The facility's own director of nursing confirmed it: LPN #1 should not have been the one contacting the physician directly.
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The inspection, triggered by a complaint, was completed on October 15, 2025.
The inspection was triggered by a complaint, not a routine survey.
That finding is documented in a complaint inspection completed October 16, 2025.
That gap, inspectors found, put at least one resident in immediate jeopardy.
The inspection was triggered by a complaint, not a routine survey.
The citation fell under what regulators call resident rights deficiencies, a category that covers the basic premise of nursing home care.
The incident at BRIA of Godfrey came to light through a complaint inspection completed October 15, 2025.
The incident involving Resident #94 was never reported to the Ohio State Survey Agency.
The deficiency affected a small number of residents and was classified as causing minimal harm or the potential for actual harm.
Federal inspectors arrived at Arbor Terrace on October 23, 2025, responding to a complaint.
Registered nurse hours came up short as well.