BRIA of Belleville: Resident Died After Delayed Care - IL
The resident, identified in inspection records only as R2, experienced a change in condition at 1:15 p.m. on September 14, 2025, according to an emergency medical technician who responded to the call. EMS wasn't dispatched until 1:53 p.m. and arrived at the facility at 2:06 p.m., nearly an hour after the crisis began.
The EMT described what he found when he entered the room. "She was unresponsive and very tachypneic in the 130s," he told inspectors. "She had vomited and it had pooled on her neck and gown. I had to wipe it away." His crew placed R2 on a high-flow oxygen mask and loaded her into the ambulance. She never regained consciousness. "I was in the room in the Emergency Department when she passed away," he said.
A nurse had told the EMT in the hallway that everything started at 1:15 p.m., and then everyone left the room.
No on-call provider was contacted before R2 was transferred. The facility's nurse practitioner, who works Monday through Friday, told inspectors the incident happened on a Sunday. He said he still would have expected the on-call provider to be notified. When asked whether an hour passing between R2's change in condition and the 911 call was acceptable, he was direct: "They should've called the on-call provider."
A telehealth note, inspectors found, wasn't entered until after R2 had already been taken away in the ambulance.
Staff told inspectors the oxygen wouldn't stay up and that they stayed with R2 the entire time, with one nurse calling 911 from her personal cell phone. "It all happened so fast that there was no change of condition to report to the physician," a staff member said.
The nurse practitioner did not agree with that account.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Belleville from 2025-10-08 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 5, 2026 · Our methodology
BRIA OF BELLEVILLE in BELLEVILLE, IL was cited for violations during a health inspection on October 8, 2025.
The resident, identified in inspection records only as R2, experienced a change in condition at 1:15 p.m.
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.