Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Memorial Care Center during CMS and state inspections, most recent first.
The facility failed to consistently implement Enhanced Barrier Precautions (EBP), appropriate PPE use, and hand hygiene for multiple residents with PICC lines, G-tubes, drains, and acute respiratory or febrile illnesses. Several residents with indwelling devices had EBP care plan or physician orders but lacked EBP signage, readily available PPE, or staff use of gowns and gloves during high-contact care. A resident on EBP for spinal infection was cohorted with a new roommate who had fever and cough, while staff were observed entering and exiting without PPE despite contact and droplet precautions being indicated. Another resident with respiratory failure, oxygen, IV fluids, and productive cough received hands-on respiratory care without any PPE and without isolation signage or PPE at the door, even after orders for contact and droplet isolation. Additionally, an RN and an LPN administered IV and other medications via PICC and to another resident without performing hand hygiene before donning gloves, contrary to the facility’s infection control policy.
A resident with a g-tube, malnutrition, dysphagia, and post-cardiac surgery status had physician orders and a care plan for Osmolite 1.5 bolus feedings and scheduled water flushes, as well as EBP due to MDRO risk. During observation, an LPN stopped the tube feeding, disconnected the line, and plugged the g-tube without flushing it afterward, despite facility leadership stating that g-tubes should be flushed with at least 30 mL of water after bolus feedings. The feeding bottle in use was labeled only with the date and formula name, lacking the resident’s name, time hung, and rate of infusion, contrary to facility policy and staff descriptions of required labeling. No PPE was available at the room entrance and the LPN did not don gown, gloves, or mask while providing g-tube care, despite an active EBP order and staff statements that residents with g-tubes should be managed under EBP.
The facility failed to administer medications as prescribed for two residents. One resident did not receive prescribed topical treatments and Metformin due to unavailability, while another missed a dose of Alprazolam for anxiety. The facility's emergency backup system lacked certain medications, and staff did not follow the protocol to notify supervisors or providers for alternatives.
Failure to Implement Enhanced Barrier Precautions, PPE Use, and Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to properly implement its infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), use of PPE, and hand hygiene. Multiple residents with indwelling devices or acute infectious symptoms were not consistently identified for EBP or isolation, and required signage and PPE were often missing or not used. For one cognitively intact resident with a PICC line receiving daily IV antibiotics for a left foot wound, there was no EBP sign or PPE outside the room, and the physician orders only listed Standard Precautions, despite the care plan documenting EBP due to high MDRO risk and requiring staff to wear gown and gloves during high-contact care. Another resident with osteomyelitis of the vertebra, a PICC line, and a JP drain had physician orders for EBP related to MDRO risk and was receiving IV and oral antibiotics for a spinal abscess. An EBP sign and PPE cart were present, and the resident reported staff usually wore masks and gloves but did not don gowns when providing care. This resident was later placed in a shared room with a newly admitted roommate who had a frequent cough and, by physician note, a fever of 101.1°F, lethargy, and new cough without sputum production. The roommate’s door had EBP signage and a PPE cart, and the infection preventionist stated the roommate was being placed on both contact and droplet isolation for an unknown illness per policy, but staff were observed entering and exiting the room without PPE. A cognitively intact resident with multiple chronic conditions, including chronic respiratory failure and dependence on supplemental O2, was observed on oxygen and later with IV fluids running wide open, a portable suction unit at bedside, and coughing up sputum. The respiratory therapist assisted with sputum without any PPE, and there was no EBP or isolation signage or PPE outside the room, even though nursing staff reported the resident had become lethargic, developed a fever, and was coughing up brown sputum, with COVID testing negative and further tests pending. A subsequent physician order documented contact and droplet isolation for fever of unknown origin, but at the time of observations there was still no signage or PPE available. Another cognitively intact resident with a G-tube had a physician order for EBP due to MDRO risk related to the G-tube. During observation, an LPN turned off the tube feeding, disconnected the feeding line from the G-tube, and plugged the tube without donning any PPE, and there was no PPE at the room entrance. Staff interviews, including the infection preventionist, LPNs, and the DON, confirmed that residents with G-tubes, PICC lines, drains, or other indwelling devices should be on EBP, with staff wearing gown and gloves (and mask as indicated), and that residents with fever and cough should be placed on contact and droplet precautions with appropriate signage and PPE. The deficiency also includes failures in hand hygiene during medication administration. One resident with a PICC line receiving IV daptomycin via the PICC was observed when an RN entered the room and administered the IV medication without performing hand hygiene before donning gloves. In another case, an LPN administered medications to a different resident without completing hand hygiene prior to gloving after entering the room. These practices were inconsistent with the facility’s Infection Control – Standard and Transmission-Based Precautions policy, which states that hand hygiene is the single most effective means of preventing infections and must be performed before passing medications and when each resident’s care is completed, and with the facility’s EBP policy requiring clear signage and readily available PPE for residents on EBP.
Failure to Flush G-Tube, Label Tube Feeding, and Follow EBP for G-Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for gastrostomy tube (g-tube) management, including flushing after bolus feedings, proper labeling of tube feeding, and adherence to Enhanced Barrier Precautions (EBP). A cognitively intact resident, dependent on staff for feeding and admitted with diagnoses including gastrostomy status, malnutrition, dysphagia, and post-coronary artery bypass graft status, had physician orders for Osmolite 1.5 tube feeding 350 mL four times daily and water bolus flushes of 115 mL every six hours. The resident’s care plan documented increased tube feeding volume due to weight loss. During observation, an LPN turned off the resident’s tube feeding, disconnected the feeding line from the g-tube, and plugged the tube without flushing it afterward, stating the resident had already been flushed earlier and would be flushed later, despite the expectation from the DON and Administrator that a g-tube should be flushed with at least 30 mL of water after a bolus feeding. The same observation showed the tube feeding bottle labeled only with the date and the word “Osmolite,” with no time hung or rate of infusion, contrary to facility policy requiring the resident’s name, formula, rate, and date/time on the bottle, and staff interviews confirming that practice. The bottle was dated the previous day with no indication of when it was started. Additionally, the resident had a physician order for EBP due to MDRO risk related to the g-tube, but there was no PPE at the room entrance and the LPN did not don PPE while providing g-tube care. Other LPNs interviewed stated that they always flush g-tubes before and after feedings, that feeding bottles should be fully labeled with name, date, time, and rate, and that residents with g-tubes or PICC lines should be on EBP with staff wearing gown, gloves, and mask, underscoring that the observed care did not follow the facility’s established practices and policies.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to physician's orders for two residents. One resident, diagnosed with diabetes, had orders for Tacrolimus and Clobetasol topical treatments for a rash, and Metformin for diabetes. These medications were not administered as prescribed over several days, with documentation indicating they were not available from the pharmacy. The resident's wife confirmed that she did not bring any medications to the facility, and staff did not request them. The Director of Nurses explained that the facility's emergency backup system does not include certain medications, and staff documented the medications as not given due to unavailability. Another resident had a physician's order for Alprazolam for anxiety, which was not administered as prescribed on one occasion. The Director of Nurses stated that when medications are not available, staff should notify the nursing supervisor and the resident's provider to seek an alternative. However, documentation of communication with the telehealth provider was incomplete, lacking resident identification. The facility's medication administration policy requires staff to contact the nursing supervisor if medications are unavailable, but this protocol was not followed, leading to the deficiency.
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| Bria Of Belleville | 1.7 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.