Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review, the facility failed to flush a gastric-tube (g-tube) after giving a
feeding bolus and properly label the bottle of tube feeding when hung for 1 of 1 resident (R67) reviewed for
proper g-tube management in the sample of 34.The findings include:R67's Face Sheet, undated,
documents R67 was admitted to the facility on [DATE] with diagnosis of Gastrostomy status, malnutrition,
dysphagia oropharyngeal and pharyngoesophageal phase, and status post-surgery on the circulatory
system - Coronary Artery Bypass Graft. R67 was discharged on the evening of 3/2/26. R67's Minimum
Data Set (MDS), dated [DATE], documents R67 is cognitively intact and is dependent on staff for feeding.
R67's Care Plan, dated 2/16/26, documents R67 is on tube feeding post open-heart surgery. Interventions:
Osmolite 1.5, 275 ML (milliliters) 4 times a day, 115 ML water flushes 4 times per day. 2/26/26: given my
weight drop from 125 lbs (pounds) before hospital stay down to 116.8 lbs on 2/25, my tube feeding amount
will be increased from 325 ML of Osmolite 1.5 4/day to 350 ML of Osmolite 1.5 4/day. R67's Physician
Order, dated 2/13/26, documents Tube feeding water bolus 115 ML Q (every) 6hr (hours).R67's Physician
Order, dated 2/13/26, documents Patient Isolation: Enhanced Barrier Precaution (EBP). Risk for MDRO
(Multidrug-Resistant Organisms) r/t (related to) G-tube.R67's Physician Order, dated 2/26/26, documents
My Dining Tube Feeding. Osmolite 1.5 Cal (calorie) 350 ML QID (4 times day).On 3/2/26 at 9:55 AM, R67
was seen lying in bed with V19, Licensed Practical Nurse (LPN), observed turning off R67's tube feeding,
disconnected the feeding line from his g-tube, and then plugging the tube. V19 stated R67 gets 350 ML
bolus feeding and then it gets turned off. When asked about flushing R67's g-tube after disconnecting the
feeding, V19 stated that R67 gets flushed four times a day and she had already done it this morning so she
will do later. R67's tube feeding bottle is dated 3/1/26 with no time indicated when it was hung or started.
The bottle had Osmolite written on the bottle with no rate of infusion. There was no PPE (Personal
Protective Equipment) seen at the entrance to the room and V19 did not don PPE prior to taking care of
R67's G-Tube. On 3/5/26 at 10:00 AM, V22, LPN, stated if she is giving a feeding through the g-tube, she
always flushes it after the feeding. V22 stated the feeding bottle should have the date and time it was hung
or started along with the rate. V22 stated if any resident has a g-tube or PICC line, they should be on EBP
and staff should be wearing a gown, gloves, and a mask when caring for that resident. On 3/5/26 at 10:06
AM, V11, LPN, stated she always flushes a g-tube before and after giving a feeding. V11 stated the bottle of
g-tube feeding should have the resident's name, date and time it was started and the rate of infusion. V11
stated if anyone has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown,
gloves, and a mask to care for that resident. On 3/3/26, at 3:35 PM, V2, Director of Nursing (DON), stated if
giving a bolus of feeding, you should flush the tube with 30 ML of water afterwards. V2 stated she would
expect the staff to be following the policies on EBP and tube feedings via g-tube.On 3/3/26 at 3:36 PM, V1,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
145102
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Administrator, stated after giving a resident a feeding through the g-tube, they should be flushed with at
least 30 ML of water.The Facility's Tube Feeding and Pump Operation/Kangaroo E-Pump Policy, dated
9/2024, documents in part Purpose: To provide guidelines for proper enteral nutrition and the use of the
Kangaroo E-Pump to provide optional fluid and nutrition. 1. Obtain physician's order, per dietician's
recommendation, which includes tube feeding formula and the TOTAL volume needed to assure caloric
needs are met. Order should also include the rate and flush volume/frequency. If tube feeding is to be off for
certain activities, order must specify such. 14. Be sure tube feeding bottle/tubing are dated and initialed.
Tube feeding bottle/bag must be labeled with the resident's name, formula and rate of instillation. Hang time
for closed system is 48 hours.
Event ID:
Facility ID:
145102
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review, the facility failed to properly identify residents requiring Enhanced
Barrier Precautions (EBP), to utilize Personal Protective Equipment (PPE) when required, and to provide
hand hygiene during medication administration for 7 of 16 residents (R6, R11, R57, R67, R94, R99, R125)
reviewed for infection control in the sample of 34.The findings include:1. R6's Face Sheet, undated,
documents R6 was admitted to the facility on [DATE] with diagnosis of Osteomyelitis, Type 2 Diabetes
Mellitus (DM) with foot ulcer, hypertension (HTN), panic disorder, and asthma.
Residents Affected - Some
R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact.
On 3/2/26 at 10:53 AM, R6 was observed in his room and stated that he has a peripherally inserted central
catheter (PICC) line in his arm because he gets daily antibiotics for a wound to the ball of his left foot. There
is no EBP sign posted on the door and there is no PPE outside his door.
R6's Physician Order, dated 2/7/26, documents Standard Precautions and did not have an order for
Enhanced Barrier Precautions.
R6's Care Plan, undated, documents R6 is on Enhanced Barrier Precautions due to high risk of MDRO
(Multidrug-Resistant Organisms) related to PICC line placement. Intervention: Staff to wear Gown and
Gloves during high contact resident care activities.
2. R99's Face Sheet, undated, documents R99 was admitted to the facility on [DATE] with diagnosis of
Osteomyelitis of vertebra. R99 has a PICC line in her right upper arm and a Jackson Pratt (JP) drain
coming out of her back.
R99's MDS, dated [DATE], documents R99 has a moderate cognitive impairment.
R99's Physician Order, dated 2/16/26, documents Enhanced Barrier Precaution. Risk for MDRO r/t (related
to) PICC.
R99's Physician Order, dated 2/15/26, documents R99 is on Cefepime 2 G (grams) IV (intravenous) Q
(every) 12hr (hours) for spinal abscess.
R99's Physician Order, dated 2/17/26, documents R99 is on Metronidazole 500 MG (milligram) PO (oral)
BID (twice daily) for spinal abscess.
On 3/2/26 at 10:26 AM, R99 has an EBP sign posted on her door and a PPE cart outside the door. R99
stated she's on antibiotics due to an infection in her bones/spine. R99 stated the staff does wear a mask at
times and usually gloves, but they don't put on a gown when caring for her.
On 3/3/26 at 8:32 AM, R99 stated she now has a roommate (R94) who was just admitted and (R94) has a
fever and cough. R99 stated she hopes that R94 doesn't have COVID or something bad because she
already has an infection and doesn't want to be exposed. R99 has her central line (PICC) and is exposed to
R94's illness.
3. R94's Face Sheet, undated, documents R94 was admitted to the facility on [DATE] with diagnosis of left
hip fracture with left artificial hip joint and at the facility for aftercare following joint
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145102
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
replacement surgery.
Level of Harm - Minimal harm
or potential for actual harm
R94's MDS has not been done yet, however, her Basic Interview for Mental Status (BIMS) was scored as a
12, indicating that R94 has a moderate cognitive impairment. A BIMS score of 0-7 indicates a severe
cognitive impact, 8-12 indicates a moderate cognitive impairment, and 13-15 indicates an intact cognitive
response.
Residents Affected - Some
On 3/3/26 at 8:35 AM, R94 was observed lying in bed with a frequent cough noted. There is a sign posted
on the door for EBP and PPE cart outside the door. Staff was observed going in and out of the room with
no PPE on.
On 3/3/26 at 10:40 AM, R94 and R99 still has a sign posted on their door for EBP and PPE available
outside her room.
R94's Progress Note Physician, dated 3/3/26 at 11:29 AM, documents in part Fever, unspecified fever
cause (primary), assessment/plan: Viral panel ordered, check UA (urinalysis), CXR (chest x-ray), blood
cultures. No leukocytosis, Encouraged IS (incentive spirometer), Will give prophylactic Tamiflu. Was asked
to see the patient this am due to development of fever. Patient is lying flat in bed, is lethargic but arousable,
reports developing a cough overnight without sputum production and significant weakness. Temp 101.1.
On 3/3/26 at 10:50 AM, V4, Licensed Practical Nurse (LPN)/Infection Preventionist, stated that R94
(sharing room with R99) does have a cough and fever and they did a COVID test which was negative and
other test, such as influenza, which is still pending. V4 stated she is putting R94 on both contact and droplet
isolation because that is what their policy says to do when there is an unknown illness with symptoms.
4. R125's Face Sheet, undated, documents R125 was admitted to the facility on [DATE], with diagnosis of
Osteoarthritis, dependence on supplemental oxygen (O2), chronic respiratory failure with hypoxia, chronic
obstructive pulmonary disease, congestive heart failure, chronic respiratory failure, urinary tract infection,
atrial fibrillation, abdominal aortic aneurysm.
R125's MDS was not fully completed, however, R125's BIMS score was a 15 indicating that R125 was
cognitively intact.
On 3/2/26 at 10:37 AM, R125 was observed in his room on O2 at 4 L (liters) per NC (nasal cannula). There
was no signage posted on his door for isolation or EBP and no visible PPE outside his door.
On 3/3/26 at 8:45 AM, R125 was observed lying in bed with IV fluid of Normal Saline (NS) running
wide-open. R125 is on Oxygen at 4 L/NC and a portable suction unit now at his bedside. R125 was seen
coughing up sputum. V21, Respiratory Therapist (RT) was at R125's bedside assisting R125 with his
sputum. V21 did not have any PPE on while caring for R125.
On 3/3/26 at 8:53 AM, V11, LPN, stated that R125 became lethargic last evening, and they thought it was
his pain medication, so they stopped his pain med and gave him Narcan but that did not work, and now he
is running a fever and coughing up a lot of brown sputum. V11 stated they tested R125 for COVID and was
negative and are waiting on further testing. There is still no EBP or isolation sign posted on R125's door
and no PPE available outside his door.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145102
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R125's Progress Note, Physician, dated 3/3/26 at 10:55 AM, documents (R125): SIRS (systemic
inflammatory response syndrome) - fever, hypotension, leukocytosis, etiology unclear. Blood culture, CXR,
urine culture, viral swab ordered. Start IVF (IV Fluids), Cefepime, Vancomycin. Check MRSA
(methicillin-resistant Staphylococcus aureus) swab - if negative could consider stopping vancomycin.
Updated son over the phone - confirmed DNR (do not resuscitate). Family requests to keep pt at (facility)
and comfortable if he has a clinical decline. (R125): Osteoarthritis of spine with radiculopathy, lumbar
region. S/p (status post) multilevel injections. Oxycontin held, Narcan given due to lethargy. Continue PRN
(as needed) Oxycodone. (R125): Acute Kidney Injury.
R125's Physician Order, dated 3/3/26, documents Patient Isolation. Contact and Droplet Precautions.
Unknown origin related to Fever.
5. R67's Face Sheet, undated, documents R67 was admitted to the facility on [DATE] with diagnosis of
Gastrostomy status, malnutrition, dysphagia oropharyngeal and pharyngoesophageal phase, and status
post-surgery on the circulatory system - Coronary Artery Bypass Graft. R67 was discharged on the evening
of 3/2/26.
R67's Minimum Data Set (MDS), dated [DATE], documents R67 is cognitively intact.
R67's Physician Order, dated 2/13/26, documents Patient Isolation: Enhanced Barrier Precaution. Risk for
MDRO (Multidrug-Resistant Organisms) r/t (related to) G-tube.
On 3/2/26 at 9:55 AM, R67 was seen lying in bed with V19, LPN, observed turning off R67's tube feeding,
disconnected the feeding line from his g-tube, and then plugging the tube. There was no PPE seen at the
entrance to the room and V19 did not don PPE prior to taking care of R67's G-Tube.
On 3/3/26 at 10:45 AM, V4 stated EBP precautions or for any resident with a line going into or out of their
body and for those with a urine catheter, or any drains, or a PICC line/Central line. V4 stated EBP should be
done by any staff member doing direct resident care. V4 stated there should be signs posted with PPE
available. V4 stated Contact Isolation is for residents who have Clostridioides difficile (c-diff), bed bugs, or
any highly contagious illness. V4 stated if a resident is having a fever, cough, and congestion, they should
be put on both contact and droplet isolation with signs for both, especially if the illness is unknown.
On 3/5/26 at 10:00 AM, V22, LPN, stated if any resident has a g-tube or PICC line, they should be on EBP
and staff should be wearing a gown, gloves, and a mask when caring for that resident. V22 stated when
she is passing medications, she always does hand hygiene between each resident. V22 stated if a resident
develops a sudden fever and cough, she will follow policy, and that resident would be put on EBP.
On 3/5/26 at 10:06 AM, V11, LPN, stated if anyone has a g-tube or PICC line, they should be on EBP and
staff should be wearing a gown, gloves, and a mask to care for that resident. V11 stated hand hygiene
should be done between residents when passing meds - Gel-In/Gel-Out. V11 stated if a resident is having a
cough and fever, they should automatically be put on EBP until we know what is going on.
On 3/5/26 at 11:05 AM, V2, Director of Nursing (DON), stated she would expect the staff to be following the
policies on EBP, tube feedings via g-tube, and hand hygiene when passing medications.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145102
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
The Facility's Infection Control - Standard and Transmission-Based Precautions Policy, dated 2/2024,
documents in part It is the policy of (facility) residences to utilize Standard and Transmission-Based
Precautions to reduce the potential for infections and disease transmission. Hand Hygiene remains the
single most effective means of preventing infections and controlling disease transmission. Wash hands
before passing medications or performing treatments and when each resident's care is completed.
Transmission-Based Precautions are always used in addition to Standard Precautions. Infection risks will be
balanced with the need for more than one occupant in a room. Considerations include but are not limited to:
Cohorting residents with the same pathogen, the presence of risk factors that increase the likelihood of
transmission (i.e., indwelling devices; pressure injuries or open wounds; immunocompromised. Information
regarding the precaution to be utilized will be communicated through verbal reports, written in-house
communication forms, and signage. Signage is to be placed in a conspicuous place outside the resident's
room with precaution instructions. Appropriate PPE shall be readily available near the entrance to the
resident's room.
The Facility's Infection Control - Enhanced Barrier Precautions Policy, dated 2/2024, documents in part It is
the policy of (facility) to implement enhanced barrier precautions to prevent transmission of novel or
targeted multidrug=resistant organisms as defined by CDC to residents, staff, volunteers, visitors or any
other individuals providing services under a contractual agreement. Enhanced barrier precautions refer to
the use of gown and gloves for use during high-contact resident care activities for residents known to be
colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents
with wounds or indwelling medical devices). Clear signage will be posted outside of the resident's room
indicating the type of precautions, required PPE, and the high-contact resident care activities that require
the use of gown and gloves. Nursing staff may place residents with certain conditions or devices on
enhanced barrier precautions empirically while awaiting physician orders. Make gowns and gloves available
immediately outside of the resident's room. Face protection may also be needed if performing activity with
risk of splash or spray.
6.R11's Facesheet documented she was admitted to the facility on [DATE].
On 3/3/26 at 8:01 AM, V10 registered nurse (RN) administered R11 her IV (intravenous) daptomycin 400
mg (milligram) via PICC (peripherally inserted central catheter) line to her RUA (Right Upper Arm) without
completing hand hygiene prior to gloving up after entering her room.
7.R57's Facesheet documented she was admitted to the facility on [DATE].
On 3/3/26 at 8:22 AM, V13 licensed practical nurse (LPN) administered R57 without completing hand
hygiene prior to gloving up after entering her room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145102
If continuation sheet
Page 6 of 6
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
FAQ · About this visit
Common questions about this visit
What happened during the March 5, 2026 survey of MEMORIAL CARE CENTER?
This was a inspection survey of MEMORIAL CARE CENTER on March 5, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MEMORIAL CARE CENTER on March 5, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.