BRIA of Woodriver: Immediate Jeopardy Tracheostomy Failures - IL
The nurse, identified in inspection records as V32, made that statement to federal inspectors on October 3, 2025, during a complaint investigation at BRIA of Woodriver, a nursing and rehabilitation center on Edwardsville Road. Her admission helped trigger a finding of Immediate Jeopardy, the most serious classification the federal government assigns to nursing home violations, reserved for situations where inspectors determine that residents face a risk of serious injury or death.
A tracheostomy is a surgically created opening in the throat that bypasses the upper airway. Patients who have one cannot be resuscitated the same way as other patients. Placing a standard CPR breathing mask over the mouth and nose of a tracheostomy patient does not deliver air to the lungs. Rescue breaths, if they are given at all, must go directly through the opening in the neck. A nurse who does not know this, responding alone to a tracheostomy patient in cardiac arrest, is not providing CPR. She is performing a procedure that does not work, while the patient dies.
V32 told inspectors she would always place the respiratory bag over the resident's mouth. That is the wrong technique for a tracheostomy patient.
The Assistant Director of Nursing, identified as V35, told inspectors at 3:15 PM that day that there had not been much staff education about tracheostomies at the facility. No formal training program existed. The Director of Nursing, V2, told inspectors she expected nursing staff to be proficient in routine tracheostomy care, including suctioning and cannula changes, and to know what to do in emergencies.
The Director of Nursing expected proficiency. The facility had provided no formal training to achieve it.
BRIA of Woodriver's own facility assessment, the internal document facilities are required to maintain describing the population they serve and the care they provide, lists tracheostomy care and ventilator care under Special Care Needs. The facility acknowledges caring for residents with COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Its listed specialized rehabilitation services include respiratory care.
The facility was, by its own description, a place where people with serious, complex airway needs came to live and recover. The nurses caring for them had not been trained on the most basic elements of keeping those patients alive.
There is a particular quality to the gap between what the Director of Nursing said she expected and what the facility had actually done. V2 described a standard of proficiency, stated it as though it were a given, and inspectors had already documented that one of her nurses did not know how to perform emergency airway rescue on the patients in her care. The ADON did not dispute the training gap. She confirmed it.
A tracheostomy cannula, the inner tube that sits inside the surgical opening, requires regular cleaning and periodic replacement. If it becomes obstructed with secretions and is not suctioned or changed, the patient cannot breathe adequately. A nurse who has not been trained in this procedure, assigned to a resident who depends on it, is not a safety net. She is an obstacle between the patient and the care they need.
The inspection record does not describe a specific incident involving a named resident. It does not detail a patient who stopped breathing while a nurse stood helpless at the bedside. What it describes is a condition, a facility-wide absence of training, that meant any one of the tracheostomy patients living at BRIA of Woodriver could have faced exactly that situation on any given shift.
Immediate Jeopardy findings are not issued lightly. Inspectors must determine that a facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death. The finding here was not based on a single nurse's knowledge gap in isolation. It was based on the finding that no formal tracheostomy training existed at a facility that had accepted responsibility for patients who require it.
The facility moved quickly once inspectors made the finding. A tracheostomy in-service was completed, and all nurses, including agency nurses brought in from outside staffing companies, were educated before the start of their next scheduled shift. Inspectors validated the corrective action through follow-up interviews with six staff members and removed the Immediate Jeopardy designation.
The correction took less than a day to implement. The training that resolved the immediate crisis, the in-service that brought nurses up to a baseline of competency on a procedure their patients depend on for survival, was apparently not a complicated undertaking. It happened fast, once regulators were standing in the building.
What is harder to account for is the time before that. The facility assessment listing tracheostomy care as a special care need is undated in the inspection record, but it represents an ongoing acknowledgment, reviewed and maintained by the facility, that this population was present. The job descriptions for registered nurses and licensed practical nurses at the facility instruct staff to remain current in facility policies and nursing trends by participating in in-services and continuing education programs. The facility had written that expectation into its employment documents. It had not fulfilled it.
V32's statement is the one that stays. She said she is not comfortable caring for residents with tracheostomies. She said she did not know how to provide respiratory support during CPR for a tracheostomy patient. She said she had not received any training. She was working at a facility that admitted tracheostomy patients. She was expected, by the Director of Nursing, to be proficient.
At some point before October 3, 2025, V32 had almost certainly stood at the bedside of a resident with a tracheostomy. She had provided care, or attempted to, without the knowledge to do it safely. So had other nurses. The ADON confirmed the gap was not specific to one employee. It was the facility's condition.
The Immediate Jeopardy was removed. The in-service was completed. The inspectors left.
The residents with tracheostomies remained.
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 immediate jeopardy violations during a health inspection on October 3, 2025.
A tracheostomy is a surgically created opening in the throat that bypasses the upper airway.
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.