Health inspection·November 14, 2024

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess 4 of 4 residents (R2, R3, R11, R12) for risks of self-harm upon their admission to the facility. This failure has the potential to affect those residents from self- harm. Findings include: 1.R2's Face Sheet undated documents he was admitted to the facility 7/26/24, with diagnoses of Major Depressive Disorder, Cerebral, Infarction, Unspecified, Restless and Agitation, Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety, and Vascular Dementia, Unspecified Severity, with Agitation. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment, reports 12-14 days (nearly every day) of feeling bad about himself or that he is a failure or that he has let his family down; is feeling down, depressed, or hopeless. R2's Psychiatric Progress note, dated 8/27/24, from the area psychiatric services documents R2's family reported R2 threatens family and threatens suicide when upset. R2's electronic nursing home records do not document a suicide assessment risk upon admission. On 11/7/24 at 2:45 PM, V4, niece of R2, stated he (R2) wanted to die, twice. 2. R3's Face Sheet undated documents he was admitted to the facility 9/11/2020, with diagnoses of Other Schizophrenia, Major Depressive Disorder, Post-traumatic Stress Disorder (PTSD), Unspecified, and Insomnia, Unspecified. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has moderate cognitive impairment, reports 7-11 days (half or more of the days) of feeling down, depressed or hopeless; Never or 1 day of thoughts that he would be better off dead or of hurting himself. R3's medical records for nursing home placement, dated 7/4/2019, documents a past medical history of Suicidal Ideation (5/16/2019). R3's electronic nursing home records do not document a suicide assessment risk upon admission. 3. R11's Face Sheet undated documents she was admitted to the facility 1/20/24, with diagnoses of (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 9 Event ID: 145656 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 145656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Godfrey 1623 29 West Delmar Godfrey, IL 62035 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)