Bria of Cahokia

In the surveyor’s words

From the most serious findings on record at Bria of Cahokia, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 31, 2023

  Based on interview, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R1) reviewed for supervision and accident prevention in the sample of 29. This failure resulted in an Immediate Jeopardy when R1 exited the facility and was found on the ground, in a field, near a busy interstate and road. This failure has the potential to affect not only R1, but R4, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R25, who have been identified as a high risk for elopement by the facility. The Immediate Jeopardy began on 8/10/23 at 9:00 PM when R1 was last seen in the facility. R1 was found at approximately 5:00 AM on 8/11/23, lying down in a field near a busy interstate and road. […]

• Immediate jeopardy, patternF600Jul 14, 2023

  Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical and sexual abuse for 8 of 12 residents (R2, R8, R9, R12, R13, R14, R15 and R16) reviewed for abuse in the sample of 30. This failure resulted in an Immediate Jeopardy when the following resident-to-resident physical abuses occurred: R15 struck R12 in the head with an unknown object causing a lump to R12's head. On a later date, R15 stabbed R16 in the left chest with a paring knife causing R16 to require emergency medical services and R15 was arrested and remains police custody; and R13 hit R14 on the head with an object and on a later date, R13 stabbed R14 in the head with a pen causing R14 to require emergency medical services and R13 was sent out for psychiatric evaluation. […]

• Immediate jeopardy, isolatedF689Sep 10, 2025

  Based on interview and record review the facility failed to properly assess and supervise a resident during an out of state physician's appointment for 1 of 4 residents (R2) reviewed for supervision in a sample of 16. This failure resulted in R2 who is known of returning from day passes intoxicated, not returning to the facility on [DATE] directly after the appointment with non-emergency ambulance transportation provider or staff escort and instead returning on public transportation after going sightseeing.The Immediate Jeopardy began on 08/19/25 when Due to the facility's failure to properly assess and supervise a resident (R2) during an out of state physician's appointment. […]

• Immediate jeopardy, isolatedF689Aug 20, 2025

  Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R5) reviewed for supervision to prevent accidents in a sample of 8. This failure resulted in R5 eloping through the front entrance at 2:38 AM, on 8/13/25, unsupervised and returning to the facility at 3:36 AM after staff found him approximately 1.2 miles from the facility.The Immediate Jeopardy began on 8/13/25 at 2:38 AM when R5, a confused resident, exited the facility unsupervised and was found 1.2 miles away. R5 returned back to the facility with staff at 3:36 AM. On 8/19/25 at 9:03 AM, V1 (Administrator) was notified of the Immediate Jeopardy. […]

• Actual harm, isolatedF686Mar 25, 2025

  Based on observation, interview and record review the facility failed to assess resident's skin upon admission, failed to provide ongoing assessments, failed to follow/update physician's treatment orders, failed to complete physician ordered pressure ulcer treatments and failed to put interventions in place to prevent skin breakdown for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing a deep tissue injury (DTI) to R2's right hip which worsened by increasing in size. evolved to an unstageable pressure ulcer and the left hip pressure ulcer a DTI evolved to a Stage 3 pressure ulcer. Findings include: 1. R2's Undated Face Sheet, documented he was initially admitted to the facility on [DATE]. […]