Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bria Of Forest Edge during CMS and state inspections, most recent first.
A resident was admitted and remained under facility care until transfer to a hospital, but the attending physician did not complete an initial face-to-face visit, any physical assessments, or the required visits every 30 days for the first 90 days. All documented medical visits and assessments were performed by NPs, and there were no physician progress notes in the record. The DON and Assistant Administrator confirmed that the NP, not the physician, saw the resident. The facility’s physician services policy describes steps when a physician does not make required visits and requires progress notes for physician visits, but it does not define a time frame for the attending physician to assess newly admitted residents.
Two residents were involved in an incident where one cognitively intact resident reported that another resident entered her room while she was sleeping, took her phone without consent, and used it to take photos. An RN documented the complaint and noted that the DON was made aware, but both the DON and the Administrator later stated they had no knowledge of any resident taking another resident’s property and that the incident had not been reported to the abuse coordinator or to the state as misappropriation of property, contrary to the facility’s abuse policy.
Staff failed to follow the facility’s abuse/misappropriation reporting policy when a cognitively intact resident reported that another resident entered her room while she slept, took her phone, and used it, and this allegation was documented by an RN but not reported to the DON/abuse coordinator or to the state agency as required. The Administrator later confirmed he had not been informed of the incident, even though the facility policy requires immediate reporting of any allegation or suspicion of abuse, including theft or misappropriation of property, to administration and timely reporting to the state.
Two residents were involved in an incident where one cognitively intact resident reported that a male resident entered her room while she was sleeping, took her phone, and used it to take pictures of himself. The RN documented the allegation in a progress note and indicated that the DON was made aware, but the DON and administrator later stated they had never been notified of any theft or misappropriation involving this resident. No abuse report was made to the abuse coordinator, and no investigation was initiated, despite facility policy requiring that all allegations of misappropriation of resident property be promptly documented and investigated.
Two residents with mental health diagnoses engaged in a physical altercation after one entered the other's room and took food without permission. Staff were not present to intervene, and the incident was not reported or investigated according to facility policy, despite both residents confirming the physical abuse.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a G-tube, as required by their infection control policy. Observations showed a lack of EBP signage, accessible PPE, and proper PPE usage by staff during high-contact care activities. Interviews confirmed that the facility's policy required EBP for residents with indwelling devices, but the resident's health record lacked a care plan or order for EBP, risking cross-contamination among other residents.
A resident at high risk for falls was left unsupervised in the dining room, resulting in a fall that caused a laceration and a C6 vertebrae fracture. The resident was not wearing shoes and required assistance for safe ambulation. Staff interviews revealed that no one was assigned to monitor the dining room, and the facility's policies on fall prevention and supervision were not followed.
The facility failed to ensure dumpster lids were closed and free from overflowing trash, potentially affecting all 194 residents. Observations revealed open lids with visible garbage and flying insects. The Regional Dietary Manager confirmed the lids should be closed, and a broken compactor lid had been reported. The Maintenance Director arranged the garbage to close the lids and stated a new compactor was needed.
The facility failed to maintain a safe and homelike environment, with a leaking ceiling in one room and structural issues like a missing tile and broken door in another. Maintenance issues were not logged, and communication breakdowns led to prolonged deficiencies, compromising residents' living conditions.
The facility failed to document the administration of controlled medications and ensure proper accountability during shift changes, affecting residents on multiple floors. Missing signatures on medication records and accountability forms were noted, with staff acknowledging the lapses. The DON confirmed the expectation for immediate documentation to ensure accurate record-keeping.
The facility failed to properly store Latanoprost eye drops for two residents, as they were found in a medication cart instead of being refrigerated. Additionally, medication refrigerators on the 4th and 6th floors were not maintained within the required temperature range, potentially affecting all residents on those floors. The Director of Nursing confirmed the need for proper temperature control to preserve medication potency.
A facility failed to obtain informed consent for administering Bupropion, a psychotropic medication, to a resident with major depressive disorder and anxiety. The resident, who was cognitively intact, was unaware of taking Bupropion and had only consented to Sertraline. The facility's policy requires informed consent for psychotropic medications, which was not obtained, as confirmed by the psychotropic nurse.
A resident's call light was found out of reach, hanging on a light fixture above their bed, contrary to facility policy. The resident, who was alert and oriented, could not locate the call light. An LPN confirmed the call light's location and acknowledged it should be within reach. The resident had a BIMS score indicating intact cognition and diagnoses including cerebral infarction and paraplegia.
The facility failed to update the PASARR for two residents with mental health diagnoses. One resident was admitted without a mental diagnosis disclosure on the PASARR, despite having multiple mental health conditions. Another resident's PASARR did not reflect their diagnoses of major depressive disorder and anxiety disorder, nor their medication use. The facility's policy requires PASARR updates after admission, which were not completed in these cases.
A facility failed to refer a resident for PASRR rescreening before the expiration of their Short Term Approval, resulting in a four-month stay without a proper plan of care. The resident had multiple medical diagnoses, including Schizoaffective Disorder and Type 2 Diabetes Mellitus. The Assistant Administrator admitted the oversight in resubmitting the PASRR.
A resident with a furuncle on the neck did not receive timely wound care, as observed by surveyors. The dressing was not changed for several days, and the wound care nurse failed to document the treatment on time. The facility's policy required dressings to be changed as ordered, but discrepancies in documentation were found.
The facility failed to properly contain respiratory equipment for two residents, leading to potential contamination. A resident with severe cognitive impairment had a nebulizer mask left uncovered, while another with moderate impairment had oxygen tubing and a nasal cannula left exposed. Both an LPN and the DON acknowledged the need for proper containment to prevent contamination.
A resident at the facility did not have a privacy curtain in their room, which is essential for maintaining privacy in shared spaces. The resident, who is cognitively intact and has multiple health conditions, reported never having a privacy curtain during their six-month stay. The absence of hooks on the privacy curtain track was noted, and the housekeeping supervisor confirmed that floor technicians are responsible for ensuring privacy curtains are installed, highlighting a lapse in adhering to the facility's policy on creating a homelike environment.
A resident with a history of mental health issues was involved in a physical altercation with another resident over a financial disagreement. After staff intervened, the resident was taken to the dining room where the former Social Service Director improperly used physical restraint techniques, leading to both falling to the floor. This action violated the facility's abuse prevention policy, and the staff member was discharged for improper use of CPI techniques.
A facility failed to ensure a resident had properly fitting clothes and did not maintain an inventory of personal belongings for four residents. A resident with multiple health issues was found with clothes that were too small and unlabeled. Despite family efforts to provide clothing, items went missing, and the facility lacked inventory lists. Other residents reported similar issues, and the laundry process was hindered by unlabeled clothes. The facility's policies on personal belongings and resident rights were not followed.
A resident with an abnormal mammogram did not have a follow-up appointment scheduled, despite a doctor's order and repeated requests. The resident, who is cognitively intact, expressed concern about her breast health. The DON and APN were aware of the need for follow-up but failed to ensure the appointment was made, contrary to facility policies.
A resident reported feeling threatened by an LPN during medication administration, but the incident was not properly reported or investigated by the facility staff. The resident, who is cognitively intact, informed a Psychiatric Rehabilitation Service Coordinator, who failed to comprehend and report the full extent of the allegation to the appropriate authorities, including the facility's abuse coordinator.
A resident was punched by another resident after entering a bathroom without knocking, but the incident was not reported to the facility's social worker or administrator. The aggressor, with a history of aggressive behavior, was moved to another floor, but the lack of proper documentation and reporting by staff led to a failure in addressing the abuse according to the facility's policy.
The facility failed to report an abuse allegation within the required timeframe. A resident reported being punched by another resident, leading to room relocations. Despite informing a CNA and a complainant, the administrator was not notified, and no report was made to the State Agency. The facility's abuse policy requires immediate reporting to the administrator, which was not followed.
The facility failed to notify residents of their trust fund balances exceeding the $2000 SSI resource limit, affecting 17 residents. The Business Office Manager believed the limit had changed to $17,500 based on a letter, leading to a lack of notification. This misunderstanding could impact residents' Medicaid and SSI eligibility.
The facility failed to maintain the dishwasher in a clean condition and used expired testing strips to determine the concentration of the sanitizing solution in the three-compartment sink. The Dietary Manager was unaware of the expiration, and the Assistant Administrator confirmed the absence of a cleaning schedule, potentially affecting all 190 residents who take food by mouth.
The facility failed to follow its medication administration policy for a resident with COPD, resulting in improper documentation and timing of inhaler medication. The resident reported receiving the inhaler only once a day, and the MAR showed multiple days without recorded administration. An LPN administered the medication earlier than scheduled, and the DON confirmed that proper documentation and timing protocols were not followed.
The facility failed to ensure timely arrival of nursing staff, proper medication administration, and accurate documentation for 37 residents. An LPN was observed arriving late and administering medications past the scheduled time without proper documentation. Multiple residents reported not receiving their medications on time, and the EMAR showed 283 overdue medications. The DON confirmed the presence of blank spaces in the MARs, indicating lapses in medication administration and documentation.
The facility failed to ensure medications were administered as ordered and that residents remained free from significant medication errors. Multiple residents did not receive their medications on time, and documentation was often missing or incomplete. The DON confirmed the presence of blank spaces in the MARs, indicating non-administration or lack of documentation.
Failure to Ensure Required Attending Physician Visits for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received the required initial face-to-face visit and ongoing visits from the attending physician. The resident was admitted on an unspecified date and remained in the facility until transfer to the hospital on 2/16/26. Record review showed that the attending physician (V10) did not perform an initial visit, did not complete any physical assessments, and did not meet the requirement of one visit every 30 days for the first 90 days of the resident’s stay. All documented medical visits and assessments during this period were completed by nurse practitioners (V8 and V11), rather than by the attending physician. During the survey, the DON (V3) and Assistant Administrator (V2) confirmed that there were no progress notes from the attending physician in the resident’s medical record, and that the nurse practitioner (V11) was the one who saw the resident. The facility’s policy on Physician Services – On Call Coverage states that if a physician does not make required visits, the DON and/or Administrator should be notified, followed by notification of the Medical Director if there is still no response, and that a progress note must be placed in the medical record when a physician visits a resident. However, the policy does not specify a time frame for when newly admitted residents must be physically assessed by the attending physician, and there was no documentation that the attending physician had seen or assessed this resident at any time during the stay.
Failure to Report and Investigate Misappropriation of Resident Property
Penalty
Summary
Facility staff failed to follow the abuse policy regarding misappropriation of property when a cognitively intact resident reported that another resident took her personal phone without consent. The resident, who had a BIMS score of 15 indicating she was cognitively intact, stated that a male resident entered her room while she was sleeping, unplugged her phone, took it, and used it to take facial pictures of himself. A progress note dated 12/11/2025 by an RN documented that the resident complained a male resident came into her room and took her phone while she was sleeping, that she recovered the phone from the other resident, and that she called the police. The note also documented that the DON was made aware and that security deescalated the situation, with social services to follow up. Despite this documentation, both the DON and the Administrator stated during interviews that they had no knowledge of any incident involving another resident taking this resident’s phone or other personal property. The DON stated he had never heard of anyone going into the resident’s room and taking her things and that the RN who wrote the note had not notified him of any theft by any resident. The Administrator, who is the abuse coordinator, stated that staff are expected to report abuse, including theft, to him and that he had not been informed of any incident of misappropriation of this resident’s property. When shown the RN’s progress note, the Administrator acknowledged that the described incident constituted misappropriation of property and stated that, had he been notified, he would have reported it to the state agency and initiated an investigation. The facility’s abuse policy affirms residents’ rights to be free from misappropriation of property and defines misappropriation as the deliberate wrongful use of a resident’s belongings without consent, but this policy was not followed in this case.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
Facility staff failed to follow the abuse/misappropriation reporting policy when an allegation of theft of resident property was documented but not reported to the abuse coordinator or to the Illinois Department of Public Health (IDPH). A cognitively intact resident (BIMS score 15) reported that a male resident entered her room while she was sleeping, unplugged her phone, took it, and used it to take facial pictures of himself. This allegation was documented in a nursing progress note by an RN, which also stated that the resident recovered her phone from the other resident, called the police, the DON was made aware, facility security de-escalated the situation, and social services would follow up. Despite this documentation, the DON later stated he had never heard of anyone going into this resident’s room and taking her things and that the RN had never notified him of any theft by any resident. The Administrator, who serves as the abuse coordinator, stated that his expectation is that staff report all abuse, including theft and misappropriation of property, to him so he can follow the abuse policy and initiate an investigation, and that he had not been informed of any incident involving this resident’s personal property. When shown the RN’s progress note, the Administrator acknowledged that the described incident constituted misappropriation of property and confirmed he had not been notified by the RN or any staff member. The facility’s abuse policy requires employees to immediately report any incident, allegation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property to the Administrator or an immediate supervisor, and further requires reporting to IDPH within specified time frames. In this case, the allegation involving two residents was not reported as required, resulting in a failure to timely notify the abuse coordinator and IDPH of suspected misappropriation of resident property for two of three residents reviewed for misappropriation in the sample.
Failure to Report and Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
Facility staff failed to follow the abuse/misappropriation policy requiring immediate reporting and investigation of alleged misappropriation of resident property. A cognitively intact resident (BIMS score 15) reported in a 12/11/2025 progress note, documented by an RN, that a male resident entered her room while she was sleeping, took her phone, and that she subsequently recovered the phone and called the police. The note further documented that the DON was made aware and that facility security de-escalated the situation, with social services to follow up. Despite this documentation, there was no evidence that the allegation of misappropriation of property was reported to the abuse coordinator/administrator or that an investigation was initiated as required by the facility’s abuse policy. During the survey, the resident reiterated that another resident had come into her room a few weeks earlier, unplugged her phone, took it, and took facial pictures of himself on her phone, and that she immediately informed the nurse who retrieved the phone. The alleged perpetrating resident denied entering other residents’ rooms or taking phones. The DON stated he was familiar with the resident but had never heard of anyone entering her room and taking her belongings, and stated that the RN had not notified him of any theft. The administrator, designated as the abuse coordinator, also stated he had not been informed of any incident involving the resident’s property and confirmed that, based on the RN’s progress note shown to him by the surveyor, the incident constituted misappropriation of property that should have been reported and investigated under the facility’s abuse policy. The facility’s written policy requires that all allegations of misappropriation of resident property be documented and result in an investigation, including interviews and record review, which did not occur in this case.
Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in both residents physically assaulting each other. One resident, with diagnoses including schizophrenia, schizoaffective disorder, and major depressive disorder, reported that another resident entered his room without permission and began taking his food. When confronted, the second resident allegedly struck the first on the head, prompting the first resident to retaliate by punching the second resident multiple times. The first resident also reported feeling unsafe due to a lack of staff presence and stated that staff did not intervene or prevent the incident. The second resident, who also had a history of mental health diagnoses such as schizoaffective disorder and bipolar disorder, confirmed the altercation but stated that he had been given permission to take the food. He reported being punched first and then defending himself by striking back. Both residents had intact cognitive function according to their most recent assessments. Staff documentation and interviews indicated that the incident was not witnessed by staff, and there was no immediate intervention during the altercation. Despite the facility's abuse policy requiring immediate reporting and investigation of abuse allegations, the incident was not reported to the administrator or investigated as required. The psychosocial rehabilitative services director was aware of the altercation but did not report it, as he had not witnessed the event and staff present did not provide details. Social service notes only documented a verbal disagreement, and there was no evidence of a thorough investigation or appropriate follow-up in response to the physical altercation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with a G-tube. Observations revealed that there was no signage indicating EBP outside the resident's room, and Personal Protective Equipment (PPE) was not made available or accessible outside the room. Additionally, a trash can for discarding PPE was not positioned near the exit of the resident's room. During care activities, staff did not wear the appropriate PPE, such as gowns, when providing high-contact care to the resident, who required extensive assistance with activities of daily living and had multiple medical conditions, including a G-tube. Interviews with staff, including the Infection Preventionist nurse and the Director of Nursing, confirmed that the facility's policy required EBP for residents with indwelling medical devices like G-tubes. The policy also mandated the use of gowns and gloves during high-contact care activities and the posting of EBP signage. However, the resident's health record lacked a care plan or order for EBP, and staff were not following the necessary precautions, potentially risking cross-contamination among the 48 residents on the 4th floor.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R194, who was at high risk for falls. This lack of supervision resulted in R194 sustaining a fall in the dining room, leading to a laceration above the left eyebrow and an acute interior column fracture of the C6 vertebrae. The incident required R194 to be transferred to a local hospital for treatment, where they received stitches and were instructed to wear a neck brace for eight weeks. On the day of the incident, R194 was ambulated to the dining room by a Certified Nursing Assistant (CNA) without wearing shoes, only friction socks. The Licensed Practical Nurse (LPN) on duty, V16, was administering medications and did not have a direct line of sight to the dining room. Both V16 and the CNA, V24, acknowledged that no staff was specifically assigned to monitor the dining room at the time, and the area was chaotic with staff attending to other residents. This lack of supervision allowed R194, who had an unsteady gait and required assistance for safe ambulation, to fall and sustain injuries. Interviews with staff, including the Director of Nursing (DON), confirmed that R194 was known to be at high risk for falls and required monitoring when in the dining room. The facility's policies on fall prevention and supervision were not adequately followed, as no staff was present to supervise R194, leading to the fall and subsequent injuries. The facility's documentation and staff interviews highlighted the absence of a systemic approach to ensure adequate supervision and prevent such accidents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster lids were closed and free from overflowing trash, which has the potential to affect all 194 residents residing at the facility. During an observation, the surveyor noted that the metal lid for the trash compactor and two lids for the dumpster were open, with bags of garbage, boxes, and food waste products visible inside. Flying insects were observed in the vicinity of the open compactor and dumpster. The Regional Dietary Manager confirmed that the dumpster lids should be closed to prevent pests from entering the trash and acknowledged that the trash compactor lid was broken, with a work order completed for its repair. Further investigation revealed that the trash compactor lid had been broken for about a month, and a work order dated 9/19/24 indicated that dietary staff reported the issue. The Maintenance Director confirmed that the trash company had been contacted for service. On a subsequent observation, the surveyor found the dumpster lids open again, with trash and boxes preventing closure. A large stone was used to keep the trash compactor lid closed. The Maintenance Director stated that the trash company had assessed the compactor and determined that a new one was needed, but the delivery date was unknown. The facility's policy on garbage disposal emphasizes the importance of collecting and disposing of garbage in a safe and efficient manner.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, the ceiling in a room shared by three residents was leaking, and a trash can was used as a catch bin. The leak was reported to have started after maintenance work on a vent, but no work order was logged for the issue, and the ceiling remained covered with plastic days later. The Director of Nursing was unaware of the problem, indicating a breakdown in communication and maintenance procedures. Additionally, the facility failed to address structural issues in another resident's room, where a missing ceramic tile under the sink and a broken closet door were observed. These issues were not reported in the maintenance log, and the Maintenance Director was unaware of them. The missing tile was noted to potentially allow mice to enter, as residents reported seeing mice in the bathroom. The facility's pest control records confirmed the presence of rodents, but no action was taken to repair the tile or door. The facility's policies and procedures emphasize the importance of maintaining a homelike environment and addressing maintenance issues promptly. However, the lack of communication and failure to log maintenance requests in the TELS system or work order book resulted in prolonged deficiencies that compromised the residents' living conditions. The facility's preventive maintenance plan and job descriptions outline responsibilities for repairs, but these were not effectively implemented in the observed cases.
Controlled Medication Documentation and Accountability Failures
Penalty
Summary
The facility failed to ensure proper documentation and accountability for the administration of controlled medications, affecting multiple residents across different floors. Specifically, there were missing signatures on the Controlled Drug Receipt Record/Disposition form for a resident receiving Tramadol, indicating that the medication administration was not properly documented. Additionally, the Shift Change Accountability Record for Controlled Substances Forms on the 3rd floor, 4th floor B-wing, and 6th floor B-wing had missing signatures, which are required to confirm the handover of correct medication counts between outgoing and incoming nurses. These deficiencies were observed during various tasks, including medication reconciliation and storage and labeling checks, with several nurses acknowledging the missing signatures. The Director of Nursing confirmed the expectation for staff to sign the accountability forms immediately after counting controlled medications to ensure accurate record-keeping. The facility's policy mandates that controlled substances be counted each shift, and both nurses involved in the count must sign the count sheet to verify the accuracy of the documented quantities.
Improper Medication Storage and Temperature Control
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, as evidenced by the improper storage of Latanoprost eye drops for two residents, R84 and R100. During a survey, it was observed that the Latanoprost eye drops, which should be refrigerated to maintain potency, were found in a brown bag in the medication cart instead of being stored in a refrigerator. The Licensed Practice Nurse (LPN) acknowledged that the medication should not be in the cart and should be refrigerated as per the pharmacy's instructions. This oversight in medication storage has the potential to affect all residents on the 3rd and 6th floors. Additionally, the facility failed to maintain the required temperature range for medication refrigerators, which is crucial for preserving medication potency. On the 6th floor, the medication refrigerator was found to have a temperature of 60F, with ice buildup in the freezer section, while the 4th floor refrigerator was recorded at 48F on consecutive days. The Director of Nursing confirmed that the refrigerator temperature should be between 36F and 46F and that staff should report any deviations to maintenance for repair. The facility's policy and the Latanoprost package insert both specify the need for refrigeration of unopened bottles, highlighting a failure to follow established guidelines.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, specifically Bupropion, for a resident identified as R103. R103, who has diagnoses of major depressive disorder and anxiety disorder, was cognitively intact as per the Minimum Data Set. The resident's medication records indicated that Bupropion was prescribed and administered daily without the resident's knowledge or consent. The resident was only aware of taking Sertraline, another antidepressant, and expressed surprise upon learning about the Bupropion medication. The facility's policy mandates informed consent for psychotropic medications, which was not obtained in this case. The psychotropic nurse, identified as V3, confirmed that informed consent is crucial for psychotropic medications due to their potential impact on cognitive function. Upon reviewing the resident's records, V3 acknowledged that the consent for Bupropion was missing, and the resident had not been informed of the medication's risks and benefits. The facility's policy requires that residents or their representatives be informed and provide consent for psychotropic medications, with verbal consent documented if written consent cannot be immediately obtained. This protocol was not followed, resulting in the deficiency noted in the report.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by their policy. During an observation, a surveyor found the call light string hanging on top of the light fixture above the resident's bed, out of reach. The resident, who was alert and oriented, was unable to locate the call light string when asked by the surveyor. The Licensed Practical Nurse (LPN) confirmed that the call light string was on top of the light fixture and acknowledged that it should be within the resident's reach. The resident involved had a diagnosis that included cerebral infarction, morbid obesity, hemiplegia, and paraplegia, but had an intact cognitive status with a Brief Interview for Mental Status (BIMS) score of 14. The Director of Nursing (DON) stated that the purpose of the call light is for residents to signal staff for help, and it should be within reach at all times. The facility's policy, revised in September 2022, also mandates that call lights be accessible to residents at all times.
Failure to Update PASARR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, R34 and R103, to the appropriate state-designated authority for a new Level I PASARR evaluation and determination. Resident R34 was admitted to the facility without a mental diagnosis disclosure on the Level I PASARR, despite having medical diagnoses including Schizoaffective Disorder, Bipolar Disorder, Brief Psychotic Disorder, Depression, and Impulsiveness. The facility's policy requires that the PASARR screening be provided prior to admission to ensure appropriate care and placement decisions. However, the Assistant Administrator acknowledged that even if the PASARR is completed at the hospital, the facility should verify its accuracy. Resident R103 was diagnosed with major depressive disorder and anxiety disorder, with active orders for antidepressant medications. However, R103's Level I PASARR did not reflect these mental health diagnoses or medication use. The Assistant Administrator, covering for the social services director, confirmed familiarity with the PASARR process and acknowledged the discrepancies in R103's PASARR. The facility's policy states that if a resident requires a PASARR update after admission, the facility should contact the state agency to update the PASARR, which was not done in these cases.
Failure to Timely Rescreen Resident for PASRR
Penalty
Summary
The facility failed to refer a resident to the state agency for Preadmission Screening and Resident Review (PASRR) rescreening before the expiration of the resident's Short Term Approval without Specialized Services determination. This deficiency affected one resident, identified as R178, out of a total sample size of 77 residents. The resident's PASRR, dated November 6, 2023, indicated that the Short Term Approval would end on February 4, 2020, and required a new Level I screen to be submitted no later than 10 days before this date if continued stay was necessary. However, the PASRR Level I rescreen for the resident was not completed until June 7, 2024, resulting in the resident staying at the facility for four months without the proper plan of care. The resident's medical diagnoses included Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus, Asthma, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, and Depression. The Assistant Administrator acknowledged that the PASRR was not resubmitted in a timely manner.
Failure to Provide Timely Wound Care and Documentation
Penalty
Summary
The facility failed to ensure timely wound care treatment and documentation for a resident with a furuncle on the neck. The resident, who is cognitively intact, was observed with a soiled and undated dressing on two consecutive days, indicating that the dressing had not been changed for about three days. The wound care nurse admitted to not dating the dressing changes and stated that the facility's policy did not require it. The nurse also acknowledged that the dressing needed to be changed and that failing to do so could lead to infection. The resident's treatment orders required dressing changes on specific days and as needed, but the Treatment Administration Record showed discrepancies in the documentation. The wound care nurse documented treatments for previous days only on a later date, indicating a lapse in timely documentation. The Director of Nursing confirmed that dressings should be changed according to orders and when soiled to prevent infections. The facility's policy and the wound care nurse's job description emphasized the importance of following physician orders and documenting care rendered.
Failure to Contain Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper containment of respiratory equipment for two residents, leading to potential contamination issues. Resident R88, who has severe cognitive impairment and multiple chronic conditions including COPD and CHF, was observed with a nebulizer mask left uncovered on a plastic bin and bedside table on separate occasions. This was acknowledged by a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who both confirmed that the mask should be stored in a plastic bag to prevent contamination and maintain infection control standards. Similarly, Resident R6, who has moderate cognitive impairment and a history of COPD exacerbation, was observed with oxygen tubing and a nasal cannula left uncovered on top of an oxygen concentrator machine. This was also brought to the attention of an LPN and the DON, who reiterated the importance of containing the equipment in a plastic bag when not in use to prevent debris and contamination. These observations highlight a lapse in following proper respiratory care protocols for residents requiring such equipment.
Privacy Curtain Deficiency for Resident
Penalty
Summary
The facility failed to provide a privacy curtain for a resident, identified as R62, which is necessary to ensure privacy in shared rooms. R62, who has been at the facility for six months, reported never having a privacy curtain and expressed a desire for one, especially for privacy while sleeping. The resident is cognitively intact, as indicated by a Brief Mental Status Interview (BIMS) score of 15, and has multiple diagnoses, including prediabetes, alcohol abuse with alcohol-induced psychotic disorder, and essential hypertension. During the survey, it was observed that R62's room lacked a privacy curtain, and the housekeeper, V15, confirmed the absence of hooks on the privacy curtain track, preventing the installation of a curtain. The housekeeping supervisor, V36, stated that floor technicians are responsible for ensuring privacy curtains are in place and acknowledged the importance of privacy curtains in maintaining residents' privacy and dignity. The facility's policy emphasizes creating a homelike environment that accommodates residents' needs and preferences, which was not adhered to in this instance.
Resident Abuse Due to Improper Use of CPI Techniques
Penalty
Summary
The facility failed to protect a resident, identified as R394, from physical abuse by a staff member, specifically the former Social Service Director, V44. The incident occurred following a disagreement between R394 and another resident, R116, which escalated into a physical altercation. After staff intervened and separated the residents, R394 was escorted to the dining room. During an attempt to redirect R394, who was being verbally aggressive, V44 used physical restraint techniques, which led to both V44 and R394 falling to the floor. This action was deemed improper use of Crisis Prevention Intervention (CPI) techniques. R394, who has a medical history including chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, and schizophrenia, was involved in a verbal and physical altercation with R116 over a financial disagreement. The situation escalated when R394, upset over a damaged cellphone, was pushed by R116, leading to a physical confrontation. Staff intervened, and R394 was taken to the dining room where the incident with V44 occurred. Despite attempts to deescalate the situation verbally, V44 resorted to physical restraint, which was not in line with CPI protocols. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, neglect, and mistreatment. However, the actions of V44, who was later discharged for improper use of CPI, violated this policy. The incident was reported to the police, and an investigation was conducted by the facility. The report highlights the need for staff to prioritize verbal de-escalation techniques and adhere to established protocols to prevent similar incidents in the future.
Failure to Maintain Inventory of Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure that a resident, R2, had clothes that fit properly and did not maintain an inventory of personal belongings for four residents, R2, R3, R4, and R5. This deficiency was identified through observations, interviews, and record reviews. R2, who has multiple diagnoses including major depressive disorder, anxiety disorder, and morbid obesity, was found to have clothes that were too small and not labeled with a name. The facility had previously experienced a flood, which resulted in the misplacement of many residents' clothes, including R2's. R2's family member, V13, reported purchasing clothes for R2, which were labeled and documented in an email to the facility's social worker, V11. However, these items were missing, and the facility did not have an inventory list for R2 or the other residents. The social service director, V4, acknowledged the lack of inventory lists and stated that social services were responsible for keeping track of residents' belongings. Despite promises to replace missing items, R2's clothes had not been replaced, and the facility failed to maintain proper documentation of personal belongings. Interviews with other residents, R3, R4, and R5, revealed similar issues with missing clothes and the absence of inventory lists. The laundry supervisor, V10, noted that clothes often arrived unlabeled, making it difficult to return them to the correct residents. A large bin of unlabeled clothes was observed, indicating a systemic issue with inventory management. The facility's policies on personal belongings and resident rights emphasize the importance of maintaining an inventory to ensure residents can retain and use their personal possessions, which was not adhered to in this case.
Failure to Schedule Follow-Up for Abnormal Mammogram
Penalty
Summary
The facility failed to ensure a diagnostic appointment was scheduled for a resident who had an abnormal mammogram and a doctor's order for a follow-up appointment. This deficiency affected one of the three residents reviewed for nursing care. The resident, who is cognitively intact with a BIMS score of 15, expressed concern about not knowing the status of her breast health after an abnormal mammogram in February. Despite mentioning her concerns to several nurses, the follow-up appointment was not scheduled. The Director of Nursing (DON) acknowledged the importance of follow-up appointments to prevent worsening conditions and ensure early treatment. The Advanced Practice Nurse (APN) was aware of the abnormal mammogram and had entered an order for a diagnostic mammogram and ultrasound, but was unaware that the appointment had not been scheduled. Facility policies require physician orders to be followed as written and appointments to be verified by staff, but these procedures were not adhered to in this case.
Failure to Report and Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of mental abuse involving a resident, identified as R2, who reported that a nurse, identified as V7, threatened him during a medication administration. R2, who is cognitively intact with a BIMS score of 15/15, reported the incident to V5, the Psychiatric Rehabilitation Service Coordinator, stating that V7 threatened to "beat the $h!+ out of" him after R2 pointed out a missing pill. V5, who had been recently in-serviced on abuse reporting, acknowledged that R2 reported feeling uncomfortable with V7 but did not recall the specific threat and did not report the incident to her supervisor, V6, or the facility's abuse coordinator, V1. V5 admitted that she might not have comprehended the full extent of R2's report due to being preoccupied as she was leaving the facility. V6, the Psychiatric Rehabilitation Service Director, stated he was never informed of any issues between R2 and V7. V1, the facility administrator and abuse coordinator, confirmed that he had not received any allegations of abuse regarding R2 until the surveyor's inquiry. The facility's policy requires immediate reporting of any abuse allegations to the administrator, which was not followed in this case, leading to a failure in addressing the potential abuse and ensuring the resident's safety.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident where one resident punched another in the face. The incident occurred when the resident entered another resident's bathroom without knocking, leading to the physical altercation. Despite the resident reporting the incident to a Certified Nursing Assistant (CNA) and a complainant, the abuse was not reported to the facility's social worker or the administrator, who is the designated abuse coordinator. The administrator was unaware of the incident until notified by the surveyor, indicating a breakdown in the facility's abuse reporting protocol. The resident who was punched did not sustain any injuries but was moved to another room, while the aggressor was relocated to a different floor. The aggressor has a documented history of aggressive and inappropriate behavior, as noted in their social service care plan. Despite the facility's policy affirming residents' rights to be free from abuse, the incident was not properly documented or reported by the staff involved, including the CNA and the Licensed Practical Nurse (LPN) on duty at the time. This lack of communication and documentation contributed to the facility's failure to address the abuse promptly and effectively.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not reporting an abuse allegation to the abuse coordinator and the State Agency within the required two-hour timeframe. This deficiency involved two residents, where one resident reported being punched in the face by another resident after entering the latter's bathroom without knocking. Although the incident did not result in any injury, the affected resident was moved to another room, and the alleged perpetrator was relocated to a different floor. Despite the incident being reported to a Certified Nursing Assistant (CNA) and a complainant, the facility's administrator was not informed, and no report was made to the State Agency. Interviews revealed that the CNA was informed of the incident by the affected resident and subsequently notified a Licensed Practical Nurse (LPN) on duty. However, the LPN stated that no report of the physical assault was made to them. The facility's administrator was only made aware of the incident during a surveyor's visit, and a review of the facility's reportable incidents showed no record of the allegation. The facility's abuse policy mandates immediate reporting of any abuse allegations to the administrator, which was not followed in this case.
Failure to Notify Residents of Trust Fund Balances
Penalty
Summary
The facility failed to notify residents of their trust fund balances before they exceeded the $2000.00 resource limit for Social Security Administration (SSI) for individuals. This oversight affected 17 residents who were reviewed for trust fund balances, with amounts ranging from $2036.95 to $14,942.58, all exceeding the SSI resource limit. The facility's Business Office Manager, V3, stated that they believed the resource limit had changed to $17,500.00 based on a letter from All Assistance Program Providers, which led to the decision not to notify residents or their families about the balances. The facility's Resident Trust Fund Policy and Procedure, which was undated, documented that residents should not have more than $17,500.00 in their trust fund accounts. However, the Social Security spotlight on Resources 2024 edition still indicated that the resource limit for SSI benefits was $2000 for an individual. This discrepancy in understanding and communication resulted in the facility not providing the required notifications, potentially affecting the Medicaid and SSI eligibility of the residents involved.
Failure to Maintain Clean Dishwasher and Valid Testing Strips
Penalty
Summary
The facility failed to maintain dishwasher equipment in a clean condition and failed to ensure the availability of valid testing strips for determining the concentration of the sanitizing solution in the three-compartment sink. During an observation, the Dietary Manager (V3) was asked about the method used to determine the concentration of the sanitizing solution. V3 produced expired testing strips, which had expired more than two years ago. V3 admitted that he was unaware of the expiration and acknowledged that expired strips should not be used. Additionally, the metal surface of the dishwasher was observed to have an accumulation of whitish grey dirt, indicating a lack of regular cleaning. V3 mentioned that an outside vendor performs maintenance every other month but was unsure about the daily cleaning schedule, which is supposed to be done by the kitchen staff. The Assistant Administrator (V1) was informed about the situation and confirmed that there was no established cleaning schedule for the dishwasher. The facility's policy on equipment cleanliness states that all foodservice equipment should be clean, sanitary, and maintained according to the manufacturer's directions. However, the observations and interviews revealed that these procedures were not being followed, potentially affecting all 190 residents who take food by mouth. Only one resident in the facility does not take food by mouth, highlighting the widespread impact of this deficiency.
Failure to Follow Medication Administration Policy for Resident with COPD
Penalty
Summary
The facility failed to follow its medication administration policy for a resident diagnosed with chronic obstructive pulmonary disease (COPD). Specifically, the facility did not document the administration of inhaler medication as ordered by the physician, did not observe the proper timing for administering the inhaler, and did not follow the respiratory care plan. The resident, who was supposed to receive Albuterol Sulfate HFA Inhalation Aerosol Solution every four hours, reported receiving the inhaler only once a day. The Medication Administration Record (MAR) for the resident showed multiple days where the medication was not recorded as administered. During the survey, it was observed that a Licensed Practical Nurse (LPN) administered the inhaler medication earlier than scheduled and did not adhere to the one-hour before and after rule. The Director of Nursing (DON) confirmed that nurses are required to document every medication administration on the MAR and follow the five rights of medication administration. The facility's policy on medication administration emphasizes the importance of administering medications at the proper time, in the prescribed dose, and documenting each administration. However, these protocols were not followed, leading to a deficiency in pharmaceutical services for the resident with COPD.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure timely arrival of nursing staff, proper medication administration, and accurate documentation for 37 residents. On the day of the survey, a Licensed Practical Nurse (LPN) was observed arriving 30 minutes late for her shift and administering medications past the scheduled time. The LPN did not have a list of residents who had received or not received their medications and was observed with multiple unlabeled medication cups on the medication cart. The Electronic Medication Administration Record (EMAR) showed 283 overdue medications, and the LPN admitted to not documenting the administration of medications properly. Several residents, including those with cognitive impairments, reported not receiving their medications on time or at all. One resident confirmed that medications were left at the bedside, and another resident mentioned that the facility sometimes ran out of medications, causing delays. The surveyor observed blank spaces in the Medication Administration Records (MAR) for multiple residents, indicating that medications were not documented as administered on several occasions. The Director of Nursing (DON) reviewed the MARs and confirmed the presence of blank spaces, which should have been coded to indicate the reason for non-administration. The facility's Medication Administration policy requires that any deviation from the physician's order be documented and the physician notified. The failure to follow these procedures led to significant lapses in medication administration and documentation, affecting the care of 37 residents on the 6th floor.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered and that residents remained free from significant medication errors. On multiple occasions, medications for four residents were either not documented as administered or were administered late. For instance, on 3/21/24, it was found that a resident did not receive their 9am medications, which included significant medications such as Cymbalta, Gabapentin, Hydrochlorothiazide, Losartan Potassium, Meloxicam, and Topiramate. The Licensed Practical Nurse (LPN) admitted to not documenting the administration of these medications. Another resident reported not receiving their medications on a previous day, and their Medication Administration Record (MAR) confirmed missing documentation for several days. The Director of Nursing (DON) reviewed the MARs and confirmed the presence of blank spaces, indicating that the medications were not documented as administered or the reason for non-administration was not recorded. Additionally, another resident's medications, including Levothyroxine, Humalog, Amlodipine Besylate, Metformin, and Nuedexta, were not documented as administered on multiple occasions. The LPN admitted to leaving the documentation open as a reminder to reorder the medication. A third resident did not receive their 9am medications, which included Amiodarone, Furosemide, Bupropion, Apixaban, Gabapentin, Lidocaine patch, Metoprolol, and Sertraline, and reported that the facility often ran out of medications. The MAR confirmed missing documentation for several medications on different days. The facility's Medication Administration policy requires that medications be administered at the proper time and any deviations be documented, which was not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,815 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya On 87th | 1.1 mi | ★★★★★ | 18 | 0 |
| Landmark At 95th Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 17 | 0 |
| Avantara Evergreen Park | 2.9 mi | ★★★★★ | 4 | 0 |
| Mercy Circle | 2.9 mi | ★★★★★ | 3 | 0 |
| Princeton Rehab & Hcc | 3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bria Of Forest Edge.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.