La Bella of Caseyville

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a resident's right to refuse a vaccination for 1 of 5 residents (R2) reviewed for resident rights in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean/comfortable/homelike environment for 1 of 4 residents (R4) reviewed for environment in a sample of 5. Findings Include: On 05/04/2026 at 10:02 AM, R4's mattress had an area on the head and side of the mattress that was sticky to touch and looked like something had been splattered on the mattress. There was also a white pasty-like substance seen under where the splatter area was. R4's Face Sheet, admission date of 11/7/25, documents she has diagnoses of but not limited to Parkinson's Disease with dyskinesia, morbid (sever) obesity, and hypertension (HTN). [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to assure that medication orders were processed accurately through the stages of ordering and administering medications by placing an order for a vaccination and then administering the vaccination when the resident's Power of Attorney (POA) had refused it for 1 of 5 residents (R2) reviewed for pharmaceutical services in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to assess 1 (R5) of 3 residents that had a change in condition. This failure resulted in R5 being transferred to the emergency room after not eating or coming out of her room for over 2 days. R5 was admitted to the hospital and diagnosed with RSV (Respiratory Syncytial Virus.)Findings Include:R5's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), pneumonia, nasal congestion and postnasal drip. R5's Minimum Data Set (MDS), dated [DATE] documents she was alert, performed activities of daily living (ADLs) with supervision or touching assistance from staff for eating, toileting, personal hygiene and transfers. Mobility device: wheelchair. Frequently incontinent of bowel and bladder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented existing accident prevention interventions and failed to review and revise interventions after changes in resident's condition in 3 of 4 residents reviewed for falls in the sample of 37. These failures resulted in R5 suffering multiple falls and right ankle fracture. 1. R5's Face sheet documents an admission date of 3/29/2021. Diagnosis include Displaced Comminuted Fracture of Shaft of Right Tibia, Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Chronic Kidney Disease. R5's Minimum Data Set, MDS, dated [DATE] R5 is moderately cognitively impaired. MDS dated [DATE] documents R5 requires partial to moderate assist with lying to sitting and sitting to standing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an RN (Registered Nurse) for at least eight hours per day when reviewed for staffing. This failure has the potential to affect all 108 residents residing in the facility. Findings Include: On 6/24/25, there were 4 LPNs (Licensed Practical Nurses), 9 CNAs (Certified Nursing Assistants), and V3, RN/ADON (Assistant Director of Nurses)/ICP (Infection Control Preventionist) working in the ADON/ICP role. The Daily Nursing Shift Assignment Sheets were reviewed and on 6/12/25, 6/14/25, 6/15/25, 6/17/25, 6/18/25, 6/19/25, 6/20/25, 6/21/25, and 6/22/25, there was not a designated RN working for at least 8 hours. On 6/24/25 at 11:50 AM, V1, Administrator, stated even with V3, ADON/IPC, they don't have enough RNs. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide an ABN (Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) form to notify a resident or their responsible party that they no longer required daily skilled services in 3 of 3 residents (R5, R25, R77) when reviewed for Medicare Coverage Notices in the sample of 37. Findings Include: 1. R5's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, documents R5 began Medicare A skilled services on 3/5/25 and the last covered Medicare A service date was 4/3/25. The SNF ABN for was not provided due to Social Worker did not realize she had to issue ABN. R5's NOMNC, dated, 5/19/25, documents the notification was not provided prior to the end date of 4/3/25. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse in 2 of 8 residents (R4, R5) reviewed for abuse in the sample of 8. This failure resulted in R5 being scared and not feeling safe in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer oxygen therapy as prescribed and provide signage on doors where oxygen is in use for residents receiving oxygen therapy for 2 of 3 residents (R2, R3) reviewed for respiratory care in the sample of 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure coordination of care with residents' community-based physician including preventative care to maintain the highest practicable physical well-being for 1 of 6 residents (R3) reviewed of quality of care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 88 residents living in the facility. Findings Include: The facility Infection Control Log was requested for the entire year since the last survey. On 5/28/2024 at 9:02 AM, An infection control log was provided but did not have any dates or organisms listed or documented. On 5/28/2024 at 10:43 AM, V3, Assistant Director of Nursing (DON) stated, I just recently was hired and took over as the infection control preventionist in March. I have completed this course and got my certificate. All of the surveillance, everything should be in the book. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were being answered in a timely manner for 5 of 7 residents (R32, R36, R70, R77, R82) reviewed for call lights in the sample of 54.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident clothes were being maintained, cleaned, and returned in a timely manner for 5 out of 7 residents (R32, R36, R70, R77, R82) reviewed for laundry in the sample of 42.

Inspectors wroteBased on interview and record review the facility failed to ensure abuse did not occur for 4 of 5 residents (R40, R49, R74, R75) reviewed for abuse in the sample of 42.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 2 of 4 residents (R40, and R74, ) viewed for antibiotic stewardship in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to provide services of a Registered Nurse (RN) for at least 8 hours daily 7 days per week. This has the potential to affect all 83 residents living in the Facility.

Inspectors wroteBased on interview, observation and record review the facility failed to pass as needed (PRN) pain medications in a timely manner and failed to provide prescribed medications as ordered to 1 of 10 residents (R2) reviewed for medications in a sample of 30. The failure resulted in R2 experiencing continued pain and the inability to sleep.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide scheduled medications as ordered for 7 of 10 residents (R1, R2, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing staff resulting in 6:00 AM medications not being passed for 6 of 10 residents (R1, R3, R12, R13, R19, R20) reviewed for medications in a sample of 30. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained an infection prevention and control program to help prevent the development and transmission of a communicable disease by staff not donning appropriate personal protective equipment (PPE) before entering a COVID positive resident's room, failed to have the correct signage in place for residents who were COVID positive, failed to provide bio-hazard receptacles in resident's rooms close to the door for proper discarding of PPE, failed to properly sanitize blood glucose monitors and failed to adhere to proper hand hygiene practices. This failure has the potential to affect all 83 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately report bruises of unknown origin to the administrator/or designee for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize their abuse policy and thoroughly investigate bruises of unknown origin for 2 of 4 residents (R20 and R21) reviewed for abuse in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to perform and monitor proper catheter care and monitor a penile wound for 1 of 3 (R3) residents reviewed for catheter care in a sample of 3. This failure resulted in R3 having a preventable penile injury resulting in a surgical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to position R2 in bed, in a safe position to prevent a fall in 1 of 1 resident (R2) in the sample of 3. R2 was sent to emergency room with a detection of acute cerebral ischemia and a small left frontal scalp hematoma. Findings Include: R2's Face Sheet documents an admission date of 1/14/2021. Diagnosis' include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery. Aphasia, Dysphasia. R2's Minimum Data Set, MDS, dated [DATE] documents, R2 is severely cognitively impaired and is totally dependent on staff for bed mobility and transfers. R2's MDS dated [DATE] documents, R2 has had no falls since admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of Antibiotics to treat a Urinary Tract Infection, (UTI), for four (R5, R6, R8 and R20) of five residents reviewed for unnecessary medication use in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on the reporting of the allegation of injuries of unknown origins for resident (R2). This failure had the potential to affect one resident (R2) one in a sample of one.

Inspectors wroteBased on interview and record review the facility failed to provide evidence, that the allegation of injuries of unknown origin was investigated. This failure affected 1 resident (R2) in a sample of 1. This failure exposed (R2) to potential harm and further injury.

Inspectors wroteBased on interview and record review the facility failed to assess and/or develop, a baseline Care Plan to furnish to attain or maintain residents' highest practicable physical, mental and psychosocial well-being for 1 of 1 resident (R2)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility on 3/23/2024 for 8 consecutive hours and that there was a full time Director of Nursing (DON). This failure has the potential to affect all 87 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to answer call lights in a timely manner for 7 of 23 residents (R4, R10, R31, R37, R42, R52, R62) reviewed for call lights in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate linens to provide a homelike environment for 7 of 23 residents (R4, R10, R28, R31, R43, R52 and R62) reviewed for homelike environment in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatments were administered for the care of pressure ulcers for 5 of 6 residents (R9, R52, R65, R85, and R190) reviewed for pressure ulcers in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a nourishing snack to residents when there were more than 14 hours between a substantial evening meal and breakfast for 5 of 23 residents (R4, R10, R31, R52 and R62) reviewed for frequency of meals and snacks in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to notify the family of a change in the resident's condition in 1 of 33 residents (R190), reviewed for notification of changes in condition in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 27 residents (R39) reviewed for significant medication errors in the sample of 33.