Bria Of Woodriver

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 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 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. 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bria of Woodriver

393 Edwardsville Road Wood River, IL 62095

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: