Health inspection·April 22, 2025

F 0760 R3's Post-Acute Transfer Report, dated 4/20/25, document R3's Principal Problem was an accidental drug overdose. Level of Harm - Actual harm R3's Physician Order Sheets (POS) were reviewed with no orders for Clozaril. Residents Affected - Few R5's POS was reviewed with an order for Clozapine (Clozaril) 100 mg, give 1.5 tablets by mouth twice daily. On 4/22/25 at 1:23 PM, V8, RN, stated she was at the medication cart, getting medications ready for another resident (R5) when R3 came up to her and asked for his medication, and she accidentally gave R3 R5's medication, Clozaril, and about 15 - 20 minutes later, she realized what she had done. V8 stated R3 was very lethargic, the Nurse Practitioner was notified, and R3 was sent to the hospital. V8 stated R3 was admitted to the hospital for a few days. On 4/22/25 at 1:30 PM, V10, Pharmacist, stated she reviewed R3's medication, and there were none of his medications that would have interacted with the Clozaril/Clozapine. V10 stated receiving one dose of this medication, would not have made R3 fatigued or lethargic. V10 stated when it is given regularly some common side effects can be lethargy, blurred vision, etc. from it building in their system with multiple doses, it would not normally be caused by just one dose. On 4/22/25 at 2:45 PM, V2, DON, stated she was not here when the medication error with R3 took place, she was called at home by V8, RN, and V8 had already notified R3's physician and called EMS, and R3 was sent to the hospital. R2 stated, (R3) did not have any adverse reaction from the medication; he is a severe brittle diabetic, his blood sugars quickly go high to low. V2 stated she was told by the hospital R3 was hypoglycemic upon arrival to the ER and was admitted . V2 stated prior to R3 going to the hospital, R3's blood sugar was 300 and he was given 22 units of insulin, and depending on when the insulin was given and he ate, could have caused his blood sugar to drop quickly, which is normal for R3. V2 stated they have changed his insulin and accu-check times to make sure when he is high and needs insulin, that he eats right then and doesn't wait. V2 stated R3 knows when his blood sugar is low and will get peanut butter cups and juice. V2 stated she is a diabetic and hypoglycemia can cause lethargy. V2 stated when a nurse is administering medications, she would expect them to follow the rights of medication administration, right medication, right person, right time, right frequency, etc. On 4/22/25 at 2:55 PM, R3 stated he doesn't remember anything about the incident on 4/17/25, or for a couple of days after. R3 stated he woke up in the hospital and was told they thought he had been given the wrong medication, but that is all he was told. R3 stated his blood sugar goes up and down quickly, and now he doesn't take his insulin until he eats so it won't drop. R3 stated he knows when his blood sugar is low and he will get some candy to raise it. R3 stated when his blood sugar is low, he feels bad and sometimes will black out. The Clozaril Information from Drugs.com documents the following: It is an anti-psychotic used to treat Schizophrenia after other treatments have failed, works by changing chemical reactions in the brain. Also used for reduce the risk of suicidal behavior in adults with Schizophrenia or similar disorders. Clozaril can affect your immune system, can cause seizures when given in high doses, cause heart problems. Overdose symptoms may include drowsiness, confusion, fast heartbeats, feeling light-headed, weak or shallow breathing, drooling, choking, or seizure. The Medication Administration Policy, dated 6/2015, documents the following: All medications are (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 04/22/2025 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 0760 Level of Harm - Actual harm administered safely and appropriately to aid in residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident, and time. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 3 of 3