BRIA of Belleville: Resident Dies After Delayed Care - IL
The nurse who met them in the hallway said the resident, identified in inspection records only as R2, had aspirated and was "not acting right." The nurse said it all started at 1:15 PM. EMS had been called at 1:53 PM. They arrived at 2:06 PM. By then, R2 was breathing at 130 breaths per minute, a rate that signals a body in severe distress. Her lungs, the EMT later told inspectors, were full.
She never regained consciousness. The EMT was in the emergency department when she died.
Federal inspectors from the Centers for Medicare and Medicaid Services cited BRIA of Belleville for causing actual harm to R2, the most serious category of violation short of immediate jeopardy. The citation, stemming from a complaint inspection completed October 8, 2025, documents a sequence of decisions, and non-decisions, that preceded her death.
The assistant director of nursing, identified as V3, told inspectors she was summoned by an LPN named V5 for a change in condition in R2's room. When she got there, R2 had audible crackling when she breathed. Staff placed her on two liters of oxygen. The oxygen level would not hold. They called 911 from the room. "It all happened so fast," V3 said, "that there was no change of condition to report to the Physician."
Nobody called the doctor. Nobody called the on-call provider. Nobody called a nurse practitioner. The telehealth system, according to the facility's own records, was not contacted until after R2 had already been transferred out.
The facility's nurse practitioner, V12, works Monday through Friday. R2's condition deteriorated on a Sunday. When inspectors asked V12 whether he would have expected to be notified, and whether he would have expected an hour to pass between the change in condition and the 911 call, his answer was the same both times. "They should've called the on-call provider."
The inspection report does not explain why no one did.
What the report does show is a staff that, by its own account, lost track of time entirely. The assistant director of nursing said she did not know when the LPN came to get her, did not know when 911 was called, and did not know when EMS arrived. "I was focusing on R2," she said. The director of nursing and the assistant director told inspectors the following day that EMS was called at 1:51 PM, a time they said came from another staff member's cell phone records. The EMT's account put the call at 1:53 PM and arrival at 2:06 PM.
The EMT, identified as V6, gave inspectors the clearest account of what the room looked like when he got there. R2 was unresponsive. Her breathing was rapid and shallow. Vomit had collected on her neck and on her gown. "I had to wipe it away," he said. His crew put her on a high-flow oxygen mask and moved her to the ambulance. She was never responsive, he said. Her lungs were full. He was there when she died.
The LPN who first recognized something was wrong, V5, had called 911 from her personal cell phone. The assistant director of nursing said the LPN came to find her, that they both stayed with R2 the whole time, that R2 was never left alone. The EMT told inspectors that when he entered the room, everyone had gone.
The inspection report does not resolve that contradiction.
R2's physician was not notified before she was transferred. The on-call provider was not reached. The telehealth system logged no contact until she was already gone from the building. The nurse practitioner said he still would have expected a call, even on a Sunday, even from someone else's rotation. The facility's own policy, dated September 2024, states that nursing will notify the physician or nurse practitioner when there is a significant change in a resident's physical status.
R2's lungs were audibly crackling. Her oxygen would not stay up. She vomited and lost consciousness.
Nobody made the call.
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.
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 25, 2026 · Our methodology
BRIA OF BELLEVILLE in BELLEVILLE, IL was cited for violations during a health inspection on October 8, 2025.
EMS had been called at 1:53 PM.
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.