Health inspection·December 19, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sit at the desk, calling myself and the other nurse fake. The level of disrespect from CNA is crazy, I've dealt with from a few that still work there. I should have sent her home earlier, but I was busy on my hall on top of dealing with that. Statement from V13, CNA documents, I was told by another coworker that (R10) called me out my name (sic) and was saying mean stuff about me while she was changing him. All I wanted to know was what was wrong. I have not had him in a while. Went down to his room to ask him was everything okay. Did I do something to make him mad? He started cussing me out. Tell me to get the fuc* out of his room and that I don't need to work here. I'm not shi* and stuff like that. I never cursed at him. I just asked him what was wrong. That's the only thing I asked him. He tried to record me and everything and not once did I cuss at him I though he hadn't said nothing to me all day yesterday 11/26 I work 16 hours do not even have the set he was on so I was just trying to figure out what was the problem. Had a situation about a month ago and it got handled but why are you bringing up a situation that already got handled by the administration? Telling the aide anything about me? And for him just trying to figure out what was the problem. Had a situation about a month ago and it got handled but why are you talking about me to somebody and why are you bringing up a situation that already got handled by the administration. Telling the aide anything about me. And for him to call me out my name and talk to me that way he did was not right, there needs to be a level of respect when it comes too these residents just like we have to respect them as well. This is not the first time he cussed me out or other staff out, The nurses that were on shift treated me as if I did something wrong and I did nothing wrong the aids can vouch for me as well. Told me to clock out and go stand outside in the cold and I did not have working transportation. I also got told that the was police was going to get called on me. All this for what I do my work the best I can and know how I do not disrespect anybody at work. I actually had a good day until all of this, I am very upset. On 12/8/2025 at 2:36 PM, V17, Licensed Practical Nurse (LPN) stated, I was not working (R10's) hall we had an agency nurse that night and she reported to me that a CNA was giving care to (R10) and he had told her that (V13) had given him care and he did not want her taking care of him anymore because she doesn't like to work and then that CNA told (V13) and (V13) then confronted (R10) and when I reported her and asked her to leave she kept saying she did not have a ride and refused to leave and sat the nurse station cussing. I got her to go outside, and she was sitting in someone's car, but then she came back in and said she didn't do anything, and she wasn't going to leave because it was cold outside. She was calling me names and I told her I was going to have to call the police, and she just refused to leave. I was working but I tried to stay close the nurse's station where she was sitting. On 12/8/2025 at 2:55 PM, V2, Director of Nursing, stated, Today is my first day of working here. I know the previous DON was walked out of the building, but I am not sure what went down. Today is my first day. If a resident made an allegation of abuse against a staff member, I would make sure the resident is safe and the staff member does not have access to them pending the investigation and for the staff to be suspended immediately so we can start an investigation. The staff member must leave the premises, they do not have a choice, it is not optional. This is about keeping the resident safe. They have to leave until we clear them. I would expect all staff that have an allegation of abuse made against them to be escorted out of the building. No staff should still be in the building unless they are in an area away from residents and do not have any access to any residents and/or being monitored for resident interaction. I would not expect the nurse's station to be away from residents because there are a lot of residents that sit near the station and/or are being monitored by staff. Plus, resident can hear and see everything that is going on. On 12/16/2026 at 2:30 PM, V1, Administrator, stated, I expect all staff to be suspended and leave the premises whenever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 2 of 6 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 12/19/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many there is an allegation of abuse, and they are not allowed to come back into the Facility until they are cleared. The Abuse was investigated and (V13) is reinstated and working in the building now. On 12/19/2025 at 1:12 PM, V13, Certified Nursing Assistant, stated, I know another CNA came to me and told me (R10) was saying bad stuff about me. I thought we were cool and I had not even provided care for him for while. I went into his room to try and talk to him and he did not want to talk to me. He started cussing me out and trying to record me. I didn't respond or say anything back to him. I just walked away. Then the nurse told me I had to leave so I left. I left when they told me to leave and I was not in the building after that. 2.R9's POS for December 2025 documents a diagnosis of Chronic traumatic brain injury, right hemiplegia, muscle contractures, complex regional pain syndrome, diabetes, hypertension, and significant behavioral dysregulation. R9s' Care Plan, with a revision date of 10/7/2025, documents, Attention Seeking Behavior -Putting self on the floor; BEHAVIOR: False Accusations saying staff hits him, other residents hit him. ADL: [NAME] requires assist with daily care needs r/t (related to) TBI (traumatic brain injury), right sided hemiplegia and Contractures of the right arm and hand. He has impulse control issues and will sporadically try to get out of his wheelchair using his left arm and left leg. R9's MDS, dated [DATE], document Resident is cognately intact for decision making of activities of daily living. Impairment on one side of upper extremity and impairment on both sides. Uses a wheelchair and requires substantial /maximal assistance for most ADL's. On 12/8/2025 at 1:48 PM, V17, Registered Nurse (RN) stated, (R9) was upset with me and made allegation of verbal abuse because he came out in the hallway and was naked except for a pillow this was about a week ago. I said something and he thought I was talking about his penis and got upset. (V1) was in the hospital. I was with my daughter. I did not say anything about his penis, and it was not investigated. I never gave any statements or anything to anybody. On 12/8/2025 at 2:38 PM, R9 stated, (V17, LPN) his nurse is always making comments about my penis being small and I told my mom, and this has been going on and on and nobody does anything about it and it bothers me. On 12/8/2025 at 2:49 PM, V21, Family of R9, stated, (R9) called me because he was very upset because he thinks his nurse is making fun of his penis and telling him it is so small. I know this upsets him. On 12/8/2025 at 3:30 PM, all abuse investigations were requested. On 12/8/2025 at 4:30 PM, no verbal abuse investigation and/or any investigation related to R9 was provided. On 12/8/2025 at 4:35 PM, V1, Administrator, stated she did not have any abuse investigation for R9. On 12/16/2025 at 1:32 PM, V1, Administrator, stated, I was in the hospital, and my DON (Director of Nursing) was in charge. I was very ill and when I came back my DON had not kept up with anything. I did not even know (R9) had made any abuse allegations until (State) brought it to my attention. I would have expected my DON to send the staff home, interview everyone and try and determine if the abuse did and/or did not happen. It's very frustrating because I take abuse seriously and she should have opened an investigation. What can I say it was not done and it should have been done. The Facility Abuse Policy, with a revision date of 9/2017, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect exploitation, misappropriation of property and mistreatment of residents. This will be done by: identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 3 of 6 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 12/19/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm aggressively investigate all reports and allegations of abuse, neglect exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; filing accurate and timely investigative reports. The CMS 671 Form, dated 12/3/2025, documents there were 50 residents living in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 4 of 6 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 12/19/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure a resident with history of falls was assessed appropriately by nursing staff after a fall. This failure would have resulted in a reasonable person enduring pain for over a day due to a rib and clavicle fracture until nursing staff was notified completed an assessment. Findings include:R2's December 2025 Physician Order Sheet (POS) documents a diagnosis of Parkinson's disease with dyskinesia, with fluctuations, chronic respiratory failure, severe protein calorie malnutrition, traumatic subarachnoid hemorrhage without loss of consciousness, abnormal weight loss, delirium due to physiological condition, and anxiety disorder. R2's Minimum Data Set (MDS), dated [DATE], document R2 was severely impaired for cognition for activities of daily living. R2 uses a wheelchair and requires substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R2's Care Plan: Falls documents, (R2) is at risk for falls. Cognitive deficits, Functional Deficits, Poor Balance, Use of Psychotropic Medication. Date Initiated: 11/27/2023. R2's Progress Notes, dated 11/25/2029 at 1:29 PM, Note Text: CNA'S reported to nurse that resident had a fall yesterday evening 11/24/25, around dinner time, CNA's got resident up without nurses knowledge, ROM (range of motion) and skin assessment provided this shift, resd (resident) does not want staff to touch her arm, Hospice assessed resident with orders to send to ER (emergency room) for eval (evaluation) and tx (treatment). R2's Progress Notes, dated 11/26/2025 at 2:10PM, Note Text: Call received from (Hospice Nurse from Hospital) DX (diagnosis of UTI (urinary tract infection) with new ABT (antibiotic orders), Multiple rib fractures and Fractured clavicle. On call Nurse to have PRN (as needed) Morphine for pain control delivery of pain medication to the facility for resident's comfort and pain control. R2's Hospital Report, with an encounter date of 11/25/2205 at 2:39 PM, documents, I called (Facility) and spoke with nurse. She reported that the patient was found on the floor yesterday around dinner time. She states that somehow, she must have fallen out of her wheelchair. Stated that the medical assistant found her and did not report it to any nursing staff. Nursing staff found out this morning that the patient fell yesterday evening. Nurse stated that the patient had pain to her left shoulder when examined. The patient is nonverbal, bed bound unless in a wheelchair up for food and does not feed herself. Elderly, frail patient observed bed bound in chronic flex/fetal posture, consistent with contractures, Requires full assistance with positioning. The CT scan final results dated 11/25/2025 document, ‘the medical portion, right clavicle, the anterior aspect right first, and second ribs are angulated with cortical irregularity could indicate subtle acute fractures. Closed fracture of multiple ribs of right side, initial encounter, closed, nondisplaced fracture of shaft of right clavicle, initial encounter.R2's Initial Report, dated 11/24/2025, documents, Resident had fall with injury. Investigation initiated DON (Director of Nursing), POA (Power of Attorney), MD (Medical Doctor) notified. This is our initial report 5 day to follow. R2's Final Report incident date of 11/24/2025 documents, Resident resides at (Facility) as a long-term care resident. She is alert and oriented x1, she is dependent for mobility throughout the facility as well as a (mechanical lift) transfer. Resident can be impulsive at times; resident sustained a non-witnessed fall in the dining room. After the investigation of the events, the resident was restless in her chair and slid out of her (geriatric) chair. She was sent to the hospital and returned without admission to hospital. Diagnostics show a right clavicle fracture and 1st/2nd ribs with subtle acute fractures and UTI (urinary tract infection) Care plan reviewed and revised to meet resident needs. This is our final report. R2's Progress Notes, dated 11/26/2025 at 12:15 AM, Note Text: Resident returned to the facility. Resident transported to room, staff assisted Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145656 If continuation sheet Page 5 of 6 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 12/19/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents into the bed and call light placed in reach. Resident seen in ER and treated for Un-witnessed fall, Abnormal CT-Scan, Closed FX (fracture) of multiple ribs on right side, Closed non-displaced Fx of right clavicle, Stercoral colitis, constipation and Acute UTI (urinary tract infection). Resident has new orders for ABT (antibiotics) from ER (emergency room). Discoloration noted to UE (upper extremity). Resident tearful during assessment and PRN (as needed ) pain medication given for discomfort. On 12/3/2025 at 6:25 AM, V7, Certified Nursing Assistant (CNA), stated she usually works midnights. R2 fell in the dining room. I did not witness it but heard she had fallen but she passed away yesterday. If a resident falls, we are supposed to get help and tell the nurse. The nurse will then tell us what to do. I am not sure why (R2) was moved. On 12/4/2025 at 1:29 PM, V8, Certified Nursing Assistant (CNA), stated, If a resident falls, we are supposed to get help and tell the nurse before moving them because we could make it worse if we moved them and they were injured. On 12/4/2025 at 4:14 PM, V14, Licensed Practical Nurse (LPN) stated, If a resident falls, staff are to yell for help and wait for nursing to assess them. If we think there may be an injury, we notify the doctor and send them out. Staff are never to get any resident up without them being assessed first. If they try and get someone up they could easily injure them. On 12/8/2025 at 1:11 PM, V2, Director of Nursing (DON), stated, I know the previous DON was walked out of the building, but I am not sure what went down. Today, is my first day. If a resident falls, I would expect staff to yell for help, nursing to assess the resident, and if there are any injuries or possible injuries to notify the physician to send them out to the hospital. I would never expect staff to get them up without assessing them and/or notifying nursing and/or are being monitored by staff. On 12/17/2025 at 3:38 PM, V23, Medical Doctor, stated, If a resident had a fall, I would expect nursing staff to be contacted so they could assess the resident look for possible injury and depending on the nature of the injury that would determine what staff to do next. In this case, (R2) did have a fracture and injury so this is something staff need to know that there was fall. On 12/19/2025 at 12:10 PM, V24, Infection Control Nurse, stated, I did speak with someone from the hospital. We went back and looked at the cameras, and it was not a medical assistant that found (R2), it was actually a CNA (V25). I am not sure what happened and why no management knew (R2) had fallen until the next day. On 12/19/2025 at 12:10 PM, V25, CNA, stated, I was in the dining room feeding another person. When I looked over, I saw a (geriatric chair) sitting at the table with no resident. I thought it was odd and when I stood up (R2) was under the table. I was trying to get staff attention and there was an agency nurse there and I thought she saw her under the table. The Facility Fall Prevention and Management Policy, with a revision date of 9/2025, documents, This 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 preventive strategies, and facilitate as safe an environment as possible. All resident fallsshall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Evaluate the resident for any injury and notify the physician and emergency contact. Complete a fall incident report in the (Computer) risk management portal. Event ID: Facility ID: 145656 If continuation sheet Page 6 of 6