La Bella Of Edwardsville

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain safe hot-holding temperatures for food on the steam table and to consistently monitor and document food temperatures as required by facility policy. During a lunch meal service, surveyors observed that the steam table was cool to the touch as food was being placed on it, and an alternate menu item (chili) was placed on the steam table without any temperature being taken. Later in the meal period, the chili showed no visible steam, and review of the Temperature Logbook revealed no documented temperatures for that lunch. After the last resident was served, measured temperatures of several items on the steam table were below the facility’s required hot-holding standard of 140°F, including pureed vegetables at 121.4°F, gravy at 128.0°F, mechanical chicken at 100.5°F, and chili at 118.0°F. The facility’s dietitian stated that staff were expected to take and document temperatures on all items placed on the steam table, acknowledged not being sure of the correct holding temperature until later, and confirmed that the facility policy required hot foods to be held at or above 140°F. Multiple residents were served food from these improperly held items, including residents who received chili and residents on pureed diets. Several residents reported that their food, including chili and other meals, was not hot, describing it as lukewarm, cold, or “hit and miss” in terms of temperature and quality. Grievance forms documented prior complaints from residents about being served cold cheeseburgers, fries, grilled cheese, and tomato soup on previous dates. The facility’s written Food Policy, revised earlier, required staff to check hot foods regularly to ensure they were held at or above 140°F and to maintain recordkeeping through a Final Cooking and Reheating Log and a Food Cold Hot Holding Log for all foods being hot or cold held, which was not followed during the observed meal service.

Penalty

Inspection fine: $72,930

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to assess and implement appropriate fall interventions for a resident identified as high risk for falls. The resident had a history of falls, impaired cognition, impaired safety awareness, balance and walking impairments, and functional impairments of the lower extremities. The care plan and assessments documented the resident's high fall risk and need for frequent monitoring, supervision, and environmental interventions such as keeping the bed in the lowest position and ensuring the call light was within reach. Despite these documented needs, the resident was left unsupervised for a period of time after being placed in bed, during which an unwitnessed fall occurred. On the day of the incident, the resident was noted to be restless and agitated, refusing to remain in either the bed or wheelchair. Staff and family observed the resident's agitation and attempts to get up, and staff discussed the need for increased supervision, including the possibility of a 1:1 sitter. However, staff did not implement a 1:1 intervention at the time, citing the need for management approval. The resident was left alone after staff believed he had calmed down, but shortly thereafter, a nurse heard a noise and found the resident crawling on the floor with a laceration to the forehead, which required sutures at a local hospital. Interviews with staff and family confirmed that the resident was known to be restless, confused, and at high risk for falls, with a pattern of attempting to get out of bed or the wheelchair. Staff acknowledged the resident's unsafe behaviors and the need for close monitoring, but did not maintain continuous supervision or implement additional interventions in response to the resident's escalating behaviors. The facility's fall prevention policy required individualized interventions for high-risk residents, but these were not fully implemented in this case, resulting in the resident sustaining a significant injury from an unwitnessed fall.

Penalty

Inspection fine: $72,930

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate housekeeping services to maintain a clean and sanitary environment for multiple residents. Observations during facility tours revealed numerous rooms with large torn pieces of incontinent briefs, food debris, empty bottles, soiled undergarments, and strong urine odors. Sticky floors, flies present on beds, and used gloves on the floor were also noted. These unsanitary conditions were observed in several resident rooms and hallways, and in some cases, the issues persisted over multiple days without being addressed. Interviews with residents, family members, and staff confirmed that rooms were not being cleaned or mopped daily as required. Residents and their families reported ongoing concerns about dirty and sticky floors, unemptied trash, and persistent odors. Some residents stated that they had to clean their own rooms due to dissatisfaction with housekeeping services. Staff interviews revealed that while there are assigned cleaning duties, not all rooms are cleaned daily, and the housekeeping supervisor acknowledged that staff shortages have prevented consistent cleaning of resident rooms. Review of facility policies and cleaning procedures indicated that daily and deep cleaning tasks are required, including mopping floors, disinfecting surfaces, and removing trash. However, documentation and staff statements confirmed that these procedures were not consistently followed due to staffing issues. Resident council meeting minutes also reflected ongoing concerns about the cleanliness of shower rooms and floors, further supporting the findings of inadequate housekeeping services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide showers twice a week as required for two residents who were unable to perform activities of daily living independently. One resident, who had quadriplegia, dysphagia, speech and language deficits, and bowel incontinence, did not receive a documented shower between 4/14/2025 and 4/23/2025, despite a care plan indicating a need for total assistance with bathing twice weekly. The resident's cognitive impairment further limited their ability to communicate or perform self-care, and there was no documentation of showers during the specified period. Another resident, who required physical help from one staff member for bathing due to an ADL self-care performance deficit, also experienced gaps in shower documentation. This resident did not have a documented shower from 4/4/2025 to 4/15/2025 and again from 4/15/2025 to 4/21/2025. Facility staff reported that a circulation pump failure resulted in a lack of hot water, which affected the ability to provide showers. The facility's policy requires documentation of showers, including reasons for refusal and interventions taken, but the records did not reflect that showers were provided or refused during the affected periods.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a gastrostomy (G) tube did not receive daily dressing changes and skin care as required by their care plan and physician orders. Observation revealed that the G-tube dressing in place was dated four days prior, and this was confirmed by an LPN. The resident's care plan specified daily and as-needed skin care to the insertion site, and the physician order directed that the site be cleansed and a dry split gauze dressing applied every night after midnight. Facility policy also required documentation of the procedure in the resident's medical record, including the date and time. Despite these directives, the required daily care and documentation were not provided for this resident, who required tube feeding due to oropharyngeal dysphagia following a cerebrovascular accident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with multiple chronic conditions, including spinal stenosis, COPD, major depressive disorder, anxiety disorder, congestive heart failure, and chronic kidney disease, was subjected to verbal abuse by a staff member. The resident's medical record and care plan did not include documentation or planning for abuse prevention. The resident, who was cognitively intact with a BIMS score of 14 out of 15 and required assistance with mobility, reported that a staff member yelled at her, was abrasive, and refused her requests to change clothes in the bathroom and to eat breakfast in her room. Another resident corroborated that the staff member had yelled at the resident and rushed her, telling her to hurry up. The staff member in question had previously been involved in another verbal abuse allegation. Interviews with staff and residents revealed ongoing complaints about staff behavior, including being rushed and forced to do things, as well as the manner in which staff spoke to residents. The facility's policy states that residents have the right to be free from all forms of abuse, including verbal abuse, but this was not upheld in this instance. The lack of a care plan addressing abuse and the repeated nature of complaints contributed to the deficiency.

Penalty

Inspection fine: $12,214

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident, identified as R2, from abuse, resulting in multiple bruises to her face that required evaluation in the emergency room. The incident involved another resident, R3, who was cognitively impaired and had a history of psychiatric diagnoses. On the night of the incident, R3 attacked R2, causing significant bruising to R2's face. R3 admitted to hitting R2 because she was getting on her nerves, and this was corroborated by staff observations and R2's non-verbal indications. R2, who was severely cognitively impaired and unable to communicate verbally due to post-stroke conditions, was found with her legs hanging off the bed and bruising on her face. Staff members, including CNAs and LPNs, responded to the altercation after hearing screaming and yelling. They found R3 getting back into bed and R2 with visible injuries. R2 was unable to defend herself due to her physical and cognitive limitations, and she indicated through gestures that R3 had hit her. The facility's records and staff interviews revealed that R3 had no prior aggressive behaviors and had participated in activities earlier that day without any signs of distress. However, the altercation occurred unexpectedly, and R3 was later found to have red and swollen hands. The incident was reported to the facility's administration, and both residents were sent to the hospital for evaluation, with R3 undergoing a psychiatric assessment.

Penalty

Inspection fine: $14,316

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely and complete incontinence care for a resident, identified as R4, who was reviewed for improper nursing care. R4's care plan indicated that she required pericare after each incontinent episode and needed to be checked every 2-3 hours. Despite these instructions, R4 was found in a severely soiled condition, having been left unchanged since the previous evening. This neglect resulted in R4 experiencing pain during incontinence care and developing open areas on her skin. Observations revealed that R4 was lying in bed with a strong foul-smelling odor in the room, and her sheets were wet and soiled with a brown stain. When the CNAs responded to R4's call light, they discovered that R4 was soaked through multiple layers of linen and had a heavily soiled incontinent brief. The CNAs proceeded to clean R4, who expressed pain and discomfort during the process. Multiple deep red and brown creases and open areas were observed on R4's buttocks and thighs, indicating prolonged exposure to moisture and lack of timely care. Interviews with the staff revealed that the CNAs were unaware of R4's condition and had not checked on her as required. The LPN acknowledged the unacceptable condition R4 was found in and stated that the staff should have performed incontinence care after each episode. The facility's Perineal/Incontinent Care Standards and Guidelines emphasized the importance of maintaining cleanliness and comfort to prevent infections and skin irritation, which were not adhered to in R4's case.

Penalty

Inspection fine: $14,316

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate its abuse policy and report and investigate injuries of unknown origin for a resident reviewed for abuse. The resident, who is moderately cognitively impaired, has a history of self-injurious behavior and verbal outbursts. The care plan for the resident includes monitoring for signs of bleeding due to anticoagulant use, and any falls require emergency room visits. Despite this, the facility did not investigate the bruises found on the resident's arms and hands, which were documented in the resident's progress notes and weekly skin integrity review. The facility's staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), acknowledged the presence of bruises but did not conduct an investigation. The DON stated that the bruises were from the resident hitting her arms on the chair, although this was not witnessed, and no investigation was performed. The ADON noted that the bruises appeared to have been present for some time but could not confirm their cause. The facility's policy requires all reports of resident abuse, neglect, or injuries of unknown origin to be thoroughly investigated and reported to appropriate authorities, which was not followed in this case. The facility's failure to investigate the bruises and follow its abuse policy is a significant deficiency. The resident expressed distress and self-harming thoughts, yet the facility did not take the necessary steps to ensure her safety and well-being. The lack of investigation and reporting of the injuries of unknown origin is a violation of the facility's policies and regulatory requirements, highlighting a gap in the facility's response to potential abuse or neglect situations.

Penalty

Inspection fine: $14,316

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate its abuse policy and report injuries of unknown origin for a resident identified as R3. R3's care plan indicated a risk for abnormal bleeding due to anticoagulant therapy, and the resident was noted to have bruising on the arms from self-injurious behavior. Despite these observations, the facility did not conduct an investigation into the bruising, nor did they report the injuries as required by their policy. The facility's policy mandates that all reports of resident abuse, neglect, or injuries of unknown origin be thoroughly investigated and reported to appropriate authorities, which was not adhered to in this case. R3 was documented as being moderately cognitively impaired with behavioral symptoms, including verbal aggression and self-harming tendencies. Progress notes indicated that R3 expressed suicidal ideation and exhibited bruising on the arms, which was attributed to self-harming behavior. However, the facility did not investigate the cause of the bruising, relying instead on assumptions made by staff members without direct evidence or witness accounts. The Director of Nursing (DON) and other staff members acknowledged the resident's behaviors but failed to follow through with the necessary investigative procedures. Interviews with facility staff, including the Administrator, DON, and Assistant Director of Nursing (ADON), revealed inconsistencies in the handling of the situation. The DON admitted that no investigation was conducted regarding the bruising, as they believed the cause was known, despite not witnessing the events. The facility's failure to investigate and report the injuries of unknown origin as per their policy represents a significant deficiency in adhering to regulatory requirements for resident safety and abuse prevention.

Penalty

Inspection fine: $14,316

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate its abuse policy and investigate injuries of unknown origin for a resident who was reviewed for abuse. The resident, who is moderately cognitively impaired, has a history of self-injurious behavior and is on anticoagulant therapy, which increases the risk of abnormal bleeding. The resident's care plan requires monitoring for signs of bleeding and reporting any abnormal symptoms to a physician. Despite this, the facility did not investigate the bruises found on the resident's arms and hands, which were documented in the resident's progress notes and weekly skin integrity review. The facility's staff, including the Administrator and Director of Nursing (DON), acknowledged that the bruises were not investigated. The DON stated that the bruises were attributed to the resident hitting her arms on the wheelchair, but this was not witnessed, and no investigation was conducted to confirm the cause. The Assistant Director of Nursing (ADON) noted that the bruises appeared to have been present for some time but could not confirm their origin. The facility's policy requires all reports of abuse, neglect, or injuries of unknown origin to be thoroughly investigated and reported to the appropriate authorities, which was not followed in this case. The facility's failure to investigate the resident's bruises and follow its abuse policy is a significant deficiency. The resident expressed distress and self-harming thoughts, yet the facility did not take the necessary steps to ensure her safety and well-being. The lack of investigation into the injuries of unknown origin and the failure to report them as required by the facility's policy highlights a gap in the facility's response to potential abuse or neglect situations.

Penalty

Inspection fine: $26,198

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to perform cardiopulmonary resuscitation (CPR) for a resident (R7) who had a full code status according to her Advanced Directives. The resident's POLST form, care plan, and physician order sheet all indicated that CPR should be attempted if her heart stopped or if she stopped breathing. However, when R7 was found unresponsive, the staff did not initiate CPR, resulting in the resident not receiving life-saving measures as per her documented wishes. On the day of the incident, R7 was assessed by a nurse at 3:30 PM and was given medication and a pain pill. The resident was noted to have consumed a cup of Boost and expressed gratitude. Later, at 6:40 PM, a staff member found R7 unresponsive and informed the nurse. The nurse confirmed the resident's death at 6:45 PM but did not perform CPR, despite being CPR certified. The nurse mistakenly believed the resident was on hospice and did not verify the code status before deciding not to initiate CPR. Interviews with various staff members revealed a lack of awareness and understanding of the resident's code status. Some staff members were unsure where to find the code status information, while others incorrectly assumed the resident was on hospice. The facility's policies on CPR and change in condition were not followed, leading to the failure to provide the necessary life-saving measures for R7.

Removal Plan

• Polst Form, Resident orders, and Resident care plans audited by Social Services Director for accuracy.
• All nurses in-serviced by the Administrator, LNHA, DON, RN or ADON on the facilities Code Status Policy and Procedures, where to find code status for each resident in the Medical Record in Point Click Care and in the Code Status Book in alphabetical order located on each RED crash cart.
• All CNAs in-serviced by the Administrator, LNHA, DON, RN or ADON on the facilities Code Status Policy and Procedures, where to find code status for each resident in the medical record in Point Click Care and in the Code Status Book in alphabetical order located on each RED crash cart.
• Audit all HR employee files for staff who have provided current CPR cards completed by HR Director.
• Identify on working schedule all current CPR card holders by DON or Staffing Coordinator.
• Continue to collect CPR cards as they become available by HR Director and communicate with DON and Staffing Coordinator daily when new ones become available.
• In-service Admissions Coordinator no one to be admitted to the facility without a confirmed code status.
• Daily QA Audits on Code Status vs POLST vs Orders by Administrator, LNHA or DON.
• Next scheduled CPR classes are scheduled at 9am and 2pm with future dates as they become available by LPN certified by local ambulance company.
• CPR Policy reviewed and revised by Administrator and approved by Medical Director.
• CPR Policy and Procedure laminated and attached to both RED Crash Carts located at each nurses station.
• The Administrator or DON will conduct a weekly audit/chart review of four residents per week times four weeks and then every two weeks for two months to ensure compliance.
• DON or ADON will conduct mock codes weekly per shift for 4 weeks, mode codes for each shift every other week for 2 weeks and monthly for 3 additional months to assure compliance and understanding of Policies and Procedures.
• Audits will be reviewed in the next QA/Risk management meeting.

Penalty

Inspection fine: $26,198

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily, which has the potential to affect all 102 residents living in the Facility. The Facility's staffing list for RN, LPN, and CNA hours scheduled from 4/30/24 through 5/13/24 documented that the Facility did not have an 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, the Administrator stated that there was no RN coverage on all of those days and that the Facility does not have a policy regarding RN staffing, instead, they just follow the regulations. The Facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/14/24 documented that there are 102 residents living in the Facility.

Penalty

Inspection fine: $26,198

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Facility failed to ensure food was stored, prepared, and served in a manner that prevents potential contamination. Observations included undated and unlabeled plastic containers of dry corn cereal, dry rice cereal, and a brown granular substance on the food preparation counter. Additionally, a stack of plates with dried crusted food particles was found next to the microwave. In the walk-in refrigerator, there were uncovered, unlabeled, and undated slices of meat, an opened box of dinner rolls with the plastic inside not resealed, and a large plastic container with an orange liquid substance that was not dated or labeled. Six trays full of cups with various colored liquids were not individually wrapped and were covered with additional meal trays, and a pan with ground meat covered in plastic wrap had no legible date or label. The standing freezer contained six plastic bags of frozen French fries that were not dated upon delivery or removal from the original box, and opened boxes of sugar cookies, dinner rolls, and biscuit dough with the plastic inside not resealed and not dated upon opening. The dishwasher's sanitizer level was tested and found to be at 0 ppm, indicating a lack of proper cleaning solution, and several cups and trays were observed to be dirty even after being run through the dish machine. The Dietary Manager acknowledged issues with the dish machine and stated that the repair company was scheduled to service it later that day. The Facility's policies on food storage and ware washing were not followed, as evidenced by the improper labeling, dating, and storage of food items, as well as the inadequate cleaning and sanitizing of dishware. The Dietary Manager and staff were aware of the issues but did not take immediate corrective actions to ensure compliance with professional standards. The Administrator stated that she expects staff to follow all food service policies, but the observations and interviews indicated a failure to adhere to these policies, potentially affecting all 102 residents living in the Facility.

Penalty

Inspection fine: $26,198

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to respond to resident needs in a timely manner by not responding to call lights and having a call light that was not in working order for two residents. Resident R41, who has diagnoses including Polyneuropathy, Chronic Respiratory Failure with hypoxia, and Generalized Muscle Weakness, reported that the call lights take a long time to answer, especially during the evening shift. R41's call light was found to be non-functional, and the resident was given a bell to use, which staff could not hear. R41's roommate confirmed that the call light had not been working for a long time. The maintenance worker was unaware of the issue, despite the system being recently down. Resident R46, who has diagnoses including Sacrolitis, Muscle Weakness, and Heart Failure, also reported long wait times for call lights to be answered, particularly during the evening shift. R46 mentioned that CNAs leave to get fast food and dismiss concerns about ringing call lights. A CNA confirmed that evening and night shifts have longer wait times for call lights to be answered. Resident Council records also documented concerns about call lights not being answered. The facility's policy states that each resident should have a working call light at their bedside, toilet, and bathing facility to call for assistance. The administrator acknowledged that all call lights should be working and answered, and mentioned that a technician had recently serviced the system. However, the issues with the call lights persisted, leading to the deficiency in responding to resident needs in a timely manner.

Penalty

Inspection fine: $26,198

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to offer a Pneumonia vaccination to one of the five residents reviewed for immunizations. The resident, who is severely impaired for cognitive skills for daily decision-making, had received an Influenza vaccine and a COVID vaccine, but there was no documentation of a Pneumonia vaccine in the resident's Electronic Health Record (EHR). The Infection Control Preventionist (ICP) acknowledged the oversight, stating that they had been focusing on Tuberculosis tests and had only been in the position for a month. The facility's policy from October 2019 mandates that all residents be offered vaccines to prevent infectious diseases unless medically contraindicated or already vaccinated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain a treatment order and implement treatments and interventions as ordered by the physician for two residents with pressure ulcers. One resident (R3) was observed lying on a low air loss mattress that was unplugged, and the dressing on his stage 4 sacral pressure ulcer was loosely covering the wound, which had yellow slough and yellowish-green drainage. The facility did not have a physician's order for the pressure ulcer treatment from 2/13/24 to 2/16/24, and the treatment was not started until 2/17/24, three days after the resident's readmission. The wound nurse and wound physician confirmed the mattress should have been alarming if unplugged and that the nurse should have obtained a treatment order upon readmission if none were provided by the hospital. Another resident (R4) was found without a dressing on her stage 4 sacral pressure ulcer, and her adult brief had stool on it. The wound nurse was unaware of how long the dressing had been off. The resident's care plan included interventions such as reporting changes in skin status, wound care as ordered by the physician, and positioning with pillows, but these were not adequately followed. The facility's policies on the identification and treatment of pressure ulcers emphasize the importance of timely assessment and treatment according to physician orders, which were not adhered to in these cases. The facility's failure to follow its own policies and physician orders for pressure ulcer care resulted in inadequate treatment and monitoring of the residents' pressure ulcers. This deficiency highlights the need for consistent adherence to care plans and timely communication with physicians to ensure appropriate wound care management for residents with pressure ulcers.