Inspection visit
Health 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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to have physician prescribed narcotic pain
medication for 1 of 3 residents (R2) reviewed for pain. This failure resulted in the resident experiencing
severe pain, becoming incontinent of bowel and bladder, and displaying agressive behaviors.
Residents Affected - Few
Findings include:
R2's Undated Face Sheet documents he was admitted to the facility on [DATE], with diagnoses including
spinal stenosis, pain thoracic spine, low back pain, and chronic pain syndrome.
R2's Care Plan documents, focus pain alteration in comfort related to the advanced disease process,
chronic physical or psychological disability, musculoskeletal, neurological issues due to diabetic neuropathy
and osteoarthritis of the right hip. Goal: resident will not experience a decline in overall function r/t (related
to) pain through next review. Will maintain adequate levels of comfort as evidence by no s/s (signs or
symptoms) of unrelieved pain or distress, verbalizing satisfaction or expressing with relief and comfort
throughout next review. Interventions: administer pain meds, assess effectiveness of pain medication,
assess pain characteristics: duration, location, quality.
R2's admission Pain Evaluation, dated 12/26/2024, documents pain diagnoses spinal stenosis, myelopathy
and right hip pain. Hurts a whole lot describes pain as radiating, stabbing, tightness and tingling. Other
comments: has a history of threatening suicide when experiencing pain.
R2's Quarterly Minimal Data Set (MDS) documents he is alert and had pain.
R2's Physician's Order Sheet (POS), dated 1/2025, documents 1/6/2025 Oxycodone 20 mg every eight
hours.
R2's Medication Administration Record (MAR), dated 1/2025, documents 9 other see nurse's note for the
following dates and times: 1/30/2025 at 2:00 PM and 10:00 PM and on 1/31/2025 at 6:00 AM.
R2's Nurse Progress Note, dated 1/30/2025, had no documentation regarding narcotic pain medication for
2:00 PM and 10:00 PM.
R2's Nurse Progress Note, dated 1/31/2025 at 1:31 PM, V3, Registered Nurse (RN), documented, resident
c/o nausea and several stools today. He has not had his pain medicine-prob side effect of that. Explained to
resident with understanding verbalized.
R2's Nurse Progress Note, dated 1/31/2025 at 3:40 PM, V3 documented, 2:30 PM Resident up to desk
(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:
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
02/28/2025
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)
F 0697
Level of Harm - Actual harm
Residents Affected - Few
yelling, demanding his pain medicine which we did not have but were ordered. He could not be redirected
or calmed regarding situation becoming louder and throwing things. 911 called however resident refused to
go to hospital. DON (Director of Nursing) trying to get his pain medicine sooner.
On 2/28/2025 at 9:33 AM, V5, Certified Nurse Aide (CNA), stated, (R2) uses a urinal and a bed side
commode for bowel movements; he is not incontinent, and he is up in his wheelchair self-propelling about
the facility most of the day.
On 2/28/2025 at 9:50 AM, V6, CNA, stated R2 is continent of bowel and bladder and is usually up in his
wheelchair, but at the end of January 2025, she was working and was assigned to (R2), and he was very
upset that he didn't have his pain medication. He was incontinent of bowel and bladder and was curled up
in bed at that time.
On 2/28/2025 at 9:58 AM, V7, CNA, stated, (R2) is continent of bowel and bladder and he is usually up in
his wheelchair.
On 2/27/2025 at 2:45 PM V3, RN stated she recalled R2's narcotic pain medication wasn't available at the
end of January 2025, but it was on the way to the facility, and she told him. He was really mad and was
having side effects from not having the medication, which was incontinent loose stools that day due to the
pain he was experiencing.
On 2/27/2025 at 11:48 AM, R2 stated he uses the urinal for bladder, and a bed side commode for bowel
moments and is up in his wheelchair self-propelling about the facility. (R2) stated he went several days
without his narcotic pain medication at the end of January 2025. Because he didn't have it, he was curled
up in the fetal position s****ing all over himself all day. The nurse (name unknown) came in and told him he
was feeling so bad because the facility didn't have his narcotic pain medication, and it was on the way from
the pharmacy in (city). He was very upset he didn't have his narcotic pain medication available at that time.
He stated he went through h*** those two days because he was in such pain; his body was breaking down,
and it takes what feels like forever to get out of that severe pain because the pain is so severe it takes
several doses of his narcotic pain medication to catch up in his body to start to relive the pain again.
On 2/27/2025 at 1:10 PM, V2, Director of Nurses (DON), stated she wasn't aware any residents, including
(R2), missed three consecutive doses of narcotic pain medication because it wasn't available at the facility.
She expected staff to call her so she could work on getting the narcotic pain medication delivered to the
facility as soon as possible. The nurse should have notified the pharmacy, and if the facility had a signed
prescription on file, then the pharmacy would have sent a code and the facility staff could have accessed
the medication in the emergency kit.
On 2/27/2025 at 3:30 PM, V2 stated R2 is alert and is usually continent of bowel and bladder. V2 recalled
the day R2 missed a few doses of his narcotic pain medication because he was up at the nurse's station
calling her a f****** b**** and everything but a white woman. At that time, she wasn't aware R2 missed three
doses of his narcotic pain medication and he was out of control. Facility staff called the police because R2
was so upset, cursing and yelling at everyone. R2 usually contacts her when he is out of his narcotic pain
medication, and she was shocked he didn't come to her sooner and let her know he was out of it. V2 stated
when staff realized he was out of narcotic pain medication on 1/30/2025, they printed a prescription and put
it in the folder for the Nurse Practitioner to sign on 1/31/2025, but she didn't come to the facility that day, so
the prescription wasn't signed. 1/31/2025 was the day R2 snapped on the staff and she got the pharmacy
to send her a code, and she got
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145656
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
145656
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/28/2025
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)
F 0697
a dose of R2's narcotic pain medication from the emergency medication kit. R2 calmed down after receiving
the pain medication.
Level of Harm - Actual harm
Residents Affected - Few
On 2/27/2025 at 12:20 PM, V4, Nurse Practitioner, stated she expected all physician ordered medication to
be available at the facility, and she expected staff to follow facility policies on medication administration.
On 2/28/2025 at 9:00 AM, V4, Nurse Practitioner, stated she wasn't aware R2 went without narcotic pain
medication for three doses at the end of January 2025. Although he has a lot of comorbidities including
spinal stenosis, which is very painful, if he was usually continent of bowel and bladder and up in his
wheelchair propelling about the facility then became incontinent of bowel and bladder and in the fetal
position in bed due to not having pain medication, that could potentially cause these side effects due to not
having the narcotic pain medication.
The Facility's Medication Administration Policy, revised 5/2017, documents, if medication is not given as
ordered, document the reason on the MAR and notify the Health Care Provider if required. if medication is
ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the
medication. If available, obtain it from the contingency or convenience box.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145656
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.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
FAQ · About this visit
Common questions about this visit
What happened during the February 28, 2025 survey of BRIA OF GODFREY?
This was a inspection survey of BRIA OF GODFREY on February 28, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIA OF GODFREY on February 28, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate pain management for a resident who requires such services."
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.