Bria of Woodriver: Tracheostomy Emergency Failure - IL
Federal inspectors rated the violation as immediate jeopardy, the most serious classification available under Medicare and Medicaid oversight, indicating the deficiency placed the resident at risk of serious injury or death. The facility is disputing the citation.
The resident, identified in inspection records only as R2, required a tracheostomy, a surgically created opening in the neck through which a tube is inserted to maintain an airway. Trach tubes can become dislodged. When that happens, the window for reinsertion is narrow. A kit with the correct replacement tube needs to be immediately available, and staff need to know what size to reach for.
Neither condition was met.
A nurse interviewed during the inspection, identified as V20, told inspectors she expected a trach reinsertion kit to be kept in the room of any resident with a tracheostomy. She also expected staff to document the resident's trach size in the medical record so nurses would know what to use in an emergency. The documentation wasn't there. The kit wasn't there either.
The facility's own tracheostomy care policy, revised as recently as October 2024, states that residents with tracheostomies will receive routine care to maintain a patent airway. It says nothing about reinsertion. There is no guidance in the policy for what staff should do if a tube comes out.
That gap is significant. Bria of Woodriver's own facility assessment, dated June 2025, lists tracheostomy care and ventilator care among its special care needs. The facility acknowledges it serves residents with COPD, pneumonia, chronic lung disease, respiratory failure, and related conditions. It offers specialized respiratory rehabilitation services. It holds itself out as equipped to manage exactly this kind of care.
R2 no longer lives at the facility. Inspectors noted that all new trach patients would be affected by the deficient practice, not just R2.
The facility moved quickly once the immediate jeopardy finding was issued. On November 14, 2025, six days before the inspection was completed, the director of nursing or a designee began in-servicing all nurses on both routine and emergency trach care. Agency nurses were to be trained before their next shift. The facility committed to monthly trach training for three months, weekly competency observations of three nurses for four weeks, and regular review through its quality assurance committee.
The immediate jeopardy finding was listed as removed as of November 14, the same day the training began.
What the inspection record does not contain is any account of what happened to R2 before the deficiency was identified, how long the reinsertion kit had been absent from his room, or how many nurses had cared for him without knowing his trach size. The facility's tracheostomy policy had been in place, and silent on reinsertion, since at least October 2024. The facility assessment listing trach care as a specialty had been on file since June.
The facility is contesting the immediate jeopardy classification.
R2 is gone. Whether he left because of what inspectors found, or before they arrived, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Woodriver from 2025-11-20 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 20, 2026 · Our methodology
BRIA OF WOODRIVER in WOOD RIVER, IL was cited for violations during a health inspection on November 20, 2025.
The facility is disputing the citation.
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.