Health inspection·March 4, 2025

F 0693 R2's Progress note, dated 2/20/2025 at 9:45 PM, documented, Scopolamine Transdermal Patch 72 Hour Apply 1 mg (milligram) transdermally every 72 hours for nausea unavailable. Level of Harm - Actual harm Residents Affected - Few R2's Progress Note, dated 2/21/25 at 8:30 AM, documented, (R2) has what appears to be tube feeding coming from his trach (tracheostomy) and having large emesis that appears to be tube feeding. (R2) being transferred to the hospital for evaluation. The phone numbers listed for the resident's emergency contact are not in service. The documenter unable to reach POA (Power of Attorney) via telephone to update her on the resident's status. R2's Progress note, dated 2/21/25 at 3:54 PM, documented, This Nurse called local hospital. (R2) is being admitted with aspiration pneumonia r/t (related to) food regurgitation. On 3/4/25 at 11:49 AM, V7, Licensed Practical Nurse (LPN), stated R2 was doing okay when he returned from the hospital on 2/20/25, but she remembers he had swelling to his right arm and hand. V7 stated she put in R2's orders as written in his hospital discharge paperwork. V7 stated she started R2 at 45mL of tube feeding not too long after he returned back from the hospital. V7 stated R2 was also having mucus coming from his tracheostomy that was thick and tan. V7 stated Scopolamine patches were ordered and can help with secretions and with nausea, but it wasn't available. V7 stated she did not call for the doctor for alternative orders. V7 stated R2 was not aspirating while she was at the facility, it happened after she left, and she doesn't know exactly what happened. On 3/4/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), stated R2 did not verbalize how he was feeling while he was in the facility. V6 stated she was not sure what happened, but he was having trach issues on 2/21/25 before R2 went back to the hospital, although she did not specify what the occurrance was which made her say he was having issues. On 3/4/25 at 11:05 AM, V3, CNA, stated R2 had something coming out of his tracheostomy the morning of 2/21/25 when he was sent back out to the hospital. On 3/4/25 at 12:27 PM, V8, Nurse Practitioner, stated R2 could have had abdominal distention, nausea, and vomiting if his tube feedings were not titrated as recommended. V8 stated starting R2's tube feedings at 45mL/hr could have been too much for him, causing him to aspirate. V8 stated if the Scopolamine patches weren't available, an alternative medication could have been requested to help prevent nausea and vomiting. The patch is also used to help with secretions in patients with tracheostomies. V8 stated she would recommend keeping a resident elevation for at least 30-60 minutes after a tube feeding to prevent aspiration. 2. R1 admitted to the facility on [DATE], with diagnoses of female intestinal-genital tract fistulae, Methicillin resistant staphylococcus aureus infection, and dysphagia. R1's MDS, dated [DATE], documented she is severely cognitively impaired and dependent on assistance with feeding and all mobility tasks. R1's Care Plan, dated 1/15/25, documented R1 is at risk for complications related to presence of a feeding tube. R1 is allowed to have a regular mechanical soft diet and regular liquids for pleasure feedings as ordered; keep HOB (head of bed) raised 30 degrees; elevate the head of the bed 30-45 degrees during feeding, check tube placement by auscultating air injection every shift; check placement of G-tube (gastrointestinal tube) using auscultation before administering food/medications/fluids, check feeding tube residual as ordered; cleanse stoma site daily with soap and water during routine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 2 of 4 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 03/04/2025 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 0693 care; may be done by nursing assistant if no open areas; keep HOB raised 30 degrees; and elevate the head of the bed 30-45 degrees during feeding. Level of Harm - Actual harm Residents Affected - Few R1's orders, dated 1/14/25, documented check placement of Gtube using auscultation before administering food/medications/fluids. R1's orders, dated 1/14/25, also documented cleanse stoma site daily with soap and water during routine care; may be done by nursing assistant if no open areas. R1's orders, dated 1/14/25, continued to document monitor enteral tube site for signs and symptoms of infection every shift for skin. On 3/3/25 at 11:03 AM, R1 stated, Sometimes the nurses will give me tube feedings while I'm flat. R1 stated the staff clean her stoma every once in a while. On 3/3/25 at 12:33 PM, V3, CNA, assisted R1 with her fruit cup for lunch. R1 stated she did not like the main dish and would like a substitute, if available. V3 placed an order for grilled cheese as a substitute, mechanically soft. On 3/3/25 at 2:03 PM, R1 stated she would like her tube feeding bolus because she didn't have a large meal. V4, Registered Nurse, provided R1 her tube feeding bolus and water flush, without checking for residual or auscultating to check for placement of the feeding tube. The dressing on R1's G-tube site was dated 2/27/25. R1's G-tube stoma site had tender reddened skin surrounding it. As V4 cleansed R1's G-tube stoma site, R1 stated oww every time it was touched. V4 applied skin prep to the stoma before covering it with split gauze. R1's tube feeding was completed at 2:35 PM. V4 stated she would need to notify the provider to see if they would like to add any new treatment to it. On 3/4/25 at 2:19 PM, R1 was observed as having same dressing from day prior, dated 3/3/25 in place. V9, Licensed Practical Nurse, stated she was not told in report that there were any concerns seen yesterday for R1's stoma site, and did not look at it today since R1 did not require a bolus feeding. V9 left the soiled dressing in place and did not remove it to assess the skin, despite R1 reported it being tender. 3. R3 was admitted to the facility on [DATE], with diagnoses of spastic quadriplegic cerebral palsy, unspecified severe protein-calorie malnutrition, and chronic hepatic failure. R3's MDS, dated [DATE], documented she is rarely/never understood, is dependent on assistance with eating and requires substantial/maximal assistance with rolling left and right on the bed, sitting to lying on the bed and lying to sitting on the bed. R3's Care Plan, dated 1/24/25, documented tube feeding: R3 is at risk for complications related to gastrostomy tube placement due to history of BMI (body mass index) of 9.0, recent weight loss and diagnosis of severe malnutrition; check feeding tube residual as ordered; check tube placement by auscultating air injection every shift; keep HOB (Head of Bed) raised 30 degrees. R3's active orders, dated 10/23/2024 at 10:00 PM, documented, Cleanse stoma site daily with soap and water during routine care. May be done by nursing assistant if no open areas. Apply antibacterial cleanser to a 2x2 drain sponge. Allow to set for 10 minutes or longer. Using a cotton tip applicator, apply cream twice daily and PRN (as needed). R3's active orders, dated 10/23/24 at 8:58 PM, documented: check placement of G-tube using auscultation before administering food/medication/fluids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 3 of 4 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 03/04/2025 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 0693 Level of Harm - Actual harm Residents Affected - Few On 3/3/25 at 3:31 PM, V5, LPN, went to R3's room to administer her enteral tube feeding that was due at 2:00 PM. V2, Director of Nursing (DON) was present during the treatment. V5 did not gown up while administering R3's tube feeding. V5 did not auscultate to check for placement of R3's Gtube prior to administering her bolus. V2 stated R3 is on Enhanced Barrier Precautions (EBP) for having a G-tube. R3 did not have a dressing on her G-tube stoma site. At 3:40 PM, V2 stated the day shift nurse didn't have time to apply another dressing to R3's site while they were here. V5 is supposed to do that during her shift, at some point. V2 stated she expects a dressing to be in place on R3's stoma site. V2 stated she expects any staff with direct contact to a resident on EBP to be gowned and gloved up while providing care. On 3/4/25 at 2:05 PM, V9, LPN, administered a bolus of tube feeding to R3 without auscultating to check for placement. On 3/4/25 at 2:30 PM, V1, Administrator, stated, (R2) was admitted to the hospital with pneumonia, and he will not be returning to the facility. I saw firsthand, (R2) had tube feeding coming out of his trach (tracheostomy) and mouth the morning of 2/21/25. I expect the nurses to follow discharge orders as recommended, and absolutely notify a provider if a prescription isn't available to see if an alternative medication can be given. V1 stated she expects her nurses to check for placement of G-tubes prior to administering anything, either by auscultation or checking for residual, but always to find a way. V1 stated she expects staff to be following EBP while providing tube feeding care and to be providing care as ordered/written in their charts and per facility policy. The facility's Tube Feeding Policy, dated 9/2024, documented the following guidelines: check tube placement by aspiration or air insertion, head of the bed should be elevated 30-45 degrees unless ordered differently, check for placement using auscultation prior to flushing, the site is cleansed with soap and water during daily care, turn on pump, set prescribed rate and start feeding, and the CNA will clean the tube site during routine care; should there be any issues with the site, the CNA will notify the nurse who will communicate with the health care provider. The facility's Enhanced Barrier Precautions Policy dated 10/16/23, documented, Our facility employs the use of Enhanced Barrier Precautions (EBP) to reduce transmission of MDROs (multi-drug resistant organisms) to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. Staff utilize gown and gloves for high-contact resident care activities when residents require EBP; high contact activities may include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 4 of 4