BRIA of Woodriver: CPR on Cold Resident - IL
The resident is identified in inspection records only as R2. What those records make clear is that by the time staff attempted resuscitation, the moment for it had long passed.
A nursing assistant identified as V8 told inspectors at 11:00 AM that R2 was already starting to stiffen during CPR. At 1:48 PM the same day, a second nursing assistant, V19, said R2 was already cold when CPR was being performed. A third, V20, interviewed at 2:09 PM, said she helped perform CPR and he was already cold.
Nobody had told a nurse.
The Director of Nursing, interviewed at 1:40 PM, said she had no idea why staff would not have reported R2's changes to the nurse on duty. She said she had no knowledge of his deterioration at all. The facility's Medical Director, interviewed at 3:50 PM, said he would expect staff to report any change in condition to the nurse on duty.
That expectation was not met. Whatever R2's condition was in the hours before his death, no licensed nurse appears to have been informed. The nursing assistants who were with him, who would have been the ones to notice something was wrong, said nothing to anyone with the authority to intervene.
The inspection that captured this was a complaint survey, completed October 3, 2025. Inspectors cited the facility under F0684, the federal tag covering failure to provide care and services that meet professional standards. The deficiency was tagged at the most serious level available: Immediate Jeopardy to resident health or safety.
What made the lapse more concrete was what inspectors found when they reviewed the facility's own written policy. The Notification of Change in Resident Condition policy, last reviewed in October 2024, describes what the facility is supposed to do once a change is identified: alert the resident, the physician, the responsible party. It says nothing about how nursing assistants are supposed to communicate with licensed nursing staff in the first place. The chain of communication that should have saved R2's life was not written down anywhere.
The Director of Nursing confirmed it. The policy had no documentation of the communication expected between aides and nurses.
That gap, between what a nursing assistant notices at the bedside and what a licensed nurse is told, is where R2's death fell.
Immediate Jeopardy findings require facilities to act fast. BRIA of Woodriver held a QAPI meeting, reviewed 24-hour nursing reports, and conducted in-service training for both clinical and agency staff on timely assessments and the notification policy. Inspectors validated the abatement through interviews with more than a dozen staff members and a review of updated records. The Immediate Jeopardy was lifted.
The Director of Nursing said the right things when inspectors asked. Staff should report to the nurse. If that nurse isn't available, find another one. The Medical Director agreed. The policy, once updated, presumably says so too.
R2 was cold before anyone with a stethoscope knew he was dying.
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 resident is identified in inspection records only as R2.
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.