393 Edwardsville Road, Wood River, IL 62095 · Madison County · (618) 259-4111
106 certified beds, about 79 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145655 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 13, 2026, inspectors cited 12 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 65 health citations since August 2023, 18 were rated as actual harm or immediate jeopardy to residents (7 immediate jeopardy).
CMS lists 6 fines totaling $468,820 in the last three years; the largest was $283,460, and the latest is dated May 13, 2026.
Nurses and nurse aides worked 3.86 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.59 of those hours.
78.5% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Bria Health Services, an affiliated group of 10 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 65 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for 1 of 3 residents (R2) reviewed for abuse in a sample of 8.
Inspectors wroteBased on interview and record review the facility failed to implement effective fall interventions for 1 of 3 residents (R2) reviewed for accidents in the sample of 7. This failure resulted on R2 falling 4 times, requiring to be sent to the hospital and receiving a laceration to her head. This past non-compliance occurred from 3/11/2026- 3/20/2026.
Inspectors wroteBased on observation, interview, and record review the facility failed to initiate and implement progressive interventions to prevent falls for 3 of 10 residents (R2, R19, and R51) reviewed for falls in a sample of 41. Findings Include: 1)R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of reduced mobility, muscle weakness, difficulty in walking, dementia, abnormalities of gait and mobility, and repeated falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing and chair/bed to chair transfers. R2's Care Plan Date Initiated 3/30/2025 documents Fall: R2 is at high risk for falls related to incontinence, weakness, history of fall, glaucoma, confusion, and use of psychotropic meds. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care, including irrigation, in 1 of 5 residents (R75) reviewed for bowel/bladder incontinence, catheter, and UTI (Urinary Tract Infection) in the sample of 41. This failure resulted in R75 being hospitalized for a UTI.Findings Include:On 2/5/26 at 1:43 PM, R75 was observed in his room with a suprapubic catheter draining clear tea colored urine. R75 stated he has a suprapubic catheter, he does not take care of it himself, the staff cleaned it two or more days ago and he has had a recent urine infection. On 2/10/26 at 12:25 PM, R75 stated he was sent to the hospital about a month ago because his catheter was clogged up and it had to be replaced. R75 stated the staff only clean his catheter site every 2-3 days. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 76 residents living in the facility.
Inspectors wroteBased on interview and record review the Facility failed to ensure call lights were being answered in a timely manner for 6 of 14 residents (R16, R17, R43, R67, R69 and R81) reviewed for call lights in the sample of 41.
Inspectors wroteBased on observation and interview, the facility failed to properly label medications for an unknown number of residents due to medications not being labeled in a sample of 41.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide Ice Cream with meals as ordered for 5 of 5 residents (R6, R24, R74, and R81) reviewed for Nutrition in a sample of 41.
Inspectors wroteBased on observation, interview, and record review, the facility failed to perform infection prevention practices during medication administration, including hand hygiene and cleansing of the glucometer to prevent infections in 5 of 9 residents (R16, R52, R69, R75, R49) reviewed for infection prevention and control in the sample of 41. Findings Include:On 2/5/26 at 8:18 AM, Medication administration was observed with V9 LPN (Licensed Practical Nurse), with R52, V9 donned gloves, completed an accu-check and removed her gloves. V9 did not perform hand hygiene before or after donning and removing the gloves and did not clean the glucometer after use. A On 2/5/26 at 8:38 AM, V9 performed an accu-check on R16 with the glucometer used on R52 that had not been cleaned after use. V9 did not perform hand hygiene before or after glove use and did not clean the glucometer after use. [...]
Inspectors wroteBased on interview, observation, and record review the facility failed to implement care plan interventions following resident falls for 1 of 10 (R51) residents investigated for falls in a sample of 41.
Inspectors wroteBased on record review and interview, the facility failed to evaluate and revise a resident's Care Plan with progressive interventions following falls for 3 of 10 residents (R2, R19, and R68) in a sample of 41. Findings Include:1.) R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of reduced mobility, muscle weakness, difficulty in walking, dementia, abnormalities of gait and mobility, and repeated falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing and chair/bed to chair transfers. R2's Care Plan Date Initiated 3/30/2025 documents Fall: R2 is at high risk for falls related to incontinence, weakness, history of fall, glaucoma, confusion, and use of psychotropic meds. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to change soiled bed linens for a dependent resident in 1 of 2 residents (R10), reviewed for ADL (Activities of Daily Living) care provided for dependent residents in the sample of 41. Findings Include:On 2/5/26 at 10:00 AM, R10 was observed in her room lying on her left side. R10 has contractures noted to the left hand, left wrist, left elbow, and left shoulder. R10 was not able to move her left upper or left lower extremities. R10 is able to move her right arm but isn't able to make significant movements or position herself in the bed. On 2/5/26 at 12:13 PM, R10 was observed in her room in bed on her left side. R10 stated they delivered her lunch tray; she ate but made a mess. R10 had a liquid reddish colored substance, on her pillow and incontinence pad that appeared to be from a red colored drink. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure relieving interventions for the prevention and treatment of pressure ulcers in 1 of 2 residents (R10) reviewed for treatment/services to prevent/heal pressure ulcers in the sample of 41. Findings Include:On 2/5/26 at 10:00 AM, R10 was observed in her room lying on her left side, a heel protector to the left foot, no pillow between her knees or under her heels and is very thin in appearance. R10 has contractures noted to the left hand, left wrist, left elbow, and left shoulder. R10 was not able to move her left upper or left lower extremities. R10 is able to move her right arm but isn't able to make significant movements or position herself in the bed. R10 stated she has several wounds that she had prior to admission to the facility. [...]
Inspectors wroteBased on observation, interview and record review the Facility to ensure staff were observing residents taking their medications and no medication was given to residents without supervision for 1 of 29 residents (R67) (reviewed for medications in the sample of 41.
Inspectors wroteBased 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. On 1/15/26 at 3:40 PM, V1 (Administrator) was notified of the Immediate Jeopardy. [...]
Inspectors wroteBased 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. This resulted in an Immediate Jeopardy which began on 11/2/2025 at approximately 2:30 AM when R2 was sent to the hospital for reinsertion of trach replacement. [...]
Inspectors wroteBased 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. On 11/14/2025 at 11:00 AM V2, Director of Nurses (DON)/Administrator in Training (AIT) and V3, Assistant Director of Nurses (ADON) were notified of the Immediate Jeopardy. [...]
Inspectors wroteBased 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.
Inspectors wroteBased 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. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. [...]
Inspectors wroteBased 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. [...]
Inspectors wroteBased on interview and record review, the Facility failed to provide Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for 2 of 2 residents (R2, R1) reviewed for CPR in the sample of 6. This failure resulted in R1 and R2 not receiving adequate respiratory ventilation when staff did not provide rescue breathing via R1 and R2's primary airway of tracheostomy. R1 and R2 both died while in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 6:40 PM when R1 was found unresponsive, and CPR was not performed in accordance with professional standards. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 11:37 AM. [...]
Inspectors wroteBased on interview and record review, the Facility failed to ensure changes in condition were reported for timely assessment and intervention for 1 of 3 residents (R2) reviewed for change in condition in the sample of 6. This failure resulted in R2 showing a change in condition with dilated pupils, hand to touch cool body temperature and decreased baseline response to care on [DATE] when V11 and V12 were providing care to R2. V11 and V12 stated they did not inform R2's nurse of R2's changes. Approximately 15-20 minutes later, V12 returned to check on R2 and R2 was found unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated. R2 died in the Facility, and death certificate is pending. This Immediate Jeopardy began on [DATE] at approximately 5:00 PM when R2 displayed changes from his baseline that were not reported to his nurse. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide a resident's medical records for 1 of 4 residents (R2) reviewed for medical records (MR) in the sample of 4. The Findings Include: R2's admission Record, dated [DATE], documents R2 was admitted to the facility on [DATE], and was discharged on [DATE], and expired on [DATE]. On [DATE] at 9:15 AM, V3, Business Office Manager, stated The previous medical record person (V5) was terminated on Thursday [DATE] and I am coordinating with the Regional Medical Records person (V4) for any medical record requests. I have not had any medical record requests since I have been assisting. [...]
Inspectors wroteBased on interviews and record reviews the facility failed to follow written orders for wound care treatment for 1 out of 4 residents, (R2); reviewed for quality of care in a sample of 5. This failure resulted in R2 being admitted to the hospital with wounds declining.
Inspectors wroteBased on interviews and record reviews the facility failed to follow wound care orders for 1 out of 4 residents, (R2) reviewed for quality of care in a sample of 5. This failure resulted in R2's experiencing severe pain.
Inspectors wroteBased on interview and record review, the facility failed assess, monitor, and treat a change of condition for 1 of 4 resident (R6) reviewed for quality of care in the sample of 15. This failure resulted in a delay of treatment for a significant change in condition resulting in R6's hospitalization.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and monitor pressure ulcers, and provide the Physician prescribed treatment for 4 of 5 residents (R1, R2, R4, R5) reviewed for pressure ulcers in the sample of 15. The failure resulted in R5 developing a pressure ulcer of unknown stage while at the facility, not receiving treatment for a pressure ulcer for 23 days at which time it was unstageable, and R4 developing 3 pressure ulcers while at the facility and a sacral pressure ulcer that became infected.
Inspectors wroteBased on interview and record review, the Facility failed to adhere to their Facility's Abuse Policy and Prevention Program for 1 of 3 residents (R1) in the sample of 3.
Inspectors wroteBased on interview and record review, the Facility failed to inform local law enforcement in a timely fashion related to suspected misappropriation of a narcotic medication for 1 of 3 residents (R1) in the sample of 3.
Inspectors wroteBased on interview and record review, the Facility failed to provide three meals daily at regular times for 4 of 6 residents (R6, R7, R8, and R10) reviewed for food and nutrition services in the sample of 10.
Inspectors wroteBased on interview and record review, the facility failed to have a physician's order to remove staples from a wound for 1 of 3 residents (R2) residents reviewed for quality of care/treatment in the sample of 3.
Inspectors wroteBased on interview and record review, the facility failed to schedule a colonoscopy ordered by the physician in 1 of 4 residents (R2) reviewed for radiology/other diagnostic services in the sample of 4.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent pressure ulcer development and failed to provide resident centered interventions, monitoring and orders for residents who were identified to be at risk for pressure ulcers and for residents with pressure ulcers for 2 of 3 residents (R1, R2) reviewed for skin impairment. This failure resulted in R1 acquiring an unstageable pressure ulcer to his/her left heel and stage 3 pressure ulcer to right buttock; R2 requiring debridement of an unstagable pressure ulcer during a hosptial stay to R2's coccyx.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure opened medications were labeled with open dates, for 5 of 5 residents (R20, R52, R242, R235 and R242), reviewed for medication storage in the sample of 40.
Inspectors wroteBased on observation, interview, and record review the Facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature for 4 of 5 (R6, R24, R47, R66) residents reviewed for food temperatures in the sample of 40.
Inspectors wroteBased on interview, record review, and observation the facility failed to follow infection control policy and guideline for 4 of 4 residents (R65, R58, R54, R20) reviewed for infection control in the sample of 39.
Inspectors wroteBased on interview and record review the facility failed to protect the resident from resident-to-resident physical abuse for 3 of 3 residents (R8, R54, R135) reviewed for abuse in the sample of 40. Findings Include: R54's Minimum Data Set (MDS) dated [DATE] documents that R54 is severely cognitively impaired. R54's Face sheet dated 3/4/22 documents R54 has Alzheimer's Disease, Schizoaffective Disorder, and Psychosis Unspecified. R54's Abuse Care Plan dated 3/15/22 documents R54 is at risk for abuse neglect due to dementia and depression (R54) will have zero episodes of abuse and neglect. Intervention: Assess resident for abuse and neglect. R54's Resident to Resident Abuse Investigation dated 1/15/24 documents an altercation between (R135) and (R54). (R54) was trying to take (135's) bedside table, when (R135) hit (R54) with her cane on the head. [...]
Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for 1 of 5 residents (R73) reviewed for abuse, in the sample of 40.
Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for 1 of 5 residents (R73) reviewed for abuse, in the sample of 40.
Inspectors wroteBased on interview and record review the Facility failed to ensure residents did not elope the facility for 1 of 3 resident (R71) reviewed for elopements in the sample of 40.
Inspectors wroteBased on interview, observation, and record review the facility failed to provide timely incontinent care for 1 of 1 resident (R54) reviewed for bowel and bladder incontinence in the sample of 40. Findings Include: R54's Minimum Data Set (MDS) dated [DATE] documents (R54) is always incontinent of urine and frequently incontinent of bowel. R54's Incontinence Care Plan documents (R54) is incontinent of bowel and bladder. (R54)'s goal is to be kept clean, dry, and odor free. (R54)'s intervention provide incontinence care when incontinent. On 9/11/24 at 11:45 AM, (V11), (CNA) Certified Nursing Assistant, (V12), CNA and (V13), CNA all entered the resident's room and told (R54) they were going to clean her up and get her ready for lunch. (V13), CNA pulled down the resident's incontinent brief and wiped each side of her vaginal area and the middle. [...]
Inspectors wroteBased on interview and record review the facility failed to provide routine drugs in a timely manner for 4 of 4 residents (R1,R2, R3, R4) reviewed for Pharmacy services in the sample of 10. This failure resulted in residents missing medications such as insulin, antihypertensives, and anticoagulants. Findings Include: 1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with the diagnoses of Pulmonary Hypertension, Mitral Valve Prolaspe, Congestive Heart Failure, and Bactermia. R1's Facesheet also documents R1's facility assigned pharmacy is 274 miles away, which is 4 hours and 16 minutes travel. [...]
Inspectors wroteBased on interview and record review the facility to provide a competent licensed nurse to provide care for one of one residents (R9) review for licensing compliance in the sample of 10. Findings Include: R9's Minimum Data Set (MDS) dated [DATE] documents R9 is cognitively intact. R9's Pain Care Plan dated 3/1/24 documents pain: alteration in comfort. Goal: (R9) will maintain adequate level of comfort as evidenced by no s/s (signs or symptoms) of pain or distress. Intervention: administer pain meds (medications) and treatments as ordered. Assess effectiveness of pain med. R9's POS (Physician Order Sheet) dated 3/1/24 documents Acetaminophen tablet 325 mg (milligrams) give two tablets by mouth every 4 hours as needed for pain. On 7/31/24 at 2:30 PM R9 stated, I started asking for Tylenol at 2:30 AM in the early hours of Saturday Morning (7/27/24). [...]
Inspectors wroteBased on interview and record review, the facility failed to administer Intravenous (IV) Medications as ordered for 1 of 11 residents (R2) reviewed for medications in the sample of 14.
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent employee to resident abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4. This failure resulted in R2 being physically and mentally abused, causing her to feel scared and not safe in the facility.
Inspectors wroteBased on interview, observation and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections (UTIs) for 1 of 3 residents (R2) reviewed for incontinent care and UTIs in the sample of 4.
Inspectors wroteBased on interview and record review, the facility failed to have enough CNAs (Certified Nurses Assistants) working to meet the needs of the residents for 1 of 4 residents (R3) reviewed for staffing in the sample of 4.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were given as ordered by the physician to 1 of 3 residents (R3) reviewed for pharmacy services in the sample of 4.
Inspectors wroteBased on observation, interview and record review, the facility failed to install the correct bed rail and get consent from the resident/resident representative prior to the installation/use of the bed rails in 4 of 4 residents (R2, R4, R7 and R8) reviewed for bed rails in the sample of 8.
Inspectors wroteBased on observation, interview and record review, the facility failed to obtain orders to treat a new pressure ulcer, to prevent deterioration of the pressure ulcer, and failed to have appropriate interventions in place to prevent new pressure ulcers from developing and keep existing pressure ulcers from getting worse for 2 of 4 residents (R3 and R4) reviewed for pressure ulcers in the sample of 11. This failure resulted in R4 developing a Stage 4 Pressure Ulcer on his right buttock.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide an adequate supply of food for the residents. This failure has the potential to affect all 83 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to prevent employee to resident abuse for 2 of 6 residents (R2, R4) reviewed for abuse in the sample of 22.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide supervision for a severely cognitively impaired resident, failed to provide progressive interventions to address the resident's exit seeking behavior, and failed to follow the facility's policy for elopement for 1 of 3 residents (R8) reviewed for resident safety in the sample of 9.
Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure prescribed nutritional supplements were provided and consumed for 4 of 4 residents (R2, R4, R5 and R6) reviewed for nutritional status, in the sample of 7. 1. On 12/19/2023 at 10:00 AM, V7 (R2's sister) stated, Sometimes when I go there (Facility) his (R2's) plate is just sitting there or it's on the floor. V7 stated when R2 was first admitted to the Facility in February 2023 he weighed 135 pounds and now weighs 111 pounds. On 12/19/2023 at 12:15 PM, V5 (Registered Nurse/RN) stated R2 is on a pureed diet, requires feeding assistance and is on nutritional supplements. V5 stated, (R2) will eat every bite if he is fed. On 12/19/2023 at 12:45 PM R2 was being fed by V12 (Certified Nursing Assistant/CNA). [...]
Inspectors wroteBased on observation, interview and record review, the Facility failed to follow their policy to ensure proper placement of the catheter bag for infection prevention measures for 1 of 3 residents (R2) reviewed for catheters, in the sample of 7.
Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition a resident that is at moderate risk for pressure sore development and failed to follow the resident's care plan interventions for pressure ulcer prevention for 1 of 6 resident (R7) reviewed for pressure ulcers in a sample of 11. Findings Include: R7's Face sheet documents an admission date of 8/9/2022. Diagnosis include Bilateral hearing loss, Polyneuropathy, Arthropathy, Contracture of bilateral lower legs, Atrial Fibrillation. R7's Minimum Data Set, MDS, dated [DATE] documents R7 has no cognitive impairments. R7's MDS dated [DATE] documents R7 requires maximum assist for showers, toileting, and bed mobility. R7's care plan dated 10/17/2023 documents Pressure ulcer: R7 is at risk for pressure ulcers related to impaired mobility and incontinence. [...]
Inspectors wroteBased on interview, observation, and record review, the facility failed to wear gloves and a hair net to prevent contamination and food borne illness while serving food onto the plates. This failure has the potential to affect all 69 residents living in the facility.
Inspectors wroteBased on interview, observation, and record review, the facility failed to adhere to infection control practices and policies related to the staff donning and utilization of appropriate PPE (Personal Protective Equipment) while caring for a resident on isolation, stocking PPE supplies for staff/visitors use, and COVID testing residents without wearing appropriate PPE, for 1 of 5 residents (R6) reviewed for infection control in a sample of 6. This has the potential to affect all 69 residents.
Inspectors wroteBased on interview and record review the facility to monitor and prevent weight loss for one of two residents (R48) reviewed for weight loss in the sample of 33. This failure resulted in R48 having a slow insidious weight loss from March 2023 through July 2023 and a 12% weight loss since January 2023.
Inspectors wroteBased on interview, record review, the facility failed to conduct and provide evidence of quarterly and ongoing QAPI (Quality Assurance and Performance Improvement Program) program and failed to have medical director attend the QAPI meetings. This has the potential to affect all 74 residents in the facility.
Inspectors wroteBased on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infections. This has the potential to affect all 74 residents living in the facility.
Inspectors wroteBased on interview, observation, and record review the facility failed to develop and implement protocol to optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic for 4 of 4 residents (R39, R226, R278, R279) reviewed for antibiotic stewardship in the sample of 33.
Inspectors wroteBased on interview, and record review the facility failed to provide showers to residents who require bathing assistance for 3 of 5 residents (R16, R276, R277) reviewed for activities of daily living (ADL) care for dependent residents in the sample of 33.
Inspectors wroteBased on observation, interview and record review the facility failed to provide progressive fall interventions for 1 of 7 residents (R34) reviewed for supervision to prevent accidents in the sample of 33.
Inspectors wroteBased interview and record review, the facility failed to provide tracheotomy (trach) care to 1 of 3 residents (R276) reviewed for trach care in the sample of 33.
| Date | Penalty | Amount or length |
|---|---|---|
| May 13, 2026 | Fine | $22,315 |
| January 22, 2026 | Fine | $71,570 |
| October 3, 2025 | Fine | $283,460 |
| October 3, 2025 | Payment Denial | 21 days from October 31, 2025 |
| May 13, 2025 | Fine | $31,603 |
| March 4, 2025 | Fine | $47,824 |
| November 15, 2023 | Fine | $12,048 |
| November 15, 2023 | Payment Denial | 12 days from February 15, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.86 | 3.45 | 3.86 |
| Registered nurses | 0.59 | 0.72 | 0.69 |
| All nursing staff on weekends | 3.23 | 3.07 | 3.42 |
| Nurse aides | 2.48 | ||
| Licensed practical nurses | 0.79 | ||
| Nursing staff turnover (share who left in a year) | 78.5% | 44.5% | 45.8% |
| Registered nurse turnover | 69.2% | 41.8% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.93 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.12 on weekdays and 3.23 on weekends, 22% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 44.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.13 in April to June 2025 to 3.86 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.86 | 0.59 | 4.12 | 3.23 | 44.0% | 0 of 90 | 79 |
| Oct to Dec 2025 | 3.73 | 0.56 | 3.99 | 3.07 | 32.7% | 1 of 92 | 81 |
| Jul to Sep 2025 | 3.91 | 0.73 | 4.18 | 3.22 | 35.3% | 0 of 92 | 84 |
| Apr to Jun 2025 | 4.13 | 0.65 | 4.42 | 3.40 | 30.6% | 0 of 91 | 87 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Illinois, all employers | |||
| CNAs (nursing assistants) | $22.10 | $18.95 to $23.26 | 68,640 |
| LPNs and LVNs | $36.06 | $30.57 to $38.25 | 17,440 |
| Registered nurses | $46.15 | $38.47 to $50.94 | 138,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.1 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.1 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.6 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 5.4 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.1 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.6 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 32.6 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 26.9 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.7 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 4.9 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Bria of Woodriver's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (43.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
43.4% this home
No different from the national rate
US median of homes 51.5% · Illinois: 106 better, 85 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 42 eligible stays.
11.3% this home
No different from the national rate
US median of homes 10.7% · Illinois: 2 better, 14 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 38 eligible stays.
8.2% this home
No different from the national rate
US median of homes 7.1% · Illinois: 3 better, 10 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 31 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois50.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 17 residents counted.
0.0% this home
Median of homes: Illinois0.3% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 40 residents counted.
0.0% this home
Median of homes: Illinois1.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 40 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 6 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BRIA OF WOODRIVER LP. CMS links this home to Bria Health Services, a group of 10 nursing homes averaging 1.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Forge Gp LLC | 5% or greater direct ownership interest | Organization | 97% | 01/01/2024 |
| Weinfeld, Avrum | Direct ownership interest | Individual | 07/01/2022 | |
| Weiss, Daniel | Direct ownership interest | Individual | 07/01/2022 | |
| Weinfeld, Avrum | Corporate officer | Individual | 07/01/2022 | |
| Weiss, Daniel | Corporate officer | Individual | 07/01/2022 | |
| Bria Health Services LLC | Operational/managerial control | Organization | 07/01/2022 | |
| Dhaliwal, Navdeep | Operational/managerial control | Individual | 01/01/2024 | |
| Lindow, Cassandra | Operational/managerial control | Individual | 07/01/2022 | |
| Weinfeld, Avrum | Operational/managerial control | Individual | 07/01/2022 | |
| Weiss, Daniel | Operational/managerial control | Individual | 07/01/2022 | |
| Wheat Chaff LP | General partnership interest | Organization | 01/01/2024 | |
| Bria Health Services LLC | Adp of the SNF | Organization | 06/26/2025 | |
| Dhaliwal, Navdeep | Adp of the SNF | Individual | 01/01/2024 | |
| Lindow, Cassandra | Adp of the SNF | Individual | 07/01/2022 | |
| Weinfeld, Avrum | Adp of the SNF | Individual | 07/01/2022 | |
| Weiss, Daniel | Adp of the SNF | Individual | 09/01/2022 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.