BRIA of Woodriver: CPR Failure During Trach Resident Death - IL
What happened next — and what did not happen — is documented in a fire department incident report, interviews with facility leadership, and a federal inspection completed October 3, 2025, that found BRIA of Woodriver had placed its residents in immediate jeopardy.
The resident, identified in inspection records as R2, had a tracheostomy. That detail mattered enormously when staff began CPR. A tracheostomy is a surgically created opening in the throat through which a person breathes. When someone with a trach stops breathing, the bag valve mask used to force air into the lungs must connect to that opening, not to the mouth and nose. The mouth and nose are no longer the airway. They are not the way in.
Staff placed the bag over his mouth anyway.
The local fire department arrived at 5:15 PM. What their crew found is recorded in their own incident report: facility staff were bagging the patient's mouth and performing CPR while he was still in his bed. The patient was cold to the touch. No femoral pulse was found. Firefighters moved him to the floor, continued CPR, and pulled the mask off his face. They connected the bag valve mask to his trach tube, the way it should have been connected from the start.
Staff told firefighters they had been bagging the mouth and not the trach because secretions were coming from the tube.
The fire department's initial end tidal carbon dioxide reading, a measure of whether air is actually moving through the airway and reaching the lungs, came back at 11. A normal reading in a person with a perfusing rhythm runs between 35 and 45. A reading of 11, in the context of cardiac arrest, indicates almost no effective ventilation had occurred.
The patient remained in asystole, meaning no electrical activity in the heart at all, for the entire resuscitation attempt. Paramedics followed ACLS protocols, administered epinephrine, checked for a pulse every two minutes. Medical control eventually advised crews to terminate resuscitation efforts. The fire department gathered its equipment and returned to service.
When inspectors interviewed the fire department chief two days later, he was direct. His staff arrived to find facility employees bagging R2 over the naso-oral pharynx, he said, which is not the standard place for the bag valve mask when a resident has a tracheostomy. The BVM should have been connected via the tracheostomy.
Every member of the facility's own leadership said the same thing when inspectors asked.
The Assistant Director of Nursing said there is a bag that goes over the tracheostomy when you provide CPR. The Director of Nursing said there is a bag that goes on the trach, and those BVMs should be at bedside. She told inspectors she had not previously been informed of any issues with staff getting the bag valve masks onto the tracheostomy. The Administrator said the respiratory bag should go over the tracheostomy site, or the residents would not be getting air. The Medical Director said he would expect staff to know how to perform CPR on residents with tracheostomies, and would expect the facility to have the necessary equipment and supplies for both maintenance and emergent situations.
The facility's own tracheostomy care policy, reviewed just a year before R2 died, states it is the policy of the facility that residents with tracheostomies receive care to maintain a patent airway. Its code blue policy instructs staff to provide two breaths via ambu bag and continue CPR per BLS guidelines until EMS arrives.
None of that happened correctly.
Then inspectors pulled the CPR certifications.
Three certified nursing assistants, identified as V19, V54, and V55, did not hold CPR certification from the American Red Cross or the American Heart Association with hands-on, in-person training. The facility's own CPR certification policy requires exactly that: certification at the CPR/BLS for Healthcare Providers level, with in-person, hands-on training. These three staff members did not meet that standard.
It is not clear from the inspection record whether any of the three were present in the room when R2 went unresponsive. What is clear is that the facility certified to federal regulators that it maintained a staff capable of responding to a cardiac emergency, and the documentation did not support that claim.
The inspection finding was classified as Immediate Jeopardy, the most serious designation available under federal nursing home oversight, reserved for situations where a facility's failures have caused or are likely to cause serious injury or death.
The facility moved quickly after inspectors cited the deficiency. Clinical and agency staff were trained on performing CPR on residents with tracheostomies. The CPR policy was reviewed. Equipment was verified as available. CPR audits were initiated. A quality assurance meeting was held. Inspectors reviewed the updated policy, observed equipment, checked purchase orders, and interviewed more than a dozen staff members before determining the immediate jeopardy had been abated.
The immediate jeopardy designation was removed.
R2 was a full code, meaning he and presumably his family had made the decision that if his heart stopped, staff should do everything possible to bring him back. That decision was documented. The equipment to honor it, a bag valve mask that could connect to a trach tube, was supposed to be at his bedside. The staff caring for him were supposed to know how to use it.
The fire department's crew arrived eight minutes after the 5:07 PM call, found a man cold to the touch, and spent the next several minutes doing what facility staff had not. It was not enough. The end tidal reading of 11 tells its own story about how long the airway had been unmanaged before firefighters walked through the door.
The Director of Nursing told inspectors she had not been informed of any issues with staff getting the bag valve masks onto the tracheostomy. That conversation happened after R2 was dead.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
BRIA OF WOODRIVER in WOOD RIVER, IL was cited for violations during a health inspection on October 3, 2025.
The resident, identified in inspection records as R2, had a tracheostomy.
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.