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 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 interviews and record reviews, the facility failed to prevent a resident injury, and failed to
determine the origin of the injury. This affected one of three residents (R1) reviewed for injury of unknown
origin. This failure resulted in R1 sustaining left eye swelling and discoloration, discolorations to chest and
right leg, scratches to face and chest area, and complaints of chest pain which were identified by the
emergency room staff when R1 presented to the hospital for agitation.
Findings include:
On 6/24/25 at 2:30 PM, V7 (Complainant) stated that R1 presented to the emergency room on 6/22/25 at
1:02 AM with bruising and swelling to left eye, bruising to mid chest area, bruising to right leg, and
scratches to face and chest area. V7 stated that the bruising on R1's chest appeared to be a heel print from
being kicked in the chest. V7 stated that R1 stated V3 (Nurse) beat him up because R1 would not give V3
the bottle of rubbing alcohol which was his. V7 stated that R1's injuries were consistent with a person being
assaulted. V7 stated that R1 also complained of chest pain.
On 6/22/25 at 12:30 PM, V4 CNA (Certified Nurse Aide) stated that the incident happened after dinner on
6/21/25. V4 denied R1 exhibiting any behaviors prior to 6/21. V4 stated that V4 was rounding on his
assigned residents when V4 observed R1 pouring rubbing alcohol into a cup. V4 stated that V4 immediately
informed V3 (Nurse). V4 stated that V3 went to R1's room to speak with R1. V4 stated that R1 was verbally
aggressive and threw the cup of rubbing alcohol at V3. V4 stated that V4 went to R1 and R2's room two
hours later to provide resident care to R2. V4 stated that R1 pulled the privacy curtain open to see who the
person was that told on R1. V4 stated that R1 walked towards V4, R1's gait was unsteady, wobbly. V4
stated that as V4 was opening the door to get staff assistance, R1 hit him on his left side of neck/shoulder
area. V4 stated that V4 informed V3 that R1 was being verbally and physically aggressive. V4 stated that V3
informed him she was going to handle the situation with V5 (Assistant Administrator). V4 stated that R2's
family member brought in the bottle of rubbing alcohol earlier on 6/21 and R1 took the bottle of rubbing
alcohol from R2's belongings.
On 6/23/25 at 10:00 AM, V6 CNA stated that V6 heard V4 CNA asking for help, he was having difficulty with
R1. V6 stated that she was walking down hallway and heard V4 say don't hit me, V6 entered room to try to
calm R1 down. V6 stated that V6 went on other side of the privacy curtain to speak with R1. V6 stated that
R1 told her to get out and head butted her on her lower lip. V6 stated that V6 ran out of R1's room due to
her lip bleeding. V6 stated that V3 and V5 were approaching R1's room as she was exiting room. V6 stated
that R1 is cranky, he can be verbally inappropriate at times. V6 denied R1 ever being physically aggressive
prior to that evening. V6 stated that she did not see R1 anymore that evening.
(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 3
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
06/24/2025
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
Level of Harm - Actual harm
Residents Affected - Few
On 6/23/25 at 10:15 AM, V3 (Nurse) stated that she was at nurses' station when V4 CNA informed her that
R1 was pouring rubbing alcohol into cup. V3 stated that she went to R1's room, saw cup 1/2 full of rubbing
alcohol. V3 stated that V3 asked R1 what he was going to do with it, R1 did not respond. V3 stated that V3
asked R1 to give her the cup. V3 stated that R1 held the cup and threw the liquid at her, V3 pulled the
curtain to block liquid. V3 stated that most of the liquid hit curtain, only a little got on her clothes. V3 stated
that R1 was verbally aggressive with her, but she was able to take the bottle of rubbing alcohol with her out
of room and placed it at the nurses' station. V3 stated that V3 then heard a scream, V3 rushed to R1's room
with V5 (Assistant Administrator) to find V6 CNA screaming. V3 stated that V3 observed V6's lip bleeding;
V6 stated that R1 head butted her. V3 stated that V3 and V5 walked with R1 to the social services' office. V3
stated that afterwards V3 called the physician and obtained orders for medication injection and to send R1
to the hospital for evaluation. V3 stated that R1 stayed in the office with V5 on 1:1 monitoring until the
ambulance crew transported R1 to the hospital. V3 stated that V3 is not sure how R1 got the bruises. V3 did
not report an injury of unknown origin to the Administrator. V3 stated that R1 is alert and oriented x 3, his
baseline.
On 6/23/25 at 12:10 PM, V5 (Assistant Administrator) stated that V5 was working in his office on Saturday,
6/21, completing needed work. V5 stated that V3 (Nurse) informed V5 that they found a bottle rubbing
alcohol in R1's possession. V5 stated that this bottle belonged to resident's roommate, R2. V5 stated that
later R1 was becoming verbally and physically aggressive with staff and V5 saw V6 (CNA) was bleeding
from her lower lip. V5 stated that V5 went to R1's room to de-escalate the situation. V5 stated that with
re-direction V5 was able to get R1 to exit his room and agree to go to the social services office. V5 stated
that while V5 was walking to the office with R1, R1 attempted to exit a back door at the facility. V5 stated
that V5 was able to get R1 into the office to monitor R1 1:1. V5 stated that V5 sat with R1 until the
ambulance crew arrived to transport R1 to the hospital for behaviors. V5 stated that R1 left the facility
around 6:00 PM. V5 stated that V5 left the facility between 7:00 PM and 7:30 PM. V5 denied any staff
member hitting R1. V5 denied R1 having any injuries prior to transporting to the hospital.
On 6/23/25 at 3:00 PM, V1 (Administrator) stated that V1 was informed that R1 was being aggressive with
staff on 6/21. V1 stated that staff are CPI (Crisis Prevention Institute) trained. V1 stated that this is not used
very much at this facility. V1 stated that it is possible R1 could have sustained bruising when staff were
trying to de-escalate the situation with R1.
R1 has diagnoses including but not limited to stroke with hemiplegia affecting left non-dominant side,
unsteadiness on feet, abnormalities of gait and mobility, major depressive disorder, bipolar disorder,
delirium, anxiety disorder, suicidal ideations, and schizoaffective disorder.
R1's outside ambulance report, dated 6/21/25, noted staff called for transport to hospital at 6:11 PM for a
resident being aggressive with staff. The outside ambulance crew were dispatched to the facility at 11:29
PM and arrived at R1 at 00:05 AM. R1 noted with contusion to left eye, complaints of chest pain, and injury
to right leg. R1 is claiming that staff struck him in the face and kicked him in the chest.
R1's hospital record, dated 6/22/25 notes R1 presented to the emergency room at 1:21 AM for aggressive
behavior/uncooperative behavior. R1 noted with hematoma (localized collection of blood) of left upper eye
with swelling to affected orbit. R1 with noted bruising to chest area and right leg. R1 complained of chest
pain, 10 out of 10. Per report, R1 found consuming rubbing alcohol in room to which altercation ensued with
staff and R1.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 2 of 3
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
06/24/2025
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
Level of Harm - Actual harm
Residents Affected - Few
R1's medical record, dated 1/7/25, notes R1 exhibited physical aggression. R1's medical record does not
note the details of this physical aggression. R1's medical record does not note any other incident of
physical aggression until 6/21/25.
On 4/25/25, Psychiatric Nurse Practitioner noted R1 is being seen for follow up visit: R1 is adherent with
medication with encouragement from staff; fair hygiene and states I am doing well. Objective: R1 is AO x
2-3, fair grooming with good hygiene has no overt indication of depressive signs/symptoms. Fair
insight/judgment; normal speech, apathetic fair concentration but denies suicidal/homicidal ideation.
Assessment: He presents cooperative; fairly guarded endorses normal sleeping habit. Nursing staff reports
R1 is adherent with medication and without exacerbation.
R1's screening assessments for indicators of aggressive and/or harmful behaviors, dated 10/29/24, 1/3/25,
1/7/25, 2/3/25, and 5/5/25, note R1 is at minimal risk for aggression.
The facility's abuse policy, revised 1/31/25, notes the nursing staff is responsible for reporting the
appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is
discovered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145898
If continuation sheet
Page 3 of 3
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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.
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.
FAQ · About this visit
Common questions about this visit
What happened during the June 24, 2025 survey of BRIA OF CHICAGO HEIGHTS?
This was a inspection survey of BRIA OF CHICAGO HEIGHTS on June 24, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIA OF CHICAGO HEIGHTS on June 24, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
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.