Bria Of Woodriver
Inspection Findings
F-Tag F0659
F 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.
FORM CMS-2567 (02/99) Previous Versions Obsolete
trach reinsert kit should be in his room, and she expected there to be one in Resident R2's room in case of dislodgement. V20 stated she expected staff to document resident's trach size in the resident's medical
record so nurses would know what size to reinsert if the trach is dislodged.The Facility's Tracheostomy Care Policy revised 10/2024 documents, it is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway. No documentation regarding trach reinsertion is addressed
in the facility policy. The Facility's Facility Assessment dated 6/18/2025 documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The facility took the following actions to remove the immediacy and prevent any additional residents from suffering an adverse outcome. Completion dated: 11/14/2025. Resident R2 no longer resides at the facility. All new trach patients have the potential to be affected by alleged deficient practice. All nurses will be in-serviced by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025.
Nurses will be in-serviced prior to the start of their next shift. Agency nurses will be in-serviced prior to the start of their next shift by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025. Nurses will be in-serviced prior to the start of their next shift.Actions to Prevent Occurrence/Recurrence: the facility took the following actions to prevent an adverse outcome from reoccurring. Trach in-servicing - completed once a month for 3 months starting 11/14/2025 by the DON/Designee. Audit logs: - 3 nurses will be observed on trach competency weekly for 4 weeks by DON/Designee initiated 11/14/2025. QAPI Review: Committee will access outcomes and adjust training as needed weekly during QA and initiate 11/14/2025.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bria of Woodriver
393 Edwardsville Road Wood River, IL 62095
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0695
F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.
FORM CMS-2567 (02/99) Previous Versions Obsolete
it should be reinserted immediately because without it could lead the resident to having respiratory distress which could lead to brain death. V20 stated when she assessed Resident R2 on 10/31/2025 she couldn't recall if there was an emergency trach reinsert kit in his room, but she expected there to be one in Resident R2's room in case of dislodgement. V20 stated she expected staff to document resident's trach size in the resident's medical record so nurses would know what size to reinsert if the trach is dislodged. On 11/14/2025 at 12:25 PM V3, ADON stated the facility's trach care policy doesn't document instructions on how to reinsert a trach if it is dislodged and they have been in-servicing nurses using a trach care skills checklist this week, but it also didn't include trach insertion instructions. V3 clarified the facility doesn't have a policy or skill checklist that covers trach reinsertion, so no staff have been in-serviced on trach reinsertion. V3 stated the facility is currently working on finding a trach skills checklist for trach reinsertion so they can in-service nurses on it.
The Facility's Tracheostomy Care Policy revised 10/2024 documents, it is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway. No documentation regarding trach reinsertion is addressed in the facility policy. The Facility's Facility Assessment dated 6/18/2025 documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The facility took the following actions to remove the immediacy and prevent any additional residents from suffering an adverse outcome. Completion dated: 11/14/2025. Resident R2 no longer resides at the facility. All new trach patients have the potential to be affected by alleged deficient practice.
All nurses will be in serviced by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025. Nurses will be inserviced prior to the start of their next shift.
Agency nurses will be in serviced prior to the start of their next shift by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025.Actions to Prevent Occurrence/Recurrence: the facility took the following actions to prevent an adverse outcome from reoccurring. Trach inservicing - completed once a month for 3 months starting 11/14/2025 by the DON/Designee. Audit logs: - 3 nurses will be observed on trach competency weekly for 4 weeks by DON/Designee initiated 11/14/2025. QAPI Review: Committee will access outcomes and adjust training as needed weekly during QA and initiate 11/14/2025.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bria of Woodriver
393 Edwardsville Road Wood River, IL 62095
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0812
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation, interview and record review the facility failed to ensure kitchen employees had food handling certificates for 4 staff, 3 cooks (V38, V39, V40) and a dietary aide (V31). This failure has the potential to affect all residents in the facility.Findings include:On 11/18/2025 at 8:40 AM V30, Dietary Manager stated she started working as the dietary manager 2 months ago and she spoke to corporate, and
they told her they were aware there are multiple kitchen staff that haven't taken the food handlers certification class and corporate set it up for all kitchen staff to attend an in person class in August 2025 but no kitchen staff attended the class. V30 stated V31, Dietary Aide told her he took the class, but she wasn't sure if he had or not.The Facility's Employee Census documents V31 is a DA (Dietary Aide) and hire date: 5/1/2025.On 11/18/2025 at 8:47 AM V31, Dietary Aide stated he thought he took the required kitchen certification but perhaps he hadn't.On 11/18/2025 at 1:00 PM V2, Director of Nurse (DON)/Administrator in Training (AIT) stated she couldn't find V31's food handler certificate.On 11/19/2025 at 11:40 AM V30 stated 2 cooks and 1 dietary aide are taking the food handler certification class today.On 11/19/2025 at 11:41 AM V2, DON/AIT stated 3 kitchen staff are taking the food handler certification classes online today and they will not work until they have the classes completed. V2 stated she wasn't aware the kitchen staff didn't have
the food handler certifications completed.On 11/19/2025 at 12:00 PM V2 DON/AIT stated all kitchen staff hire date is 5/1/2025 because the dietary department was contracted by another company and on 5/1/2025
the facility took over the dietary staff, and she doesn't know any of the dietary employee's original hire date due to this.The Facility's Employee Census documents V39 is a [NAME] and hire date: 5/1/2025.On 11/19/2025 at 12:19 PM V39, [NAME] stated her initial hire date was 9/9/2024 and she has had 6 dietary mangers since she's started working at the facility. V39 stated on 9/25/2025 the former dietary manager informed her she needs to take the food handlers class to work in the kitchen but no one told her how or when to take the class then that dietary manager left and V30 didn't notify her of when or how to take the class either.On 11/19/2025 at 12:48 V30 stated there is another cook that doesn't have the food handler course completed which is V38 and she is completing it today. V30 clarified there are 3 cooks and 1 dietary aide that hadn't completed the food handler's course.The Facility's Employee Census documents V38 is cook and hire date: 10/14/2025.On 11/19/2025 at 12:52 PM V38, [NAME] stated her initial hire date was 10/11/2025 and no one told her she needs to take a food handlers class prior to working as a cook. V38 stated she has been a cook many years and she's taken the food handler's class before but she couldn't recall where she took the course, so she has to retake it.On 11/19/2025 at 1:00 PM V30 stated she has 2 cooks V38 and V39 and the dietary aide V31 taking the food handler class online today and she can't get ahold of V40, [NAME] to let him know to take the course as well.The Facility's Employee Census documents V40 is a cook and hire date: 5/3/2025.On 11/19/2025 at 1:45 PM V2 DON/AIT stated the facility does not have a policy on kitchen employees having the food handler certification course being completed but she expected all kitchen employees to have the certification completed.The Facility Daily Census Form dated 11/6/2025 documents 80 residents in the facility.
Event ID:
Facility ID:
If continuation sheet
BRIA OF WOODRIVER in WOOD RIVER, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WOOD RIVER, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRIA OF WOODRIVER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.