BRIA of Godfrey: Fall Prevention Failures Cited - IL
Federal inspectors cited the facility following a complaint inspection completed August 20, 2025. The citation, tagged F0689 and assessed at a level of minimal harm or potential for actual harm, centered on a single resident whose fall went unwitnessed and whose departure from the facility came the same day.
The resident fell. Nobody saw it happen. Then, hours later, they were discharged.
BRIA of Godfrey's own fall prevention policy, in place since May 2015 and last revised in January 2024, spells out what is supposed to happen after every fall. A nurse evaluates the resident. An incident report goes into the electronic medical records system. A fall risk score is calculated, and anyone scoring 10 or above is designated high risk. Most critically, the care plan is supposed to be updated with new interventions based on a root cause analysis of what caused the fall in the first place.
That last step, the root cause analysis and care plan update, exists for a reason. Falls in nursing homes are rarely random. They tend to have causes: a medication that affects balance, a resident who needs more assistance to the bathroom at night, a call light that isn't being answered quickly enough, a walker that isn't within reach. The point of reviewing each fall and updating the plan is to keep the next one from happening.
For this resident, inspectors found the facility's own process wasn't completed. The fall happened. The discharge followed. The review and care plan update that the facility's own policy required did not occur before the resident left.
The facility's policy language is direct about the commitment involved. It acknowledges that preventing every fall isn't possible, but states that the facility will identify residents at risk, plan preventative strategies, and facilitate as safe an environment as possible. It says all falls shall be reviewed. Not most falls. Not falls where the resident stays long enough for the paperwork. All of them.
This resident was discharged on August 6, 2025, at 3:51 p.m., to a different facility.
What the inspection report does not say is whether the resident was injured in the fall. The harm level assessed was minimal harm or potential for actual harm, the lower end of the federal scale, which means inspectors determined no serious injury resulted or was likely. But the citation reflects something the harm level alone doesn't fully capture: a resident fell, and the system designed to understand why and prevent the next fall was never completed for them.
The gap matters beyond this one person. Fall prevention protocols are built on accumulated information. Each review, each root cause analysis, each care plan update contributes to a facility's understanding of which residents are vulnerable and what interventions actually work. When a resident leaves before that process happens, the data point disappears. So does the accountability.
BRIA of Godfrey's policy sets a score of 10 or greater on the fall risk evaluation as the threshold for high risk designation. The inspection report does not state what this resident's score was, or whether the initial nursing evaluation following the fall was completed before the discharge. What it documents is that the full protocol, the piece that closes the loop, was not done.
The inspection covered few residents, according to the citation's scope notation. This was not a facility-wide pattern identified across dozens of cases. It was one resident, one fall, one discharge, and one set of required steps that didn't happen.
That resident is now at a different facility. Whatever information a completed root cause analysis might have produced about why they fell at BRIA of Godfrey, and what might have been done differently, went with them unanswered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Godfrey from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
BRIA OF GODFREY in GODFREY, IL was cited for violations during a health inspection on August 20, 2025.
Federal inspectors cited the facility following a complaint inspection completed August 20, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.