Bria of Godfrey

In the surveyor’s words

From the most serious findings on record at Bria of Godfrey, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 8, 2023

  Based on interview and record review, the facility failed to provide supervision to prevent elopement for 1 of 9 residents (R3) reviewed for supervision to prevent accidents in the sample of 15. This failure resulted in an Immediate Jeopardy when R3 exited the facility twice, once found standing next to a busy roadway in the rain, and once found ambulating around a nearby neighborhood. This failure has the potential to not only affect R3, but R2, R4, R7, R8, R9, R10, R11, and R12, who have been identified as a high risk for elopement by the facility. The Immediate Jeopardy began on 3/24/23 at 6:50 PM, when R3 eloped from the facility, and was found out in the rain by a busy street. The staff was unaware of R3's had exited the facility, and failed to check on the door alarm. […]

• Actual harm, isolatedF684Dec 19, 2025

  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. […]

• Actual harm, isolatedF760Apr 22, 2025

  Based on interview and record review, the facility failed to prevent a significant medication error in 1 of 6 residents (R3) when reviewed for medication administration in the sample of 6. This failure resulted in R3 being admitted to the hospital with a principal problem of Accidental Drug Overdose. Findings Include: R3's Progress Note, dated 4/17/25 at 6:59 PM, documents the following: This Nurse recognized that I administered a wrong medication to the resident. Res. (Resident) has NKA (No Known Allergies). Res sent to ER (emergency room ) for evaluation. NP (Nurse Practitioner, Administrator, and D.O.N (Director of Nurses) all made aware. […]

• Actual harm, isolatedF693Mar 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure enteral gastrointestinal feedings and care were provided as ordered for 3 of 3 (R2, R1, R3) residents reviewed for enteral feeding management. This failure resulted in R2 requiring hospitalization for treatment of aspiration pneumonia related to food regurgitation. Findings include: 1. R2 was admitted to the facility on [DATE], with diagnoses of diffuse traumatic brain injury with loss of consciousness, severe protein-calorie malnutrition, dysphagia, and acute respiratory failure. R2's Minimum Data Set (MDS), dated [DATE], documented he is severely cognitively impaired and dependent on staff to assist with all mobility. […]

• Actual harm, isolatedF697Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to have physician prescribed narcotic pain medication for 1 of 3 residents (R2) reviewed for pain. This failure resulted in the resident experiencing severe pain, becoming incontinent of bowel and bladder, and displaying agressive behaviors. Findings include: R2's Undated Face Sheet documents he was admitted to the facility on [DATE], with diagnoses including spinal stenosis, pain thoracic spine, low back pain, and chronic pain syndrome. R2's Care Plan documents, focus pain alteration in comfort related to the advanced disease process, chronic physical or psychological disability, musculoskeletal, neurological issues due to diabetic neuropathy and osteoarthritis of the right hip. […]