BRIA of Wood River: Tracheostomy Care Failures - IL
These were not isolated gaps. They were the rule.
Federal inspectors who visited BRIA of Wood River on October 3, 2025, found that the facility had been admitting and caring for residents with tracheostomies while providing its nursing staff essentially no training on how to keep those residents alive. The finding triggered an Immediate Jeopardy citation, the most serious level of deficiency the federal government assigns, reserved for situations where a facility's failures have placed residents in immediate risk of serious harm or death.
The facility's own assessment documents that it provides care for residents with COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. It lists tracheostomy care and ventilator care among its special care needs. Respiratory rehabilitation is listed as a specialized service. In other words, BRIA of Wood River had told regulators, in writing, that caring for patients who breathe through surgically placed tubes in their throats was a core part of what it does.
What inspectors found when they asked the staff about that care was a different picture entirely.
V31, a certified nursing assistant, told inspectors at 12:56 p.m. that she had received no training at the facility on CPR for residents with tracheostomies. Her plan, if one of those residents stopped breathing, would have been to cover their mouth with a bag mask. For a patient with a tracheostomy, that does nothing. The airway is in the throat, not the mouth. Air delivered to the mouth bypasses the trach tube entirely.
Four minutes later, at 1:00 p.m., the LPN, identified in the report as V32, told inspectors she was not comfortable with tracheostomy care and did not know what to do in a respiratory emergency involving a trach patient. She had not been trained at the facility either.
At 2:00 p.m., a second CNA, V16, offered a different kind of testimony. She told inspectors she wished CNAs were permitted to suction residents with tracheostomies, because nurses were often too busy to respond quickly and she believed it would reduce the number of residents sent out to the hospital. "I think it would cut back on sending residents out to the hospital and save a lot of people," she said. She was describing a gap she had watched play out in real time, on real patients.
At 3:15 p.m., the Assistant Director of Nursing confirmed what the staff had been saying one interview at a time. There had not been much staff education regarding tracheostomies, she said. There had been no formal training at the facility.
That admission came from the second-highest nursing official in the building.
The Director of Nursing, interviewed at 9:03 a.m., said she expected nursing staff to be proficient in routine tracheostomy care, including suctioning and inner cannula changes, and to know what to do during an emergency. The expectation and the reality were not close to each other. The DON expected proficiency. Her staff, by their own account, had none.
A tracheostomy is a surgically created opening in the front of the neck that allows a tube to be placed directly into the trachea. Patients who have them often cannot breathe through their nose or mouth at all, or do so only partially. They require regular suctioning to clear secretions that would otherwise block the airway. The inner cannula, a removable inner tube, must be cleaned or replaced on a schedule to prevent obstruction. In an emergency, a responder who does not know these things, and who reaches for a face mask instead of addressing the trach tube, is not helping. They may be making things worse while time runs out.
The facility's own tracheostomy care policy, revised in October 2024, states that residents with tracheostomies should receive routine care to maintain a patent airway, including suctioning as needed and cleaning of the stoma site. The policy existed. The training to carry it out did not.
A policy revised one year before the inspection. No formal training to match it. Staff who could not describe basic emergency response. Residents who depended on that response to breathe.
That is what Immediate Jeopardy looks like in a nursing home.
The citation covers "some" residents, in the language of the inspection report, meaning more than one person living at BRIA of Wood River was affected. These were not hypothetical patients. They were people already in the building, already dependent on their tracheostomies, already relying on the nurses and aides around them to know what to do when something went wrong.
The CNA who wished she could suction residents herself, because nurses were too stretched to get there in time, was not describing a theoretical risk. She was describing the situation as she had observed it.
After inspectors made their findings known, the facility moved to correct the deficiency. An in-service on tracheostomy care was completed, and all nurses, including agency nurses, were required to complete the training before their next scheduled shift. Inspectors validated the abatement through follow-up interviews with six staff members.
The Immediate Jeopardy was removed.
What the record does not show is how long the facility had been admitting tracheostomy patients without ensuring the staff could care for them. The inspection was a complaint investigation, meaning someone, a resident, a family member, a staff member, had already raised a concern significant enough to bring inspectors to the building. The tracheostomy policy had been revised in October 2024. The inspection took place in October 2025. Somewhere in that year, or before it, the gap between what the facility said it could do and what its staff actually knew how to do had become wide enough that someone felt compelled to report it.
The CNA who wanted to learn how to suction residents, who watched nurses run from room to room while call lights went unanswered and patients waited, put it plainly. She thought it would save a lot of people.
She was probably right.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Woodriver from 2025-10-03 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 26, 2026 · Our methodology
BRIA OF WOODRIVER in WOOD RIVER, IL was cited for violations during a health inspection on October 3, 2025.
The facility's own assessment documents that it provides care for residents with COPD, pneumonia, asthma, chronic lung disease, and respiratory failure.
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.