Inspection·April 9, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to administer medications as ordered by the physician in 2 of 4 residents (R2, R3) reviewed for pharmacy services in the sample of 4. Residents Affected - Few Findings include: 1. On 4/8/25 at 11:55 AM, V5, R2's Daughter, stated R2 had not been receiving her daily medications. R2's Face sheet, undated, documents R2 has the following diagnoses: Three Part Fracture of the Left Humerus, COPD (Chronic Obstructive Pulmonary Disease), Neuropathy, MDD (Major Depressive Disorder), CHF (Congestive Heart Failure), Cardiac Pacemaker and Defibrillator, History of Falling, Arthropathy, Gout, HTN (Hypertension), Low Back Pain, and Chronic A. Fib (Atrial Fibrillation). R2's MAR (Medication Administration Record), dated 4/1/25 through 4/30/25, documents the following physician orders, dated 4/1/25: Spironolactone Oral Tablet 25 MG (Milligrams) give 0.5 tablets by mouth one time a day for High Blood Pressure; Sertraline HCl (Hydrochloride) Oral Tablet 25 MG give 1 tablet by mouth one time a day for Depression; Furosemide Oral Tablet 40 MG give 1 tablet by mouth one time a day for Cardiac Failure; Empagliflozin Oral Tablet 10 MG give 1 tablet by mouth one time a day for Heart Failure; Neurontin Oral Capsule 100 MG give 1 capsule by mouth one time a day for Neuropathy; Protonix Tablet Delayed Release 40 MG give 1 tablet by mouth one time a day for GERD; Clopidogrel Bisulfate Tablet 75 MG give 1 tablet by mouth one time a day for blood clot prevention; - Atorvastatin Calcium Oral Tablet 40 MG give 1 tablet by mouth one time a day; and Amiodarone HCl Oral Tablet 200 MG give 1 tablet by mouth one time a day for Atrial Fibrillation. The MAR goes on to document those medications were not administered on 4/2/25 or 4/3/25. R2's Progress Notes, dated 4/2/25 and 4/3/25, document these medications were not administered due to not on hand. 2. On 4/8/25 at 8:00 AM, R3 stated she is supposed to get 4 calcium carbonates after meals, and they were out for a while, so she wasn't getting them. R3's Face sheet, undated, documents R3 has a diagnosis of GERD (Gastro-Esophageal Reflux Disease). R3's MAR, documents an order, dated 3/22/25, for Calcium Carbonate Oral Tablet Chewable 500 MG (Antacid) give 4 tablets by mouth three times a day for supplement. R3's MAR goes on to document that R3 did not receive her medication as ordered on 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, and 3/27/25; therefore, missing a total of 8 doses. (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 2 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 04/09/2025 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)