Bria of Woodriver: Tracheostomy Emergency Failure - IL
Federal inspectors rated that gap as immediate jeopardy at Bria of Woodriver, a 393 Edwardsville Road facility that, by its own documentation, specializes in exactly this kind of care.
The resident at the center of the citation, identified in inspection records only as R2, was a patient whose tracheostomy tube required active management. When a nurse identified as V20 was asked about the safeguards in place during her October 31, 2025 assessment of R2, she could not recall whether an emergency trach reinsertion kit was even in his room. She said she expected one to be there. She said she expected staff to have documented his trach size in his medical record so nurses would know what size to use if the tube came out.
Whether those things were true, she could not confirm.
The inspector's findings went further than a missing kit. On November 14, 2025, the facility's Assistant Director of Nursing, identified as V3, acknowledged that the facility's tracheostomy care policy contained no instructions for reinsertion if a tube became dislodged. The skills checklist nurses had been using for trach care didn't cover reinsertion either. V3 said staff had been in-serviced on trach care that very week, but that training also did not include reinsertion. No such training had ever been provided.
"The facility doesn't have a policy or skill checklist that covers trach reinsertion," V3 told inspectors, "so no staff have been in-serviced on trach reinsertion."
The facility was, at the time of that conversation, actively searching for a checklist it could use to start training nurses.
The tracheostomy care policy at Bria of Woodriver was revised as recently as October 2024. Its stated purpose is to ensure residents with tracheostomies receive routine care to maintain a patent airway. The word "reinsertion" does not appear in it.
This is not a facility that stumbled into caring for tracheostomy patients without understanding the complexity involved. Its own facility assessment, dated June 18, 2025, lists tracheostomy care and ventilator care as designated special care needs. It lists respiratory failure among the conditions it treats. It identifies specialized rehabilitation services as including respiratory care. The facility built its identity, at least on paper, around caring for people with the most fragile airways.
A tracheostomy tube sits in a surgically created opening in the throat, bypassing the upper airway entirely. For patients who depend on it, accidental dislodgement is not a theoretical risk. It is a documented, anticipated complication of the tube's presence. When it happens, the window for response is short. Without reinsertion, the stoma can begin to close within minutes. The patient cannot breathe through their mouth or nose in the usual way. V20 described the consequence plainly: without immediate reinsertion, a patient could go into respiratory distress, which could lead to brain death.
That is the outcome the facility had no plan to prevent.
Bria of Woodriver is disputing the citation.
The immediate jeopardy designation was removed on November 14, 2025, the same day inspectors documented V3's admissions. The facility's plan of correction notes that R2 no longer resided at the facility by that point. It does not explain when he left or under what circumstances.
The correction plan the facility submitted describes a rapid response: all nurses in-serviced on emergent and routine trach care on November 14, with agency nurses to receive the same training before their next shift. Monthly trach in-services planned for three months. Weekly observations of three nurses on trach competency for four weeks. A QAPI committee review to assess outcomes and adjust training.
Everything completed or initiated, the plan states, on November 14, 2025.
That is the same day the assistant director of nursing told inspectors the facility was still looking for a reinsertion checklist to use as the basis for that training.
The inspection was completed November 20, 2025.
The facility assessment that listed tracheostomy care as a special care need was dated June 2025. The trach care policy that omitted reinsertion instructions was revised October 2024. The gap between what the facility said it could do and what its nurses were actually prepared to do had been in place, by those dates, for at least a year before an inspector walked in to ask about it.
R2 was the patient whose care exposed it. He had a tracheostomy. He was assessed on October 31. His nurse could not confirm his emergency kit was in his room. His trach size may or may not have been documented where nurses could find it. And if his tube had come out on any shift before November 14, not one nurse in that building had been trained to put it back.
The facility is contesting whether that constitutes immediate jeopardy. The inspectors who reviewed the evidence concluded it did.
R2 is gone from the facility now. Where he went, 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 resident at the center of the citation, identified in inspection records only as R2, was a patient whose tracheostomy tube required active management.
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.