11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Godfrey, IL
1-star overall rating with 2-star inspections with $225,974 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1623 29 West Delmar, Godfrey, IL
(618) 466-0443
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
68
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bria Health Services
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 1 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.65
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
2.61
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
12,163
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.13
Baseline 20.39% · Performance 19.52% · Measure score 4.13 · Achievement 4.13 · Improvement 2.08
Healthcare-associated infections
1.19
Baseline 7.50% · Performance 7.48% · Measure score 1.19 · Achievement 1.19 · Improvement 0
Total nurse turnover
0.14
Baseline 75.00% · Performance 71.80% · Measure score 0.14 · Achievement 0 · Improvement 0.14
Adjusted total nurse staffing
0
Baseline 2.62 hours · Performance 2.49 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.86% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 8.45% · Lower 95% interval 7.18% |
| Discharge to community | 62.98% |
50.57%
12.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 55.81% · Lower 95% interval 47.6% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.55% |
95.27%
1.3 pts better
|
Numerator 28 · Denominator 29 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 29 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.48% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 11.9% |
8.2%
3.7 pts better
|
Numerator 5 · Denominator 42 |
| Staff flu vaccination coverage | 5.63% |
42%
36.4 pts worse
|
Numerator 4 · Denominator 71 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.4 |
2.0
2.4 pts worse
|
1.9
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 3.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.3
0.9 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.1% |
89.6%
14.5 pts worse
|
93.4%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.8% · Q2 97.6% · Q3 83.0% · Q4 71.7% · 4Q avg 75.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
91.6%
4.1 pts better
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.3%
1.8 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.3% · Q3 4.3% · Q4 4.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 100.0% |
50.3%
49.7 pts worse
|
11.4%
88.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
6.5%
0.3 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 3.4% · Q3 5.9% · Q4 8.3% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
18.5%
2.7 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 13.3% · Q3 27.8% · Q4 19.4% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
22.8%
2.4 pts better
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 20.0% · Q3 20.8% · Q4 9.1% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.3% |
17.2%
13.9 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
15.0%
8.8 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.1% · Q3 0.0% · Q4 8.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.9% |
21.3%
16.4 pts better
|
19.8%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 2.8% · Q3 2.3% · Q4 4.1% · 4Q avg 4.9% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.2%
1.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.5% · Q3 2.0% · Q4 5.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 12.6% |
68.8%
56.2 pts worse
|
81.7%
69.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.9% · Q3 9.8% · Q4 21.6% · 4Q avg 12.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
14.0%
4.3 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 11.8% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.3%
0.1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 11.1% |
63.0%
51.9 pts worse
|
79.7%
68.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 11.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.2% |
26.2%
10 pts worse
|
23.9%
12.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.2% · Observed 38.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (11 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-09-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-18
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-21
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-29
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-29
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-20
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-08
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2025-06-17
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-14
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-04-01
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-13
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-03
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-10
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-06-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-10
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-08
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-06-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-08
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-11
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-11
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-11
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-11
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-12
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-04-25
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-25
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-25
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-14
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-10-14
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-14
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-14
Penalties and ownership
Payment Denial · denial start 2025-09-10 · 15 days
15 day denial
Fine · fine $19,115
Fine
Fine · fine $17,713
Fine
Fine · fine $41,730
Fine
Fine · fine $131,010
Fine
Payment Denial · denial start 2023-08-04 · 24 days
24 day denial
Fine · fine $16,406
Fine
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Limited Partnership Interest · Organization
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