BRIA of Godfrey: Fall Death After Staff Moved Resident - IL
That sequence of events is at the center of a federal inspection complaint filed against BRIA of Godfrey following a December 2025 investigation that cited the facility for causing actual harm to residents. Inspectors documented two separate falls, one fatal, and found that staff had lifted a resident from the floor without notifying nursing, without an assessment, and without calling a physician — steps that every nurse, aide, and doctor interviewed said were standard and non-negotiable.
The first resident, identified in the report as R2, fell in the dining room. A certified nursing assistant named V25 was in the room feeding another resident when she noticed something wrong. A geriatric chair sat at a table with no one in it. She stood up and found R2 on the floor beneath the table. She said she tried to get staff attention and believed an agency nurse who was nearby had seen the resident on the floor. What happened next — who moved R2, why, and on whose direction — is not fully explained in the inspection record. What the report makes clear is that no one in management knew R2 had fallen until the following day.
R2 died before inspectors could complete their interviews.
The facility's infection control nurse told inspectors on December 19 that she had reviewed security camera footage and confirmed it was V25, the CNA, who found R2, not a medical assistant as had been initially reported. "I am not sure what happened and why no management knew R2 had fallen until the next day," she said.
The midnight-shift CNA, V7, told inspectors she had heard about the fall secondhand. "R2 fell in the dining room. I did not witness it but heard she had fallen but she passed away yesterday," she said. "I am not sure why R2 was moved."
A second resident, identified as R2's counterpart in the report, was found on the floor on a separate occasion and was moved back into bed before nursing staff assessed her. She was sent to the emergency room, where a CT scan came back abnormal. Doctors found she had fractured multiple ribs on her right side, a closed non-displaced fracture of the right clavicle, stercoral colitis, constipation, and an acute urinary tract infection. She left the ER with new antibiotic orders. Inspectors noted discoloration on her upper extremity. She was tearful during the assessment and was given pain medication.
Every staff member interviewed by inspectors described the same protocol: if a resident falls, do not move them, call for help, wait for a nurse to assess, and if there is any sign of injury, notify the physician and consider sending the resident to the hospital. The consistency of those answers made the departures from that protocol harder to explain.
"If we think there may be an injury, we notify the doctor and send them out," the LPN on staff told inspectors. "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."
The facility's own doctor said the same. "R2 did have a fracture and injury so this is something staff need to know that there was a fall," he told inspectors on December 17.
The Director of Nursing who spoke with inspectors on December 8 said it was her first day on the job. The previous director, she said, had been walked out of the building, though she did not know the details. "I would never expect staff to get them up without assessing them," she said.
The facility's fall prevention policy, revised as recently as September 2025, states that all resident falls shall be reviewed, that residents must be evaluated for injury, and that physicians and emergency contacts must be notified. The policy also calls for a fall incident report to be filed in the facility's risk management system.
None of that happened in time to help R2.
V25, the CNA who found her under the table, said she thought the agency nurse nearby had seen the resident on the floor. Whether that nurse intervened, what she did or did not do, and how R2 ended up moved without a nursing assessment, the inspection record does not say. What it says is that a woman fell, was found beneath a table in the dining room, and was gone by the time anyone in management learned she had ever been on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Godfrey from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
BRIA OF GODFREY in GODFREY, IL was cited for immediate jeopardy violations during a health inspection on December 19, 2025.
The first resident, identified in the report as R2, fell in the dining room.
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.