La Bella of Edwardsville

Inspectors wroteBased on interview and record review the facility failed to supervise and properly assessed 1 of 3 (R6) residents investigated for elopement in a sample of 11. This failure led to R6 eloping on 7/18/26 sometime between 6:00 PM and 6:30 PM from the facility and wandering through busy streets in the evening time and night, being gone for approximately an hour and half before staff realized he was missing, and being found almost a mile from the facility on 7/19/26 at 12.54 AM. This past non-compliance occurred from 07/18/26 to 07/19/26. An Immediate Jeopardy began on 7/18/26 at approximately 6:30 PM when R6 left the facility unsupervised out the front door. V1, Administrator, V2, Director of Nursing, and V15, [NAME] President of Clinical Operations were notified of the Immediate Jeopardy on 7/24/26 at 10:10 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure newly identified pressure wounds were assessed and failed to follow physician orders for administration of treatments to pressure wounds for two (R3 and R7) of four residents reviewed for pressure wounds in the sample list of 10.1. R3's undated Care Plan documents R3's diagnoses include Severe Protein-Calorie Malnutrition, Pressure Ulcer to Right Heel, Open Wound to Right Foot, Muscle Weakness, and Parkinson's Disease. This Care Plan further documents an admission date of 03/15/2025. R3's Care plan dated 12/04/2025 documents a Focus to Document Pressure Ulcer with interventions to evaluate skin for areas of blanching or redness, evaluate ulcer characteristics, monitor bony prominences for redness, and provide wound care per treatment orders. [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure steam table holding temperatures were in safe range, to prevent the growth of harmful pathogens for ensuring the safety and quality of the food served to residents for 8 of 13 residents (R2, R3, R7, R8, R10, R11, R12 and R13) reviewed for food temperatures in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to assess and implement appropriate fall intervention for 1 of 3 (R3) residents reviewed for falls in a sample list of 28. This failure resulted in R3 experiencing an unwitnessed fall, sustaining a laceration to his forehead requiring 8 sutures by local hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment for 9 of 14 (R3, R8, R16, R17, R18, R19, R20, R21, R22, R23) residents reviewed for housekeeping on the sample list of 23.

Inspectors wroteBased on interview and record review the facility failed to provide showers twice a week to 2 of 4 residents (R1 and R8) reviewed for bathing in the sample of 11.

Inspectors wroteBased on observation, interview and record review the facility failed to change dressing and provide skin care daily to Gastrostomy (G ) tube for 1 of 3 residents (R2) reviewed for enteral feeding tubes in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to prevent verbal abuse for 1 of 3 residents (R6) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in (R2) sustaining multiple bruises to her face requiring to be evaluated in the emergency room at the local hospital. This past non-compliance occurred on 10/31/2024 through 11/19/2024. R3's Face Sheet dated 11/4/2024, documents she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, schizophrenia, depression and dementia. R3's Minimum Data Set (MDS) dated [DATE], documents she is cognitively impaired with inattention and disorganized thinking. No indicators of psychosis. Behavioral symptoms not directed toward others. R3's Care Plan, dated 10/31/2024 documents focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely and complete incontinence care for 1 of 3 (R4) residents reviewed for improper nursing care. This failure resulted in R4 feeling sad, and unsafe in the facility and experiencing pain to buttocks during incontinent care and obtaining open areas.

Inspectors wroteBased on interview and record review the facility failed to initiate its abuse policy and report and investigate injuries of unknown origin for 1 of 3 (R3) residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to initiate its abuse policy and report injuries of unknown origin for 1 of 3 (R3) residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to initiate its abuse policy and investigate injuries of unknown origin for 1 of 3 (R3) residents reviewed for abuse.

Inspectors wroteBased on interview and Record Review the facility failed to perform cardiopulmonary resuscitation (CPR) for 1 of 1 resident (R7) reviewed for CPR in the sample of 48. This failure resulted in R7 not receiving life saving measures according to her Advanced Directives. The Immediate Jeopardy began on [DATE] when R7 did not received CPR. V1, Adminstrator and V2, Director of Nursing were notified of the Immediate Jeopardy on 05//16/24 at 3:14 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE]. Findings Include: R7 's Minimum Data Set (MDS) dated [DATE] documents R7 has moderately impaired cognitive skills for daily decision making. [...]

Inspectors wroteBased on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 102 residents living in the Facility. Findings Include: The Facility's Staffing List for RN (Registered Nurse), LPN (Licensed Practical Nurse), and CNA (Certified Nurse Aid) hours scheduled was provided from 4/30/24 through 5/13/24. These document the Facility did not have a RN for eight hours on 5/4/24, 5/7/24, 5/8/24, or 5/12/24. On 5/21/24 at 7:20 AM, V1, Administrator, stated she did not have RN coverage on all of those days. She stated the Facility does not have a policy regarding RN staffing, and they just follow the regulations. The Facility's Long-Term Care Facility Application For Medicare And Medicaid dated 5/14/24 documents there are 102 residents living in the Facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure food was stored, prepared, and served in a manner that prevents potential contamination. This has the potential to affect all 102 residents living in the Facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to respond to resident needs in a timely manner, by not responding to call lights, and call light not in working order for 2 of 2 residents (R41, R46) in the sample of 48. Findings Include: R41's Facesheet documents an admission date of 12/19/2023. Diagnosis include Polyneuropathy, Chronic Respiratory Failure with hypoxia, Chronic Obstructive Respiratory Disease, Generalized Muscle Weakness. R41's Minimum Data Set, MDS, dated [DATE] documents R41 has no cognitive deficits. R41's MDS dated [DATE] documents R41 requires partial/moderate assist with showering. R41's Care Plan dated 12/19/2023 documents R41 is at risk for falls. Interventions include anticipate and meet R41's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. [...]

Inspectors wroteBased on interview and record review the facility failed to offer Pneumonia vaccinations for 1 of 5 residents (R42) reviewed for Immunizations in the sample of 48 Findings Include: R42's Minimum Data Set (MDS) dated [DATE] documents R42 is severly impaired for cognitive skills for daily decision making. R42's Electronic Health Record (EHR) Influenza vaccine was given on 10/19/23 and COVID vaccine was given on 12/18/23. R42's EHR did not document a Pneumonia Vaccine. On 5/17/24 V4 Infection Control Preventionist (ICP) stated, They haven't had an IP in a while. I'm focusing on the TB (Tuberculosis) tests, But I will start on vaccinations, I have only been here a month. The facility policy Vaccination of Residents dated October 2019 documents all residents will be offered vaccines that aide in preventing infectious diseases. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a treatment order and have treatments and interventions in place as ordered by the physician to treat pressure ulcers for 2 of 3 residents (R3 and R4) observed for pressure ulcers in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were appropriately in place for 2 out of 4 residents (R2, R7) reviewed for accidents in a sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe transfers for 1 of 3 residents (R2) reviewed for transfers, in the sample of 12. This failure resulted in R2 being transferred incorrectly and resulted in severe bruising on her body covering her right shoulder from the back and underneath side and her entire chest which resulted in her being hospitalized .

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain resident rights and dignity by providing timely care as needed, including answering call lights, for 5 of 10 residents (R1, R3, R5, R9, R10) reviewed for resident rights and dignity in the sample of 10.

Inspectors wroteBased on interview and record review, the Facility failed to notify family/resident representative of significant physical change resulting in hospital transfer for 2 of 3 residents (R2, R3) reviewed for notifications in the sample of 4.

Inspectors wroteBased on interview and record review, the Facility failed to provide the necessary ADL's Activities of Daily Living (ADL's) for 2 of 3 dependent residents (R1, R3) reviewed for bathing in the sample of 4.

Inspectors wroteBased on interview and record review, the Facility failed to monitor residents' vital signs to monitor overall physical/medical condition per physician orders for 2 of 3 residents (R1, R3) reviewed for quality of care in the sample of 4.

Inspectors wroteBased on interview, observation and record review the facility failed to maintain a clean and sanitary environment for 1 (R7) of 16 residents sampled.

Inspectors wroteBased on interview, observation and record review, the facility failed to operationalize their COVID-19 infection control policy and procedures to prevent and/or contain COVID-19, by not wearing appropriate Personal Protective Equipment, (PPE), when providing care to residents with COVID-19 or suspected COVID-19, not appropriately disinfecting shared medical equipment, and not performing adequate hand hygiene while caring for residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was treated with dignity, and had needs met timely for 4 of 4 residents (R35, R51, R54, R77) observed for dignity in a sample of 43. This failure resulted in R77 feeling dirty, nasty and embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, store medication, and discard expired medications. This has the potential to affect all 95 residents living in the facility.

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 and foodborne illnesses. This has the potential to affect all 95 residents living in the Facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to assess, monitor, and provide turning and repositioning for pressure ulcer prevention and treatment for 2 of 6 residents (R17, R85) reviewed for pressure ulcers in the sample of 43. Findings Include: 1. R17's Minimum Data Set (MDS) 1/26/23 documents R17 is at risk for pressure ulcers. R17's MDS also documents R17 requires extensive assist of two for bed mobility. R17's Physician Order Summary (POS) Report dated 1/25/23 documents apply house barrier cream to the buttocks/coccyx as needed for prevention each brief change and or incontinence episode. R17's POS dated 2/23/23 documents R17 has a diagnosis of Mixed Incontinence. [...]

Inspectors wroteBased on interview, record review and observation the facility failed to provide adequate services and range of motion to prevent further weakness for 2 of 3 residents (R30, R51) reviewed for range of motion in the sample of 43. Findings Include: 1. R30's Electronic Health Record Documents R30 has a diagnosis of Cerebral Infarction, Muscle Wasting and Atrophy, and Muscle Weakness. R30's Physician Order Sheet (POS) dated 2/3/22 documents cleanse left hand with soap and water, dry, apply rolled up towel to left hand related to contracture daily and whenever necessary. On 2/23/23 at 1:45 PM, R30 was able to open and close both right and left hands, and no contracture was noted to either hand. R30's Minimum Data Set (MDS) dated [DATE] documents R30 has impairment to upper and lower extremities on one side. R30's MDS also documents R30 requires extensive assist of one person for transfer. [...]

Inspectors wroteBased on observation, interview and record review, the facilty failed to perform complete and thorough incontinent care for 2 of 5 residents (R19, R79) reviewed for incontinent care in the sample of 43.

Inspectors wroteBased on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for 1of 5 residents (R70) reviewed for antibiotic stewardship in the sample of 43.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R11) reviewed for falls in the sample of 49. This failure resulted in R11 falling and sustaining a subdural hematoma requiring hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinent and catheter care in a manner to prevent Urinary Tract Infections (UTI) and discomfort for 5 of 6 residents (R18, R25, R29, R41 and R71) reviewed for Urinary Tract Infections in the sample of 49. This failure resulted in R18, R25, and R71 requiring hospitalizations for treatment of their Urinary Tract Infections.

Inspectors wroteBased on interview, observation and record review, the facility failed to date and store oxygen supplies/equipment appropriately in 4 of 4 residents (R14, R25, R60 and R71) reviewed for oxygen/respiratory therapy in the sample of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene, glove changes and maintain adequate infection control practices to prevent cross contamination while providing incontinent care, catheter care and wound treatments for 6 of 16 residents ((R18, R25, R29, R41, R71 and R275) reviewed for infection control in the sample of 49.

Inspectors wroteBased on interview, and record review the facility failed to develop baseline care plans for 1 of 20 residents (R278) reviewed for baseline care plans in a sample of 49.

Inspectors wroteBased on observation, interview and record review the facility failed to apply pressure ulcer treatments as ordered by the physician and failed to identify, assess and treat a new pressure ulcer for 3 of 3 residents (R18, R25 and R29) reviewed for pressure ulcers in the sample of 49.

Inspectors wroteBased on interview and record review, the facility failed to monitor fluid intake and assess for fluid volume balance per plan of care for 1 of 1 residents (R287) reviewed for dialysis in the sample of 49.

Inspectors wroteBased on record review and interview, the facility failed to obtain and administer intravenous (IV) medication and an anticoagulant as ordered by the physician for 1 of 3 residents (R274) reviewed for significant medication error in the sample of 49.