Health inspection·August 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation, undated, or the fall on 8/4/24 at 8:09 pm, documented interdisciplinary team (IDT) met and documented upon investigation, it was found the fall is the result of R2 attempting to get up from the wheelchair without help. The interventions include sending R2 to evaluation and treatment. Upon return physical therapy is to screen for strengthening and positioning. On 8/18/25 at 11:15 am, V3, Registered Nurse, (RN) stated R2 returned to the facility on 8/5/35 at 12:49 am, and the EMS attendant placed R2 in bed. V3 stated she was at the facility about an hour and fell out of bed again. V3 stated V4, Certified Nursing Assistant (CNA) was the CNA working that night and was sitting in the hallway across from R2's room to keep a close eye on her. When V4 went into her room, R2 was lying on the floor. V3 stated she assessed R2 had a laceration in the back of her head, and due to R2 receiving blood thinners, V3 sent R2 out to the hospital again. V3 stated R2 was alert to self and described her as impulsive.On 8/5/25 at 12:49 am, R2's progress notes by V3 documented R2 returned to the facility per EMS, who assisted R2 in bed and call light placed in reach. No new orders received from local ER at time of return to the facility. V3 documented range of motion (ROM) and Neuro checks within normal limits (WNL) for R2. CNA staff aware of the need to frequently to monitor resident post-fall. On 8/20/25 at 9:21 am, V4 stated on 8/5/25 during her night shift, she was sitting in the hallway outside of R2's room, a little to the right of the doorway across the hall. She stated from that vantage point she could not directly visualize R2, but was able to get up often and check on R2, along with all of her other residents on the hallway. V4 stated she kept going back and forth checking on R2 frequently. V4 stated she didn't think about sitting at her doorway because she was also thinking of being available for all her other residents on the hall. V4 stated she did not see or hear her fall, but on one of her checks, R2 was lying on the ground.On 8/5/25 at 1:48 am, progress note by V3 documented she called to R2's room by CNA staff and R2 observed laying on floor next to bed with head towards wall and bilateral lower extremities (BLE) extended outward toward bathroom. Call light not activated at time of fall. V3 noted blood on the floor under R2's head. Raised hematoma noted to back of head with laceration noted to area. CNA staff remained with resident. At 1:52 am, V3 documented call placed to 911 for transfer back to local hospital ER for another assessment due to second fall.On 8/5/25 at 2:08 am, V3 documented EMS arrived at the facility and R2 assisted on the stretcher by EMS staff and transported to local hospital ER. R2's fall investigation undated fall investigation for the fall on 8/5/24 at 1:48 am documented Interdisciplinary Team (IDT) met and documented upon investigation, it was found that the fall was the result of R2 rolling out of bed. The intervention is sending R2 to evaluation and treatment. On 8/5/25 at 2:26 pm, R2's progress notes documented she returned from local hospital via EMS and was transferred from stretcher to bed.On 8/5/25 at 9:47 pm, R2's progress note documented CNA alerted nurse at 9:15 pm that R2 was on the floor. When nurse arrived at R2's room, she was on the floor on her left side with blood noted around her head. Nurse controlled the bleeding to R2's head and then contacted 911 for transfer to local hospital ER for further observation. On 8/19/25 at 12:33 pm, V12, LPN, stated R2 was already in the facility when she arrived for her evening shift on 8/5/25. V12 added all the staff were aware a close eye needed to be kept on R2. V12 stated R2's bed was in the lowest position, and her call light was in reach when R2 returned to her room. V12 stated the CNA had just left the room about ten minutes prior to R4, (R2's roommate) coming out and stating R2 was trying to get up. V12 stated she went into the room, R2 was lying on the floor.On 8/18/25 at 12:08 pm, V5, ER supervisor, stated R2 was in the ER on [DATE] from 8:51 pm until 8/5/25 12:24 am, due to an unwitnessed ground level fall. V5 stated R2 then returned to the ER again on 8/5/25 at 2:32 am for a fall, was admitted for observation, and was discharged at 2:54 am. V5 stated R2 was once again admitted to ER on [DATE] at 10:05 pm for an (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 08/20/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete unwitnessed fall and then discharged on 8/6/25 at 3:51 pm to a different facility.Fall Prevention and Management policy, dated 5/2015, with last revision date of 1/2024, documented the facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Facility guideline following a fall incident are to evaluate the resident for any injury and notify the physician and resident responsible party. Complete a fall incident report in the EMR risk management portal. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for fall. Care plan to updated with a new intervention based on root cause analysis after each fall occurrence. Event ID: Facility ID: 145656 If continuation sheet Page 3 of 3