Inspection visit
Health 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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the Facility failed to prevent the reoccurance of a pressure ulcer
for a resident with a history of wounds and risk factors, as well as initiate a timely and appropriate treatment
for 1 of 3 residents (R3) reviewed for pressure ulcers, in the sample of 7.
Residents Affected - Few
Findings include:
On 3/13/2025 at approximately 8:45 AM, V8, Certified Nursing Assistant (CNA) stated R3 has a new open
area, about the size of a dime, to her coccyx (buttocks). At this time, R3 also confirmed she had a wound to
her bottom.
On 3/13/2025 at approximately 10 AM, the facility provided their Resident Matrix. R3 is not listed as having
a pressure ulcer.
R3's Face Sheet dated 3/13/2025 documents R3 has multiple diagnoses include Diabetes Mellitus,
atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the right and
left knees.
R3's Skin Attention Form dated 3/10/2025 documents a Xon the diagram of a body. This form continues to
document, Indicate the area with an 'X' where you notice abnormality or change in color, moisture,
temperature, integrity or turgor and answer the questions. If you are not sure if area is a real problem, mark
it down anyway. The nurse should assess all areas where the CNA had indicated change.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a functional limitation in range of motion
on both sides of her lower extremities as well as R3 is dependent on staff for rolling from left to right and for
transfers from chair/bed to chair.
R3's current Care Plan was requested and documents, (R3) is at risk for development and/or decline in
current pressure ulcers related to decreased mobility and incontinence. The goal includes, She (R3) will
have no new development of pressure ulcers through the next review. It further documents, 3/10/2025re-opened area to coccyx. and 3/13/2025 WCP (Wound Care Plus) to eval and treat as indicated.
On 3/13/2025 at 10:15 AM, V2, Director of Nursing (DON) provided a list titled, Pressure Wound Log. This
document was dated 3/13/2025 and does not include R3 on it. This Wound Log does not include stage,
measurements, or locations of the pressure wounds. At this time, V2 stated currently there is no wound
nurse, so he has assumed the responsiblities of wounds in the absense of the wound nurse position. V2
stated he would look and see if R3's pressure ulcer had been assessed/measured.
(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 4
Event ID:
145581
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
145581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Meadows of Cahokia
2 Annable Court
Cahokia, IL 62206
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/13/2025 at 10:20 AM, V5, Licensed Practical Nurse (LPN) was observed initiating a treatment to R3's
left buttocks. R3 did not have any type of dressing or cream to her buttocks. In the crease of R3's left
buttocks was an approximately 1 cm open area. At this time V5 stated she, Just got the order 'fixed'
because they just put gauze and tape on it but it needed (the special foam gel dressing).
On 3/13/2025 at 11:04 AM, the Pressure Ulcer Log was reviewed with V2. At this time, V2 stated he needed
to add R3 to the list. V2 confimed the open area was first identified on 3/10/2025. V2 stated it was an old
healed area and had opened back up. V2 confirmed treatment was not intiated until 3/13/2025 and should
have been done when it was first reported (3/10/2025).
On 3/13/2025 at 11:24 AM, V16, Registered Nurse (RN) stated when an open area is first identified, she
would do a whole body skin assessment, measure the wound, call the doctor and get a treatment order in
place. V16 stated she would absolutely not just put gauze and tape on the open area.
On 3/13/2025 at 11:58 AM, V2 stated he had just obtained measurements on R3's wound to R3's left
buttock and it measured 0.5 centimeters (cm) by 1 cm.
R3's Physician's Orders dated 3/13/2025 documents, WCP (Wound Care Plus- an outside agency) to eval
(evaluate) and treat as indicated. It further documents an order for a gel formula dressing was ordered on
3/13/2025. It continues, Apply to left buttock topically every 72 hours for open area to left buttock. Cleanse
area with wound spray, apply wound prep around the outside of the wound and apply (dressing). Change Q
(Every) 72 hrs (hours) and prn (as needed).
R3's Progress Notes dated 3/10/2025 at 2:03 PM documents, CNA notified me of a new sore area on the
lower left thigh (back) on resident. Pink and about 1/2 centimeter in length, pink in color, no bleeding noted.
Cleansed with wound cleanser and covered with tape and gauze. Nurse Practitioner notified, will continue
to monitor.
R3's Progress Notes dated 3/13/2025 at 11:26 AM documents, Np (Nurse Practitioner) gave orders to
cleanse area with wound spray, apply skin prep around the outside of wound and (dressing) change Q 72
hrs and prn.
The Facility's Skin-Ulcer-Wound Policy dated 10/12/2023 documents, All caregivers are responsible for
preventing, caring for, and providing treatment for skin ulcerations. It further documents the purpose of the
policy is, To prevent breakdown of tissue or ulcerations and To provide treatment that promotes prevention
of ulcerations and healing of existing ulcerations. It continues to document risk factors as
impaired/decreased mobility, co-morbidities such as diabetes, exposure of skin to urinary or fecal
incontinence and history of a healed ulcer makes pressure ulcers more likely to have recurrent breakdown.
This policy documents all orders must be approved by the physician within 24 hours. It also documents, At
the time a skin issue is discovered it must be measured. Wounds are 3 dimensional, therefore length, width
and depth must be documented if using a measuring instrument.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145581
If continuation sheet
Page 2 of 4
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
145581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Meadows of Cahokia
2 Annable Court
Cahokia, IL 62206
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the Facility failed to perform Range of Motion (ROM) exercises to
a resident with contractures for 1 of 3 residents (R3) reviewed for Restorative Programs/Physical Therapy,
in the sample of 7.
Findings include:
R3's Face Sheet dated 3/13/2025 documents R3 has multiple diagnoses include Diabetes Mellitus,
atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the right and
left knees.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a functional limitation in range of motion
on both sides of her lower extremities as well as R3 is dependent on staff for rolling from left to right and for
transfers from chair/bed to chair.
R3's current Care Plan was requested and documents, (R3) is at risk for pain (joints), stiffness, edema,
redness, decreased ROM, weakness, physical deformity and skin breakdown r/t (related to) diagnosis of
arthritis and BLE (bilateral Lower Extremities) contractures. It further documents to provide ROM exercises
with daily care as tolerated. It continues to document R3 has self care deficit due to weakness and poor
trunk control. It continues to document R3 is at risk for falls, pain and decreased mobility related to bilateral
knee contractures and should be receiving a restorative ROM program.
R3's Current Physician's Orders were requested and do not include an order ROM to be performed.
On 3/13/2025 at approximately 12:10 PM, R3 was observed sitting in a chair, with her bilateral legs bent at
both knees. At this time, V8, Certified Nursing Assistant (CNA) stated R3 does have contractures to both
her legs and there were no interventions in place for them. V8 stated she does not perform any kind of
exercises on R3. At this time, R3 confirmed no one does any exercises on her legs, but she would
participate if they did.
On 3/13/2025 at 12:13 PM, V2, Director of Nursing (DON) stated the Facility is working on starting a
restorative program back up. V2 stated in the meantime, the CNAs assigned to the hall are responsible for
completing ROM exercises. V2 stated R3 does have contractures and should be receiving ROM to stretch it
out. V2 confirmed R3 was not enrolled in any therapy services at the moment. V2 stated the restorative
program is a step below physical therapy. V2 stated the Facility has been without a restorative program for a
month or two. V2 stated any resident with contractures should be receiving ROM exercises.
On 3/13/2025 at 12:39 PM, V1, Administrator, stated the Facility does not currently have a restorative
nurse, but has one starting next week. V1 stated residents with contractures can be referred to therapy
services. V1 stated she will get R3 a referral for therapy services.
On 3/13/2025 at 12:52 PM, V7, CNA coordinator, stated the Facility did have a restorative program with 4
CNAs that would perform ROM, but they have not had it for months. V7 stated the CNAs assigned to the
resident should be performing ROM.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145581
If continuation sheet
Page 3 of 4
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
145581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Meadows of Cahokia
2 Annable Court
Cahokia, IL 62206
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 0688
Level of Harm - Minimal harm
or potential for actual harm
On 3/13/2025 at 1:17 PM, V1, Administrator, stated she called and got R3 an order for therapy services for
positioning and her contractures.
On 3/13/2025 at 2:00 PM, V1, Administrator, stated the Facility does not have a policy for contracture
prevention/ROM.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145581
If continuation sheet
Page 4 of 4
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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.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
FAQ · About this visit
Common questions about this visit
What happened during the March 14, 2025 survey of La Bella of Cahokia?
This was a inspection survey of La Bella of Cahokia on March 14, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at La Bella of Cahokia on March 14, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
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.