMA. V1 said R99 verbalized his
understanding, and he did sign the form.
On 5/29/25 at 11:44am V11, MDS nurse V11 said I modified it (the MDS) today. V11 said I thought R99
went to the hospital. V11 said I saw the progress notes today. V11 said it was an error on my part.
Surveyor reviewed Release of Responsibility form dated 4/17/25 with R99's name on it.
Facility submitted an MDS dated [DATE] stated the discharge was unplanned and was discharged to home.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 8 of 18
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
05/30/2025
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to refer one resident who was later identified with serious
mental illness for a level II preadmission screening. This affected one of one resident (R66) reviewed
preadmission screening.
Findings include:
R66 was admitted to the facility on [DATE] with a diagnosis of alcoholic polyneuropathy, liver disease. R66
documents a diagnosis of major depressive disorder dated 9/30/22 and schizoaffective disorder dated
10/5/22.
R66's preadmission screening and resident review (PASRR) level one screen outcome dated 9/8/22
documents no level II required-no Severe mental illness, intellectual disability. The level I screen indicates
that a PASRR disability Is not present because e of the following reason: There is no evidence of a PASRR
condition of an intellectual/developmental disability or a serious behavioral health condition. If changes
occur or new information refutes these findings a new screen must be submitted
On 5/29/25 at 10:51AM, V1(Assistant Administrator) said they review resident preadmission screening and
resident review (PASRR) prior to admission and quarterly, V1 said they review to see if there are any
changes with the resident and if there are any changes a new screening would be recommended. V1
verified that R66 had a diagnosis of major depressive disorder and schizoaffective disorder. V1 said a
referral should have been sent for a new screening. V1 was asked to provide any additional documentation
a screening was conducted.
Facility failed to provide any additional screening for R66 during the survey.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 9 of 18
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
05/30/2025
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on interviews and records reviewed the facility failed to review and revise the resident's wound care
interventions. This affected one of three residents (R42) reviewed for care plan review and revisions.
Residents Affected - Few
The findings include:
On 05/29/25 at 11:00 AM V7, Wound nurse said R42 had one pressure ulcer on his ankle and it was found
on 4/4/25 and documeted as a stage 3.
On 5/29/25 at 12:35PM Wound Care Nurse, said R42's skin impairment needs to be identified in the care
plan to specify the staging of the wound. I added the pressure ulcer stage 3 to the care plan. V7 said actual
vs risk for skin impairment are different and will have different interventions. V7 said, it is important to know
the history of a resident's skin impairments. The goal will be to resolve and prevent decline or
complications. V7 was asked why the goal is not specified on the care plan, V7 did not answer the question.
R42's MDS Skin Conditions dated 4/22/25 identifies he had a stage 3 pressure ulcer. The area was
identified as healed on 5/23/25 in the progress notes. The goal identified is to maintain adequate skin
integrity. Interventions for 2025 include notify MD and monitor for adequate for urine output.
The surveyor reviewed R42's care plan in the facility and requested a copy on 5/29/25. The facility provided
a copy of the care plan that states it was revised on 5/29/25. R42's care plan states at risk for skin
complication r/t incontinence, immobility, weakness, skin pressure S 3 to the ankle. When the surveyor
reviewed the care plan on the morning of 5/29 it did not include skin pressure S 3 to the ankle. No history of
impairment was listed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 10 of 18
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
05/30/2025
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R94 was
admitted to the facility on [DATE] with a diagnosis of major depressive disorder, anxiety and conversion
disorder with seizures or convulsions.
Residents Affected - Few
R94's physician orders document monthly Tegretol(Carbamazepine) level dated 2/14/25. Carbamazepine
extended release 100 mg. Give one tablet two times a day for conversion disorder with seizures.
R94 carbamazepine level dated 2/19/25 was 5.3 normal. There was no level drawn for March. R94
carbamazepine level dated 4/11/25 documents 2.6 low. Reference range for carbamazepine is (4.0 -12).
There were no carbamazepine levels for May.
R94's Nurse Practitioner (NP) note dated 4/11/25 documents: Tegretol level 2.6. Conversion disorder with
seizures or convulsions Give additional dose of Carbamazepine ER 100 mg x 1 Continue Zonisamide and
current dose of Carbamazepine Seizure precautions.
On 5/29/25 at 12:04PM, V19 (NP) said she ordered monthly Carbamazepine levels to ensure R94's
medication is at a therapeutic level. V19 said it is recommended to check monthly. If levels are low
medication level would be rechecked in a month and if still low medication change would be initiated. V19
said she did order one time dose of Carbamazepine after April results. V19 said she was unable to find any
other lab results for R94's Carbamazepine level after April. V19 said she would expect her orders to be
followed, and another lab draw to have occurred for May to follow up. V19 said if the therapeutic level is low,
it can put the resident at higher risk for seizures.
On 5/30/25 at 10:18AM, V24 (Pharmacist) said if the carbamazepine level is low it is recommended to
adjust the dose and recheck the level within a week to see if there are any changes. If only a one-time dose
of carbamazepine was given it would not have any long term effect on therapeutic levels and it would be
expected to recheck the level within a week.
R6's medical record notes R6's primary diagnosis is unspecified convulsions.
R6's POS (physician order sheet), dated 2/14/25, notes an order for monthly lacosamide, Keppra,
phenobarbital, and valproic levels.
R6's medical record, dated 10/23/24, notes R6's lacosamide level was 5.7 (normal range 5-10); Keppra
level was 5.51 (normal range 10-40); phenobarbital level was 30.3 (normal range 15-40); and valproic acid
level was 49.1 (normal range 50-100).
There is no documentation found in R6's medical record noting these laboratory tests were completed and
reported monthly or that the physician was notified laboratory testing was not done.
Facility policy titled physician orders revised 1/2023 document: Physician orders are followed as written.
Follow through with orders by making appropriate contact or notification (lab or pharmacy).
A. Based on interviews and records reviewed the facility failed to prevent one dependent resident receiving
narcotic medication known to the cause side effect of constipation from developing a large stool burden.
This affected one of one resident (R41) reviewed for quality of care and hospitalizations. This failure
resulted in R41 being transferred to the hospital and admitted for a diagnosis of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 11 of 18
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
05/30/2025
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 0684
Sterocoral Colitis secondary to severe constipation.
Level of Harm - Actual harm
B. Based on interview and record review, the facility failed to follow physician' s orders for obtaining monthly
laboratory draws for seizure medications levels for residents identified with seizure disorders. This affected
two residents (R94 and R6) reviewed for following physician orders.
Residents Affected - Few
Findings include:
On 2/23/25 hospital History and Physical identifies R41's chief complaint constipation. R41 is being
admitted for Sterocoral Colitis, Urinary Retention, and UTI. According to National Institutes of Health, they
define Sterocoral as a rare inflammatory form of colitis that occurs when impacted fecal material leads to
distention of the colon. R41 returned to the facility on 2/24/25. R41's diagnosis include but are not limited to
malignant neoplasm of right breast and constipation.
On 05/28/25 at 1:06 PM R41 in bed observed twice, both times R41 was non-responsive.
On 5/29/25 at 11:31AM V12, LPN, said R41 called 911, it happened before for bowels. V12 said R41 was
on a narcotic that she took everyday, she took 2 a day. V12 said R41 was educated that a side effect of the
narcotic was constipation. V12 said R41 was on a stool softener. V12 said R41 gets agitated when she can't
go, it was not her first time not being able to go. V12 said R41 panics about not being able to have a bowel
movement. V12 said R41 has a prescription for bowel care daily. V12 said in the past I have given her
lactulose one time to go. V12 said R41 has a cancer diagnosis. V12 said if residents complain of not having
a bowel movement we assess for distended abdomen or blood in the stool. V12 said I would ask R41 when
she pooped last, and I would encourage fluids. V12 said we try to avoid using an enema on R41 because
she might bleed. V12 said we discuss the care for R41 bowels with the Nurse Practitioner. V12 said we
would document in the progress notes the assessment we did. (The facility provided V12 as an assigned
nurse to R41 during 2/20/25-2/23/25.)
On 5/29/25 at 9:59AM V22, LPN said R41 didn't tell me she needed anything on 2/23/25. V22 said R41 just
called 911. I saw the ambulance came in; I was surprised. We went to her room and R41 transferred to the
hospital. She never told me anything was wrong in the beginning. There was nothing told to me in report
and no pain reported. V22 said R41 left, I didn't get an assessment.
On 5/29/25 at 12:36PM V19, Nurse Practitioner, said R41 had breast cancer, and she had pain to the
breast. V19 said R41 was on norco for pain management. V19 said constipation can be a side effect of the
norco. V19 said constipation can be related to norco, immobility being in a wheelchair and age. V19 said
R41 had bowel concerns for at least 1 year that I have been coming to the facility. V19 said R41 was on a
bowel regimen with medications and providing adequate hydration. V19 said to monitor R41 she was verbal
and could report her bowel concerns. V19 said the CNAs will report if a resident is not going. V19 said R41
was obsessive about her bowels. V19 said I would expect nurses to confirm with CNAs and give PRNs if
needed if R41 was reporting the need to have a bowel movement. V19 said they should document
symptoms and give the PRN if needed. V19 said R21 would probably present with pain or discomfort in the
abdomen and possibly some tenderness. V19 said R21 would have been able to report that to us. V19 said
the ER visits could have been avoided if treated in the facility for bowel care.
On 5/30/25 at 9:49AM V3, Director of Nursing, reviewing R41's Documentation Survey Report for Bowel
Continence with the surveyor and said the report shows R41 had small bowel movements on 2/21/25 and
2/22/25 day shifts and evening shifts. V3 said monitoring for constipation includes monitoring the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 12 of 18
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
05/30/2025
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 0684
Level of Harm - Actual harm
Residents Affected - Few
stool output and how much she is going. V3 said the interventions were not effective in preventing
constipation. At 10:30AM V3 said the only documentation with an assessment for R41 I have is the SBAR
that was provided already, there was no progress notes documented. The only bowel related policy we have
is for Retraining and 3 day assessments for new admissions. While reviewing the Medication Administration
Record (MAR) for R41 with the surveyor, 2/1/25-2/23/25, V3 said R41 was not given as needed (PRN)
Dulcolax suppository, enema or lactulose. R41 has Dulcolax suppository, enema, and lactulose available for
administration on her MAR. V3 said the PRN constipation medication would be given based on
assessment. At 10:43AM V3 said R41 had no inhouse labs for 2/1/25-2/23/25.
R41's care plan states she has a bowel elimination problem (constipation) related to decreased GI motility.
Interventions include assess and monitor bowel routine. Assess and monitor medication which may cause
diarrhea. Give medication as ordered. Monitor for signs and symptoms of GI distress. Monitor medications
which may contribute to constipation. Observe for decreased bowel sounds.
R41's cognitive pattern assessment for 1/1/25 identifies a score of 13 and on 4/2/25 14, both are cognitively
intact scores. R41's MDS 1/1/25 identify she uses a wheelchair. R41's requires substantial to maximum
assist for toileting hygiene and is dependent for toilet transfers. R41 is always incontinent of stool.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 13 of 18
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
05/30/2025
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on interviews and record reviews, the facility failed to follow its medication regimen review policy to
ensure the outside pharmacist identified and reported the absence or inadequate indications for use of a
medication. This failure affected 2 residents (R6 and R68) out of 3 residents reviewed for medication review
in a sample of 48.
Findings include:
On 5/29/25 at 11:25 AM, V18 ADON (Assistant Director of Nursing) stated that the medication, apixaban, is
a blood thinner. V18 stated that it is not used to treat tachycardia (increased heart rate) as is noted in R68's
physician orders. V18 stated that she will correct R68's medical record now.
On 5/30/25 at 10:30 AM, V24 (pharmacist) stated that apixaban is prescribed for persons with history of
blood clots, traumatic brain injury, atrial fibrillation, or stroke. V24 stated that it is not used to treat
tachycardia. V24 stated that benztropine mesylate is prescribed to treat movement disorder. V24 stated that
she is not aware what other symbolic functions refers to as a diagnosis.
R6's POS (physician order sheet), dated 6/5/24, notes an order for benztropine mesylate 1mg oral two
times a day related to other symbolic functions.
V25's (Consultant pharmacist) pharmacist clinical review and recommendations, dated 11/5/24 - 4/4/24,
does not note any irregularities noted.
R68's medical record does not note a diagnosis of tachycardia.
R68's POS, dated 11/8/2022, notes an order for apixaban 2.5mg (milligrams) two times a day related to
tachycardia, unspecified.
R68's medical record, dated 2/28/25-5/29/25, notes R68's pulse rate ranges from 62-83 beats/minute. On
one occasion, 5/10/25 at 10:59 PM, R68's pulse is documented as 94 beats/minute.
V25's (Consultant Pharmacist) pharmacist clinical review and recommendations, dated 11/5/24 - 4/4/24,
does not note any irregularities noted.
This facility's consultant pharmacy services provider agreement, undated, notes the consultant pharmacist
review the medication regimen of each resident at least monthly and documenting the review and finding in
the resident's medical record. The consultant pharmacist is responsible for completing orders, including
diagnoses and resident information. The pharmacist reviews the physician order and compares with
resident profile for appropriate drug for indication (diagnosis).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 14 of 18
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
05/30/2025
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow their transmission-based isolation policy by not
relocating one resident's roommate after a resident was found to have Extended-Spectrum
Beta-Lactamases (ESBL) in the urine and failed to discontinue the isolation order after treatment was
completed. This affected two of two residents (R1, R38) reviewed for transmission-based precautions.
Residents Affected - Few
Findings include:
R38 was admitted to the facility on [DATE] with a diagnosis of dysuria, weakness, hernia, major depressive
disorder, and ulcerative colitis. R38's Minimum Data Set, dated [DATE] under toileting hygiene documents
substantial. Maximal assistance. Under section H documents no indwelling catheter and under urinary
incontinence documents frequently incontinent.
R38's physician order dated 3/22/25 created 3/25/25 documents: Contact Isolation related to
Extended-Spectrum Beta-Lactamases (ESBL) in the urine. No discontinued or stop date.
On 5/28/25 at 10:51AM, V16 (Infection Prevention RN) said once an infection is suspected a resident will
be placed on isolation while results are pending, if results come back positive than the resident is placed on
appropriate isolation. Roommate would be moved or resident with infection would move to another room.
V16 said R38 required contact isolation in March for an infection of her urine which indicated
Extended-Spectrum Beta-Lactamases (ESBL) and R1(R38's roommate) was moved to another room while
on medication. V16 was unsure why there was still an order for contact isolation, but the order should be
discontinued and R38 would be placed on enhanced standard precautions.
R1 was admitted to facility on 12/2/20 with a diagnosis of Alzheimer's disease, dementia, bipolar. Age
related bilateral cataracts and schizoaffective disorder. R1's brief interview for mental status dated 3/31/25
documents a score of 7/15 which h indicates moderately impaired cognition.
R1's census and medical record do not document any room changes in March.
Facility census sheets dated 3/22/25- 3/29/25 document R1 remaining in the room with R38. Census sheet
documents open beds available.
Facility policy titled transmission-based isolation precautions revised 3/24 documents: It is the policy of this
facility to follow and implement isolation precautions according to the recommendations of the centers for
disease control and prevention in order to aid in the prevention and transmission of pathogens. Contact
precautions are used for residents with suspected or known infections of colonized microorganism that can
transmitted by direct contact with the patient or resident or indirect contact. Also includes infections or
colonization with multidrug resistance organisms (MDRO) IE Extended-Spectrum Beta-Lactamases
(ESBL). Guidelines for isolation for MDRO; isolate residents who are infected with drainage that cannot be
contained. Maintain contact isolation precautions for high risk residents including those who are totally
dependent on Nursing aides for Activities of daily living. Discontinue isolation once residents has been
treated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 15 of 18
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
05/30/2025
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interviews and record reviews the facility failed to administer the influenza vaccine during
influenza season, failed to screen residents for and offer the pneumococcal vaccine to residents. This
failure affected 4 of 5 residents (R38, R68, R78, and R93) reviewed for influenza and pneumococcal
vaccines in a sample of 48.
Residents Affected - Some
Findings include:
On 5/28/25 at 10:57 AM, V16 (Infection Prevention Nurse) stated that residents are educated and offered
the influenza and pneumococcal vaccines. V16 stated that she is responsible for educating and obtaining
consent/refusals for vaccinations. V16 stated that an outsourced clinic comes to this facility and administers
residents' vaccinations.
On 05/29/25 1:14 PM, V16 stated that when she started working here in March 2025, she was informed by
previous IP nurse that if resident refused flu and/or pneumonia vaccine, they were not provided any
education. V16 stated that she is unable to provide any documentation of education provided to the
residents that refused vaccination(s).
1.R38's medical record, dated 10/22/24, notes R38 received education for the influenza and pneumococcal
vaccinations and consented to receive both vaccines. R83 only received the pneumococcal vaccination. It is
documented in R38's medical record R38 refused the influenza vaccine. There is no documentation noting
R38 refused the influenza vaccine during 2024 influenza season.
R38's POS (physician order sheet), dated 9/13/23, notes an order for annual influenza vaccine.
2.R68's medical record does not note any documentation that R68 received education or was offered the
influenza or the pneumococcal vaccinations. R68's medical record notes R68 refused both vaccinations.
R68's POS, dated 11/8/22, notes an order for pneumococcal vaccine per facility policy. It also notes an
order for annual influenza vaccine.
3.R78's medical record, dated 10/21/24, notes R78 received education for the influenza and pneumococcal
vaccinations and consented to receive both vaccines. R78 only received the pneumococcal vaccination. It is
documented in R78's medical record R78 refused the influenza vaccine. There is no documentation noting
R78 refused the influenza vaccine during 2024 the influenza season.
R78's POS, dated 4/13/23, notes an order for annual influenza vaccine.
4.R93's medical record, dated 10/22/24, notes R93 received education for the influenza and pneumococcal
vaccinations and consented to receive both vaccines. R93 only received the pneumococcal vaccination. It is
documented in R93's medical record R93 refused the influenza vaccine. There is no documentation noting
R93 refused the influenza vaccine during 2024 influenza season.
R93's POS, dated 10/7/24, notes an order for annual influenza vaccine.
This facility's immunization record policy, revised 9/5/23, notes if the vaccines have not been given, the
health care provider will be contacted for an order. If the vaccine is contraindicated, the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 16 of 18
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
05/30/2025
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
physician or nurse will document why in the medical record. The resident or resident responsible party will
be contacted for consent. If the resident or responsible party refuses the vaccine, then documentation in the
resident's electronic medical record shall include education regarding why the vaccine is important. The
vaccine will be documented on the eMAR (electronic medication administration record) as given.
This facility's pneumococcal vaccination policy, revised 03/23, notes all current residents or the resident's
responsible party will be screened yearly and offered the pneumovax PPSV23 and/or PCV13, PV15, and
PCV20.
This facility's influenza vaccination policy, reviewed 9/2023, notes annually all residents or resident
responsible parties will be asked if they want to receive the influenza vaccine. If the resident or responsible
party signs the consent, the health care provider will be contacted for an order. The influenza vaccine will
be administered and documented in the eMAR.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 17 of 18
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
05/30/2025
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to have an effective pest control policy/program, by
not ensuring the facility was free of pest to include (rodents and flying insects). This affected two of two
residents (R18, R15,) reviewed for pest control practices. This has the potential to affect the entire facility.
Residents Affected - Few
Findings include:
On 5/28/25 surveyor was informed that Resident # 18 came out her room screaming saying there was a
mouse in the room.
On 5/28/25 R83(Resident Council President) said R18 was screaming about a mouse. R83 said her and
R18 heard the mice in the room a few days ago, they made V5 (Maintenance Director) aware and he put
traps down. R83 said this morning V4 (Housekeeping) removed the trap with the mouse on it.
On 5/28/25 at 12:37pm V4 (Housekeeping) said he did remove the mouse trap with a mouse on it this
morning from R83 and R18's room, under R18 bed. V4 said the facility should be pest free.
On 5/27/25 at 1:57pm there were many flies observed in R15's room, landing on the soiled linen that was
on the floor. V28(CNA) and housekeeper were summoned to make observation, both identified the flies.
Facility policy titled Pest Control with last review date 8/2024 denotes in-part the facility shall maintain an
effective pest control program. The facility maintains an ongoing pest control program to ensure that the
building is kept free of insects and rodents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 18 of 18
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
37 citations 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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0531GeneralS&S Epotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
F700 - Bed Rails
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
- 0781GeneralS&S Fpotential for harm
Have restrictions on the use of portable space heaters.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F916 - Have a floor at or above grade level
Have a battery powered remote alarm panel in a location accessible by operating personnel.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the May 30, 2025 survey of BRIA OF CHICAGO HEIGHTS?
This was a inspection survey of BRIA OF CHICAGO HEIGHTS on May 30, 2025. The surveyor cited 37 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIA OF CHICAGO HEIGHTS on May 30, 2025?
Yes, 37 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.