Bria of Woodriver

In the surveyor’s words

From the most serious findings on record at Bria of Woodriver, in the surveyor’s own words.

• Immediate jeopardy, patternF659Oct 3, 2025

  Based on interview and record review, the Facility failed to ensure staff were educated and competent in providing the necessary care and services for tracheostomies for 4 of 4 residents (R2, R4, R5, R6) in the sample of 6. This failure resulted in R2, R4, R5, and R6 being sent out emergently for routine tracheostomy care. R2 was found unresponsive in the Facility and staff performed CPR that was not in accordance with professional standards using R2's primary airway because they did not know how to do so. R2 died in the Facility, and death certificate is pending.This Immediate Jeopardy began on [DATE] at approximately 10:44 PM when R5 was sent to the hospital for suctioning/removal of mucus plug and tracheostomy replacement. […]

• Immediate jeopardy, patternF695Oct 3, 2025

  Based on interview, observation, and record review, the Facility failed to ensure nursing staff had the knowledge, skills, and necessary supplies to provide tracheostomy care for 5 of 5 residents (R1, R2, R4, R5, R6) reviewed for respiratory care in the sample of 6. This failure resulted in Cardiopulmonary Resuscitation (CPR) not being performed in accordance with professional standards on R1 and R2 and caused unnecessary emergency hospital transport for R4, R5 and R6. R1 and R2 died in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 10:44 PM when staff were unable to replace R5's tracheostomy and adequately suction R5 to ensure airway remains clear and patent. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. […]

• Immediate jeopardy, isolatedF689Jan 22, 2026

  Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 2 out of 2 residents (R2, R4). This failure resulted in R2 eloping through the front entrance at 2:05 AM unsupervised and the facility being notified of his location 4.4 miles away at 10:52 AM. This failure resulted in R4 eloping from the front door and being found across a busy two-lane road that borders the front of the facility approximately 500 feet away from the entrance at 1:27 PM. The Immediate Jeopardy began on 11/22/25 at 2:05 AM when R2 eloped through the facility's front door, R2 was not reported missing until six hours later at approximately 8:00 AM and found at 10:52 AM about 4.4 miles away from the facility in R2's wheelchair. […]

• Immediate jeopardy, isolatedF659Nov 20, 2025

  Based on interview and record review, the Facility failed to ensure staff were knowledgeable and competent to provide emergent tracheostomy reinsertion for 1 of 1 resident (R2) in the sample of 1. This failure resulted in R2 being transported via EMS (Emergency Medical Services) for reinsertion of a trach after dislodgement after nursing staff on duty failed to attempt to reinsert the trach because they weren't properly trained and didn't feel comfortable/confident in doing so. R2 remains in the Intensive Care Unit following trach reinsertion. This has the potential to affect current and new admissions that require tracheostomy care. […]

• Immediate jeopardy, isolatedF695Nov 20, 2025

  Based on interview and record review, the facility failed to provide necessary emergent care and services for 1 of 1 resident (R2) with a tracheostomy in the sample of 1. This failure resulted in R2 being sent out urgently via EMS (Emergency Medical Services) for trach reinsertion after staff failed to attempt to reinsert R2's trach when it was found dislodged. R2 was admitted to the ICU (Intensive Care Unit) for respiratory distress. This has the potential to affect current and new admissions that require tracheostomy care.This Immediate Jeopardy began on 11/2/2025 at approximately 2:30 AM when R2 was sent to the hospital for reinsertion of trach replacement. […]