Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bria Of Godfrey during CMS and state inspections, most recent first.
A resident who was cognitively intact was given quetiapine for prophylaxis without a documented supporting diagnosis. The MAR showed the antipsychotic was administered for several days, but the hospital H&P, rehab prescriptions, prior med list, and psychotropic consent did not include it. The DON could not find a reason for the Seroquel order, and the APRN later discontinued it after finding no appropriate indication.
A resident with severe cognitive and physical impairments experienced an unwitnessed fall that was not immediately reported to nursing staff. The resident was moved without a nursing assessment, and staff did not follow facility protocol for post-fall evaluation. As a result, the resident endured pain from undiagnosed rib and clavicle fractures for over a day before receiving appropriate medical attention.
The facility did not ensure that staff accused of abuse were immediately removed from resident access and failed to investigate all reported abuse allegations. In one case, a CNA remained in resident areas after an abuse allegation, and in another, a resident's repeated claims of verbal abuse by a nurse were not investigated or documented, contrary to facility policy.
A resident with diabetes and cognitive impairment received a double dose of Lantus insulin after two LPNs each administered the prescribed amount, due to confusion over resident assignments and inability to document in the MAR because of computer issues. The error was discovered after the resident's blood pressure was found to be elevated, leading to hospital evaluation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A resident was provided with a makeshift closet area consisting of a PVC pipe and a portable metal rack, without any shelving or a proper wardrobe. The family had to add a curtain to make the space more homelike, as the facility did not meet its policy of providing sufficient individual closet space.
A nurse administered the wrong medication, Clozaril, to a resident who was not prescribed this drug after the resident requested his medication while the nurse was preparing medications for another individual. The resident, who has diabetes, became lethargic and was sent to the hospital, where he was admitted for hypoglycemia and accidental drug overdose. The error was recognized shortly after administration, and staff interviews confirmed that the nurse did not follow proper medication administration protocols.
Two residents did not receive their prescribed medications as ordered by their physicians due to the medications not being available on hand, resulting in multiple missed doses. One resident with multiple chronic conditions missed several daily medications, while another with GERD missed eight doses of calcium carbonate. Facility policy and the DON confirmed that medications are to be administered as ordered.
A resident with complex medical needs was discharged to a hospital without proper arrangements for housing, DME, and medications. The facility assumed the resident would be admitted to the hospital, but when this did not happen, they refused to accept the resident back, leaving him without a place to live and necessary medical support. The discharge process was inadequately managed, with incomplete documentation and lack of coordination, resulting in the resident being temporarily housed by a community social worker.
A long-term care facility failed to manage enteral feeding properly for three residents, leading to severe health complications. One resident was hospitalized with aspiration pneumonia due to incorrect feeding rates and lack of prescribed medication. Another resident received tube feedings while lying flat, and her stoma site was not properly cared for. The third resident's tube placement was not checked before feedings, and Enhanced Barrier Precautions were not followed. These deficiencies indicate a failure to adhere to medical orders and facility policies.
A resident with chronic pain conditions did not receive prescribed Oxycodone due to unavailability, leading to severe pain, incontinence, and aggressive behavior. The facility's staff failed to follow medication administration policies, resulting in missed doses and significant distress for the resident.
The facility failed to conduct suicide risk assessments for four residents upon admission, despite their histories and diagnoses indicating a need for such evaluations. This oversight involved residents with conditions like Major Depressive Disorder, Schizophrenia, and a history of suicidal ideation or self-harm, contrary to the facility's policy requiring such assessments.
The facility failed to administer medications on time for four residents, resulting in significant medication errors. Residents received medications two hours or more after scheduled times, affecting various medications for conditions like depression, dementia, and hypertension. Staffing issues contributed to the delays, and the facility's policy on timely administration was not followed.
The facility failed to implement fall interventions for two high-risk residents. One resident did not receive a required therapy evaluation after multiple falls, while another experienced falls due to improper transfer techniques and lack of prescribed safety measures like a floor mat and lowered bed. Staff were unaware of specific fall interventions, indicating a communication gap.
Two residents in the facility did not receive adequate pressure ulcer care as per physician orders. One resident, who is severely cognitively impaired, was found without pressure-relieving boots, leading to red heels. Another resident with multiple sclerosis had a pressure ulcer without a dressing, and CNAs failed to inform the nurse, leaving the ulcer exposed. The Director of Nursing was unaware of these lapses in care.
A resident with a history of falls and multiple medical conditions experienced several falls and injuries due to inadequate supervision and ineffective fall prevention strategies. Despite being identified as high risk, the facility failed to implement and monitor appropriate interventions, leading to repeated falls and a head laceration. The facility also lacked timely fall risk assessments and documentation of enhanced supervision.
A resident with multiple health conditions, including an above-the-knee amputation and severe malnutrition, was admitted to the facility and identified as high risk for pressure ulcers. The facility failed to provide timely wound care and follow the care plan, resulting in severe pressure wounds and infection, necessitating hospitalization.
The facility failed to perform catheter care for three residents with indwelling catheters, as documented in their care plans and treatment administration records. The residents experienced delays in catheter care documentation and treatment, leading to issues such as contaminated catheters and bladder infections.
The facility failed to complete wound treatments as ordered for a resident with a stage 4 pressure ulcer on the left buttock. The Treatment Administration Record showed multiple instances of undocumented wound care over several months. The DON acknowledged the issue, particularly with agency staff, and the resident confirmed delays in dressing changes.
The facility failed to provide adequate CNA coverage, particularly during the evening and night shifts, as reported by multiple residents and staff members. The DON and Administrator confirmed staffing shortages, exacerbated by high call-offs and staff leaving for higher-paying jobs. A review of Daily Staffing Sheets revealed multiple instances where the facility did not meet its own staffing grid requirements.
The facility failed to provide proper perineal and catheter care, leading to UTIs in two residents. One resident with acute cystitis and Alzheimer's disease received inadequate perineal care, while another resident with an indwelling urinary catheter received improper catheter care. Staff interviews revealed a lack of awareness and concern regarding the high incidence of UTIs.
A resident with chronic pain did not receive Hydrocodone/Acetaminophen as ordered by the physician due to delays in obtaining the medication from the pharmacy and the need for a hard prescription. The resident experienced significant distress, and the medication was eventually administered from the emergency kit.
The facility failed to provide quality and good tasting food to three residents, who reported issues with food palatability, portion sizes, and overall quality. Staff confirmed frequent complaints, and the facility lacked a policy for Food Palatability.
The facility failed to adhere to infection control practices for two residents, leading to deficiencies in infection prevention and control. Improper hand hygiene and perineal care techniques were observed, likely contributing to recurrent UTIs in the affected residents. Staff acknowledged the presence of UTIs but did not express significant concern or awareness of the potential link to improper practices.
Unsubstantiated Antipsychotic Order
Penalty
Summary
The facility failed to have a supporting diagnosis for a prescribed antipsychotic medication for one resident, who was cognitively intact and admitted with diagnoses including right tibia and fibula fractures, alcohol abuse, insomnia, and major depressive disorder. The resident’s medication order audit showed quetiapine fumarate 50 mg twice daily was ordered for prophylaxis, with notes to obtain informed consent, but the resident’s hospital history and physical, rehabilitation prescriptions, previous facility medication list, and psychotropic consent did not document quetiapine as part of her treatment. The resident received quetiapine from 1/17/26 through 1/23/26 on the MAR. The hospital social worker stated the resident had previously reported being kept doped up and taking 10 pills at one time at another facility. The DON stated she could not find a reason the resident was prescribed Seroquel, and the APRN stated she was unable to find a supporting diagnosis for quetiapine and discontinued it because it was not appropriate for the resident. The facility’s psychotropic medication policy required documentation of the indication for the medication and informed consent for psychotropic use.
Failure to Timely Assess and Report Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a complex medical history, including Parkinson's disease, chronic respiratory failure, severe malnutrition, and cognitive impairment, experienced a fall in the dining room that was not witnessed by nursing staff. The resident was dependent on staff for mobility and required substantial assistance for activities of daily living. After the fall, the resident was found on the floor by a CNA, but the incident was not immediately reported to nursing staff, and the resident was moved without a nursing assessment. The fall was only brought to the attention of nursing staff the following day, at which point a range of motion and skin assessment was performed, and the resident was noted to be in pain and resistant to having her arm touched. Subsequent evaluation by hospice and hospital staff revealed that the resident had sustained multiple rib fractures and a fractured clavicle, as well as a urinary tract infection. The delay in notifying nursing staff and the lack of immediate assessment resulted in the resident enduring pain for over a day before appropriate medical intervention was initiated. Interviews with facility staff confirmed that the expected protocol was for staff to notify nursing immediately and not to move a resident after a fall until assessed by a nurse, but this protocol was not followed in this instance. Facility policy required that all falls be promptly evaluated for injury, with the physician and emergency contact notified, and an incident report completed. However, in this case, the failure to follow these procedures led to a significant delay in the identification and treatment of the resident's injuries. The deficiency centers on the lack of timely assessment and communication following the resident's fall, contrary to facility policy and standard care expectations.
Failure to Remove Accused Staff and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff members accused of abuse were immediately removed from resident access and that all abuse allegations were properly investigated. In one instance, a resident with significant physical impairments and cognitive intactness reported a verbal altercation with a certified nursing assistant (CNA). The CNA was not immediately removed from the premises and remained in areas accessible to residents, including the nurse's station, after being told to leave. Statements from staff and the CNA confirm that she was present in the facility and in proximity to residents after the allegation was made, contrary to facility policy requiring immediate suspension and removal of accused staff pending investigation. Additionally, the facility did not investigate all reported abuse allegations. Another resident with a history of traumatic brain injury and behavioral issues made repeated allegations that a nurse made inappropriate comments about his body. The resident's family also reported these concerns. Despite these reports, there was no documentation of any investigation into the allegations, and the administrator confirmed that no investigation was conducted. The administrator attributed this failure to the absence and inaction of the previous Director of Nursing (DON), who did not initiate or document any inquiry into the matter. The facility's own abuse policy requires immediate protection of residents and prompt, thorough investigation of all abuse allegations. However, in both cases, the facility did not follow its policy: the alleged perpetrator was not immediately removed from resident areas, and one resident's abuse allegation was not investigated at all. These failures were confirmed through interviews, record reviews, and the absence of required documentation.
Double Dosing of Insulin Due to Medication Administration Error
Penalty
Summary
A resident with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, and Anxiety Disorder was admitted to the facility and prescribed 27 units of Lantus insulin to be administered subcutaneously at bedtime. On the night in question, two LPNs each administered a full dose of Lantus insulin to the same resident, resulting in a double dose. The first LPN administered the insulin and was unable to immediately document the administration in the Medication Administration Record (MAR) due to computer and internet issues. Subsequently, the second LPN, confused about her assigned residents and not seeing the prior administration on the MAR, also gave the resident the prescribed dose of insulin. Following the double administration, the resident's blood sugar and blood pressure were monitored, with the blood pressure found to be elevated. The on-call physician was notified, and the resident was given glucose gel and snacks as a precaution. The resident was then transferred to a local hospital for evaluation of hypertension, which was reported to be related to the double dose of insulin. Documentation from the hospital confirmed the double dosing incident and the resident's subsequent evaluation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Closet Space and Shelving
Penalty
Summary
The facility failed to provide adequate closet space with shelving for one resident. According to a family member, the resident's room was located at the end of the hall and did not contain an actual closet or a portable wardrobe. Instead, the facility had installed a PVC pipe from the ceiling, forming a box-like structure intended for hanging clothes, but there were no shelves available. The family had to purchase a curtain and tension rod to make the space more homelike, as the original setup was not considered homelike. Observation of the room confirmed the absence of a built-in wardrobe or closet. The only available storage was a portable metal clothes rack and the PVC pipe structure, with no shelving present. The facility administrator acknowledged that the wardrobe had been removed from the room and that maintenance had installed the PVC pipe, but no shelves were provided. The facility's own policy requires sufficient individual closet space for each resident, which was not met in this case.
Significant Medication Error: Wrong Medication Administered to Resident
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong medication to a resident. The nurse was preparing medications for another resident when the affected resident approached and requested his medication. The nurse mistakenly gave the resident another individual's medication, specifically Clozaril (Clozapine) 150 mg, which was not prescribed for him. The error was recognized by the nurse approximately 15-20 minutes after administration, at which point the resident exhibited lethargy. The resident, who has a history of diabetes and is described as a severe brittle diabetic with rapidly fluctuating blood sugars, was sent to the emergency room for evaluation. Upon arrival at the hospital, the resident was found to be hypoglycemic and was admitted for observation due to accidental drug overdose and altered mental status. The emergency department records indicate that critical care was necessary to manage the resident's hypoglycemia and acute ingestion of the medication. The resident remained hospitalized for several days before returning to the facility. Review of the resident's physician orders confirmed there was no order for Clozaril for this individual, while another resident did have an active order for the medication. Interviews with facility staff confirmed the sequence of events, with the nurse acknowledging the error and the DON stating that the nurse did not follow the rights of medication administration, which include verifying the right medication and right resident prior to administration.
Failure to Administer Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by physicians for two of four residents reviewed for pharmacy services. One resident, who had multiple diagnoses including a three-part fracture of the left humerus, COPD, neuropathy, major depressive disorder, CHF, cardiac pacemaker and defibrillator, history of falling, arthropathy, gout, hypertension, low back pain, and chronic atrial fibrillation, did not receive several prescribed medications on two consecutive days. Documentation in the Medication Administration Record (MAR) and progress notes indicated that these medications were not administered because they were not available on hand. Another resident, diagnosed with GERD, reported not receiving her prescribed calcium carbonate tablets after meals for several days, resulting in a total of eight missed doses. The MAR confirmed these omissions, and the resident's care plan specifically included the intervention to administer medications as ordered. The facility's policy requires all medications to be administered safely and appropriately, and the Director of Nurses confirmed that medications are to be given as ordered by the physician.
Incomplete Discharge Process for Resident
Penalty
Summary
The facility failed to ensure a complete discharge process for a resident, identified as R2, who was transferred to a hospital due to behavioral issues. R2, who had a complex medical history including spinal stenosis, diabetes, and bipolar disorder, was discharged to the hospital without proper arrangements for housing, Durable Medical Equipment (DME), and medications. The facility assumed R2 would be admitted to the hospital, but when the hospital did not admit R2, the facility refused to accept him back, leaving R2 without a place to live and without necessary medical equipment and medications. The discharge process was inadequately managed, as evidenced by incomplete documentation and lack of coordination between the facility and external parties. R2's discharge plan assessment and instructions were left blank, and there was confusion regarding the ordering and approval of DME. The facility's Social Service Director and Administrator were not fully aware of the readiness of R2's apartment, and the facility did not hold a bed for R2's potential return. This lack of communication and preparation resulted in R2 being temporarily housed in a Bed and Breakfast by his community social worker until his apartment was ready. The facility's actions were based on the assumption that R2 would be admitted to the hospital for a psychiatric evaluation, but this did not occur. The facility's Administrator and staff did not verify R2's admission status before proceeding with the discharge, leading to a situation where R2 was left without adequate support. The facility's discharge policy was not followed, as evidenced by the lack of a completed discharge instruction form and the failure to ensure R2 had access to his medications and necessary equipment upon discharge.
Inadequate Enteral Feeding Management and Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate enteral feeding management for three residents, leading to significant health complications. Resident R2, who was admitted with severe cognitive impairment and multiple medical conditions, was returned from the hospital with specific discharge orders for tube feeding. However, the facility did not follow these orders, starting the feeding at a higher rate than recommended, which likely contributed to R2's aspiration pneumonia and subsequent hospitalization. Additionally, the facility failed to provide the prescribed Scopolamine patch for nausea and secretions, and no alternative medication was sought. Resident R1, also severely cognitively impaired, reported that nurses sometimes administered tube feedings while she was lying flat, contrary to her care plan that required the head of the bed to be elevated. During an observation, a nurse provided a tube feeding bolus without checking for residuals or tube placement, and the stoma site was not properly cleaned or assessed for infection, despite signs of tenderness and redness. The dressing on the stoma site was not changed as required, indicating a lack of adherence to care protocols. Resident R3, with a history of severe malnutrition and cerebral palsy, did not receive proper care for her gastrostomy tube. The facility staff failed to check the tube placement before administering feedings and did not maintain a dressing on the stoma site as expected. Additionally, staff did not follow Enhanced Barrier Precautions during care, which is crucial for preventing the transmission of infections. These deficiencies highlight a pattern of inadequate care and failure to follow medical orders and facility policies, putting residents at risk for serious health issues.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed narcotic pain medication for a resident, resulting in severe pain and distress. The resident, who had a history of spinal stenosis, chronic pain syndrome, and other related conditions, was admitted with a care plan that included administering pain medication and assessing its effectiveness. However, the facility did not have the prescribed Oxycodone available for the resident on multiple occasions, leading to missed doses and significant pain. During the period when the medication was unavailable, the resident experienced severe pain, became incontinent of bowel and bladder, and exhibited aggressive behaviors. The resident was documented as being in a fetal position, experiencing loose stools, and expressing extreme distress due to the lack of pain management. Staff interviews confirmed that the resident was usually continent and mobile but was significantly affected by the absence of the medication. The Director of Nursing and other staff members were unaware of the missed doses until the resident's behavior escalated, prompting a call to the police. The facility's medication administration policy required documentation and notification of the healthcare provider if medication was not given as ordered, but these steps were not followed. The delay in obtaining the medication from the pharmacy and the lack of immediate access to the emergency medication kit contributed to the resident's prolonged suffering.
Failure to Conduct Suicide Risk Assessments
Penalty
Summary
The facility failed to assess four residents for risks of self-harm upon their admission, which is a necessary component of behavioral health care and services. Resident 2 was admitted with diagnoses including Major Depressive Disorder and Vascular Dementia, and had a history of threatening suicide when upset, as reported by family members. Despite these indicators, there was no documentation of a suicide risk assessment upon admission. Similarly, Resident 3, with a history of Suicidal Ideation and diagnoses such as Schizophrenia and Major Depressive Disorder, also lacked a documented suicide risk assessment upon admission. Resident 11, admitted with multiple diagnoses including Major Depressive Disorder and a history of Suicidal Ideations, did not have a suicide risk assessment documented in her records. Resident 12, who had a diagnosis of Non-Suicidal Self-Harm and Major Depressive Disorder, was also not assessed for suicide risk upon admission. The facility's policy requires a suicide assessment for residents with a history or diagnosis of suicidal ideation, but this was not followed for these residents, as confirmed by the facility administrator.
Significant Medication Errors Due to Delayed Administration
Penalty
Summary
The facility failed to administer medications as prescribed and according to its policy and procedures for four residents, resulting in significant medication errors. Residents received their medications two hours or more after the scheduled times. This issue was identified through interviews and record reviews, highlighting a pattern of delayed medication administration. Resident 2, who has a history of major depressive disorder, vascular dementia, and other conditions, received multiple medications late, including Aricept, Seroquel, Depakote, Synthroid, Xarelto, Metoprolol, Paroxetine, Losartan, and Hydroxyzine. The delays ranged from 3 to 19 doses being administered more than two hours late. The resident's niece confirmed that medications were not given on time, and the facility's administrator acknowledged the issue, citing staffing challenges as a contributing factor. Similarly, Resident 3, with diagnoses including schizophrenia, PTSD, and hypertension, experienced delays in receiving medications such as Lidoderm Patch, Acetaminophen, Aspirin, Metoprolol, Bupropion, Clozapine, Fluoxetine, Lisinopril, Amlodipine, Vraylar, Olanzapine, and Donepezil. The delays affected a significant number of doses, with some medications consistently administered late. Resident 5 and Resident 13 also faced similar issues, with medications like Norco, Morphine, Lyrica, Gabapentin, Lasix, Duloxetine, Lopressor, Mirtazapine, Prozac, Hydroxyzine, Metoprolol, Metformin, Trulicity, and Lisinopril being administered late. The facility's policy requires timely medication administration, and the failure to adhere to this policy was not communicated to the nurse practitioner, potentially impacting medication management decisions.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement progressive fall interventions for two residents identified as high risk for falls. The first resident, admitted with conditions such as bipolar disorder and unsteadiness, had multiple falls documented over several months. Despite a fall intervention requiring a therapy evaluation after a fall in February, the evaluation was never completed. This oversight indicates a lack of follow-through on planned interventions to mitigate fall risks for this resident. The second resident, with severe cognitive impairment and dependent for transfers, experienced falls due to improper transfer techniques and self-transferring. The root cause analysis identified that a mechanical lift should have been used for transfers, but this was not consistently implemented. Additionally, the resident's care plan included interventions such as keeping the bed in the lowest position and using a floor mat, but these were not in place during an observation. Staff members were unaware of the specific fall interventions, highlighting a communication gap and failure to adhere to the care plan designed to prevent falls.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, R3 and R35, as observed during the survey. R3, who is severely cognitively impaired and requires substantial assistance, was found without the physician-ordered pressure-relieving boots on multiple occasions, resulting in red heels. Despite having a care plan intervention to protect her heels, the boots were not utilized as required, and the Director of Nursing acknowledged the oversight. R35, diagnosed with multiple sclerosis and pressure ulcers, was admitted with skin complications. Despite having a care plan and physician orders for wound treatment, R35's pressure ulcer on the left ischium was found without a dressing during incontinent care. The CNAs did not inform the nurse about the missing dressing, and the Director of Nursing was unaware if the treatment was applied after the resident was changed. The wound nurse later applied the necessary treatment, but the deficiency in care was evident as the pressure ulcer was exposed without protection.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement appropriate fall interventions and supervision for a resident, resulting in multiple falls and injuries. The resident, who was admitted with a history of falls and several medical conditions including hemiplegia, diabetes, and a recent hip fracture, was identified as being at high risk for falls. Despite this, the facility did not ensure adequate supervision or implement effective fall prevention strategies, leading to the resident experiencing multiple falls, including one where she sustained a head laceration. The resident's care plan and fall risk assessments documented her high risk for falls and outlined interventions such as keeping the call light within reach and providing a clutter-free environment. However, these interventions were not effectively implemented or monitored. The resident reported that staff were slow to respond to her call light, and she attempted to transfer herself to the bathroom, resulting in falls. The facility also failed to conduct timely fall risk assessments and root cause analyses following each fall, as required by their policy. Additionally, the facility did not maintain adequate documentation of the resident's enhanced supervision, which was supposed to include 15-minute checks. The lack of documentation and failure to update the care plan with new interventions after each fall further contributed to the resident's repeated falls and injuries. The facility's inaction and inadequate supervision directly led to the resident's multiple falls and injuries, highlighting a significant deficiency in their fall prevention and management practices.
Failure to Assess and Treat Pressure Wounds
Penalty
Summary
The facility failed to assess and treat pressure wounds for a resident (R2) who was admitted with multiple health conditions, including severe protein calorie malnutrition, type 2 diabetes mellitus, and an above-the-knee amputation. Upon admission, R2 was identified as high risk for pressure ulcers and required assistance with turning and repositioning. Despite this, there was no documentation of wound care from the time of admission until several days later, and the resident's care plan was not followed. The resident's treatment administration record (TAR) showed gaps in wound care documentation, and there was no record of indwelling catheter care. When R2 was transferred to the emergency room, the resident was found to have severe pressure wounds, including stage 3/4 ulcers, and an infection at the surgical site. The ER staff noted that the resident's catheter appeared filthy and had not been properly cared for. The facility's policy on skin management and pressure injury treatment was not adhered to, as evidenced by the lack of timely wound care and documentation. The failure to follow the care plan and provide necessary treatments led to the resident's condition worsening, requiring hospitalization and further medical intervention.
Failure to Perform Catheter Care for Residents
Penalty
Summary
The facility failed to perform catheter care for three residents who required the use of indwelling catheters. Resident 2 (R2) was severely cognitively impaired and had an indwelling catheter due to obstructive uropathy and urinary retention. R2's care plan did not include instructions for cleaning the catheter, and the treatment administration records (TAR) for March, April, and May did not document any catheter care until late May. R2 was noted to have a contaminated catheter by a local hospital, which led to a catheter change on May 18, 2024. Resident 3 (R3) was moderately cognitively impaired and required an indwelling catheter due to neurogenic bladder and obstructive uropathy. R3's TAR for March, April, and May also lacked documentation of catheter care until May 22, 2024. R3 was placed on isolation for a multidrug-resistant organism in the urine and had multiple instances of bladder infections requiring antibiotic treatment. Resident 4 (R4) had a diagnosis of obstructive and reflex neuropathy and was moderately cognitively impaired. R4's care plan did not address catheter cleaning, and the TAR for March, April, and May did not document catheter care until May 22, 2024. Multiple CNAs confirmed that catheter care was not performed until late May, despite the facility's policy requiring daily and as-needed catheter care.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments as ordered by the physician for a resident with multiple diagnoses, including Multiple Sclerosis, Paraplegia, and a stage 4 pressure ulcer on the left buttock. The resident's Treatment Administration Record (TAR) showed multiple instances where the wound care was not documented as completed over several months. Specifically, the TAR for February, March, and April 2024 showed that the wound care was not documented 4, 17, and 5 times, respectively. The Director of Nurses (DON) acknowledged that the treatments might not have been done or were not signed off, particularly by agency staff, and attempts were made to contact them to ensure treatments were completed as ordered. The resident confirmed that there were instances where the dressing was not changed for up to three days, although the wound was not worsening, it was also not improving. The resident's care plan included an intervention to provide treatment as ordered for the left buttock wound, but the facility failed to adhere to this plan. The facility's policy on Skin Management: Pressure Injury Treatment/General Wound Treatment required documentation of routine and PRN treatments in the treatment administration record of the Electronic Health Record (EHR) and significant observations in the Nursing Progress Note. The failure to consistently document and possibly perform the wound care treatments as ordered led to the deficiency noted in the report.
Inadequate CNA Coverage During Evening and Night Shifts
Penalty
Summary
The facility failed to provide adequate CNA coverage for residents, particularly during the evening and night shifts. Multiple residents and staff members reported that the facility often had only one nurse and one CNA working during these times. The Director of Nurses (DON) confirmed that the staffing levels were lower than required, especially in the evenings and nights, and that they were relying on agency staff and recruitment efforts to fill the gaps. The Administrator also acknowledged the staffing issues and mentioned that they had experienced a high number of call-offs recently, which exacerbated the problem. The Social Services Director noted that many staff members had left for higher-paying jobs at other facilities, further contributing to the staffing shortages. A review of the Daily Staffing Sheets from 4/1/24 to 4/25/24 revealed multiple instances where the facility did not meet its own staffing grid requirements. For example, on 4/14/24, the day shift had only 1 LPN, 1 RN, and 2 CNAs, while the evening shift had 1 LPN, 1 RN, 1 nurse in training, and 2 CNAs. Similar deficiencies were noted on other dates as well. The facility's staffing policy, dated 6/2015, mandates that appropriate numbers of staff be available to meet the needs of the residents, a standard that was not met according to the documented staffing levels and the Midnight Census Report, which showed 45 residents residing in the facility on 4/25/24.
Failure to Provide Proper Perineal and Catheter Care
Penalty
Summary
The facility failed to provide proper perineal care and adhere to infection control practices, leading to urinary tract infections (UTIs) in two residents. One resident, diagnosed with acute cystitis and Alzheimer's disease, was observed receiving inadequate perineal care. The CNA did not perform hand hygiene or change gloves during the procedure, and the resident was left soiled with urine and feces. This resident was later admitted to the hospital with a UTI and readmitted to the facility with the same diagnosis. Another resident, with a diagnosis of obstructive and reflux uropathy and an indwelling urinary catheter, also received improper catheter and perineal care. The CNA did not maintain a clean/dirty field and failed to change gloves or perform hand hygiene during the procedure. This resident had multiple UTIs, as documented in their progress notes, and was treated with various antibiotics. Interviews with facility staff revealed a lack of awareness and concern regarding the high incidence of UTIs. The Director of Nursing denied any concerns, while an LPN acknowledged the frequent occurrence of UTIs but was unsure of the cause. The facility's policies on perineal and incontinence care were not followed, contributing to the deficiencies observed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered by the physician for a resident diagnosed with chronic pain. The resident's physician had prescribed Hydrocodone/Acetaminophen 10/325mg to be given every 4 hours. However, the Medication Administration Record (MAR) showed that the medication was not administered as ordered. The resident, who was cognitively intact with a BIMS score of 15, reported not receiving any medications for a week upon admission and experienced delays in receiving pain medication due to issues with the pharmacy and the need for a hard prescription from the Nurse Practitioner or Medical Doctor. The resident's progress notes documented multiple instances where the pharmacy was contacted regarding the medication, and the resident expressed significant distress due to the delay. On one occasion, the resident was yelling and screaming in pain, and the nurse had to obtain the medication from the emergency kit to administer it. The Director of Nurses confirmed that nurses have access to the emergency medication kit and can obtain medications from there if needed. The facility's Medication Administration policy emphasizes the importance of administering medications safely and appropriately, but this was not adhered to in this case.
Failure to Provide Quality and Palatable Food
Penalty
Summary
The facility failed to provide quality and good tasting food to three residents, as evidenced by multiple complaints about the food's palatability, portion sizes, and overall quality. Resident R2 reported not receiving a full meal and described the food as horrible, particularly during the evening meal. R2 had previously filed a grievance regarding the unsatisfactory food, which was addressed by educating R2 on available menu items and substitutions. Resident R4 also complained about the food quality, stating it tasted bad and the portions were sometimes insufficient, leading to hunger at night. Resident R3 echoed similar sentiments, describing the food quality and taste as horrible. All three residents were cognitively intact, as indicated by their BIMS scores of 15, 13, and 14, respectively. The Resident Council Note documented issues with the quality and variety of food, including the lack of meat for breakfast and repetitive meals. Staff members, including an RN and an LPN, confirmed that residents frequently complained about the food's taste, quality, and portion sizes. The Administrator acknowledged that the menu options were not the greatest but mentioned a new menu with more hearty meals was forthcoming. The Dietary Manager claimed no complaints had been brought to her attention and stated that they followed the menu and production guide for portion sizes. The Social Services Director noted that food presentation and taste had been an ongoing issue for the past year. The facility was unable to provide a policy for Food Palatability when requested.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to deficiencies in infection prevention and control. Resident 1 (R1) had multiple diagnoses, including acute cystitis and Alzheimer's disease, and was dependent on assistance for toileting. During an observation of perineal care, a CNA did not perform hand hygiene or change gloves while providing care, and the resident was left soiled with urine and feces. This improper technique likely contributed to R1's recurrent urinary tract infections (UTIs), as documented in the resident's progress notes and hospital records. Resident 5 (R5) had a diagnosis of obstructive and reflux uropathy and required an indwelling urinary catheter. During an observation of catheter and perineal care, a CNA failed to maintain a clean/dirty field and did not change gloves or perform hand hygiene until the care was completed. R5 had a history of UTIs, as indicated by multiple progress notes and urine culture results showing the presence of Citrobacter freundii and vancomycin-resistant Enterococcus faecalis. The improper infection control practices observed during care likely contributed to R5's recurrent UTIs. The facility's hand hygiene and perineal care policies, dated June 2015, emphasize the importance of proper hand hygiene and perineal care to prevent infections. However, the observations and interviews with staff revealed a lack of adherence to these policies. The Director of Nursing (DON) and other staff members acknowledged the presence of UTIs but did not express significant concern or awareness of the potential link to improper infection control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 580 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Godfrey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Bella Of Alton | 4.4 mi | ★★★★★ | 3 | 0 |
| Alton Memorial Rehab & Therapy | 5.2 mi | ★★★★★ | 9 | 0 |
| Nexus At Alton | 7 mi | ★★★★★ | 19 | 0 |
| Robings Manor Rhc | 7 mi | — | 0 | 0 |
| Bria Of Woodriver | 9.4 mi | ★★★★★ | 21 | 7 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bria Of Godfrey.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.