Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
Based on observation, interview and record review the facility failed to perform and monitor proper catheter
care and monitor a penile wound for 1 of 3 (R3) residents reviewed for catheter care in a sample of 3. This
failure resulted in R3 having a preventable penile injury resulting in a surgical intervention.
Residents Affected - Few
Findings include:
R3's Care Plan, dated 3/11/22, documents R3 is at risk for skin breakdown and/or pressure ulcer formation
d/t (due to) dx (diagnosis) hemiplegia, anemia, multiple sclerosis, muscle weakness, contractures, Vit D
deficiency et (and) DMII (Diabetes). R3 is total care for ADL's (activities of daily living). Incont (incontinent)
of bowel. Has foley catheter. Currently has reddened area to penis - (Barrier) q (every) shift. No open areas
noted. Apply (barrier) protect to reddened area on penis as ordered. Skin checks weekly. 3/16/22
documents (R3) has indwelling 16FR foley catheter r/t (related to) dx neurogenic bladder, hemiplegia et
(and) multiple sclerosis. 6/21/23 (R3) has: Condom/Intermittent/Indwelling/ Suprapubic) Catheter:
CATHETER: Position (R3's) catheter bag and tubing below the level of the bladder and away from entrance
room door. CATHETER: Change R3's catheter per MD (physician) orders, see PO (Physician Order)
sheet/MAR. Empty Catheter bag every shift and prn (as needed). Monitor/document for pain/discomfort due
to catheter. Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no
output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine,
fever, chills, altered mental status, change in behavior, change in eating patterns.
R3's Physician Order Sheet, not dated, documents 4/18/2023 Neosporin Original External Ointment
(Neomycin-Bacitracin-Polymyxin). Apply to penis topically one time a day for tear to meatus cleanse with
wound cleanser apply Neosporin oint (ointment) leave open to air. Discontinued 6/15/2023.
R3's Electronic Health Record was reviewed and no documentation of assessment and monitoring or R3's
meatus tear was found.
R3's Treatment Administration Record (TAR) from April 2023 to June 16, 2023 documents daily catheter
care. Catheter care discontinued 6/15/2023. No further documentation of catheter care in June. July TAR
documents 7/7/2023 Catheter Care Daily and PRN (as needed) every day shift. August TAR documents
blanks on 8/4/2023. September TAR documents blanks 9/1, 9/4, 9/13, 9/18, 9/25, October TAR documents
blanks 10/5, 10/6, 10/23, 10/24, 10/28, 10/30.
R3's Urology Report, dated 8/7/2023, documents R3 has Iatrogenic Hypospadias has developed at the
base of the penis.
(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 3
Event ID:
145585
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
145585
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caseyville Nursing & Rehab Ctr
601 West Lincoln Avenue
Caseyville, IL 62232
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 0684
On 11/14/2023 at 1:10 PM, R3 was lying in bed on back. V4, Certified Nursing Assistant (CNA), completed
peri care. V4 opened the incontinent brief revealing a slit in R3's penis from the tip to the base of the penis.
Level of Harm - Actual harm
Residents Affected - Few
On 11/14/2023 at 1:20 PM V5, Licensed Practical Nurse (LPN), stated she takes care of R3. V5 stated R3
received a new super pubic catheter. V5 stated R3 had problems when the catheter was in the penis. V5
stated when changing the catheter, it was difficult to replace and R3 would bleed from his penis. V5 stated
the tubing was causing a slit to R3's penis. V5 stated they treated the area with Bactroban and open to air
because you can't put a dressing on it. V5 stated when it was time to change the catheter, they could not do
it and there was a lot of bleeding. V5 stated R3 was sent to the hospital for the catheter to be changed. V5
stated after R3 returned from the hospital orders were received for the facility to not change the catheter
and have changed at a urologist. V5 stated they sent R3 to the a (local) urologist. V5 stated the catheter
was not changed due to possible complications. V5 stated R3 was then referred for tests and suprapubic
catheter placement. V5 stated R3 received the suprapubic catheter on 10/10/23.
On 11/15/2023 at 12:40 PM, V4 (CNA), stated she has worked at the facility for a few months. V4 stated
she has taken care of R3. V4 stated R3's penis has been way since she started providing care for R3. V4
stated R3 is a large man and with turning R3 the catheter pulls and causes pressure on the penis.
On 11/15/2023 at 2:35 PM, V15 (CNA), stated it has been a while since she has worked with R3. V15
stated she has not worked with him in about 6 months. V15 stated she remembers the area because it
would leak. V15 stated they thought it was urine but found out by the nurse it was drainage.
On 11/15/2023 at 3:00 PM, V17 (LPN), stated R3 had a catheter in penis. V17 stated R3 was on hospice
and due to this R3 was not sent out to the hospital. V17 stated the catheter continued to pull on the penis
causing it to continue to tear. V17 stated they put ointment on the wound but because R3 was hospice he
was not sent out.
On 11/16/2023 at 9:24 AM, V11 (Hospice Clinical Supervisor), stated R3 was discharged from hospice
services on 1/9/2023. V11 stated R3 did not have a penile wound prior to or upon discharge from services.
V11 stated the family would have been told if the resident went to the hospital. However, residents can't be
on both (on hospice and sent to the hospital). V11 stated the resident would revoke hospice services. V11
stated when a resident is receiving hospice, they are not aggressive with treatment as this can be a sign of
dying. V11 stated if R3 would have had this penile wound, the nurse would have documented it and
followed up on it at visits. V11 stated a penile wound is not documented in the chart. V11 stated a catheter
change on 12/25/23 was documented but nothing about a wound to the penis.
On 11/15/2023 at approximately 3:20 PM, V2 (Director of Nursing), stated she was new to the facility about
2 months ago. V2 stated she was not familiar with R3's care yet. V2 stated she would expect the slit in R3's
penis would be a documented wound. V2 stated she would expect the staff to continue to assess and
monitor the wound. V2 stated she would expect monitoring would be documented in R3's medical record.
On 11/15/2023 at 2:41 PM, V18 (Wound Nurse), stated she is new to the facility. V18 stated the wounds are
to be monitored and documented with measurements and progression of wound weekly. V18 stated she
could not find any wound documentation in the system for R3.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145585
If continuation sheet
Page 2 of 3
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
145585
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caseyville Nursing & Rehab Ctr
601 West Lincoln Avenue
Caseyville, IL 62232
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 0684
Level of Harm - Actual harm
Residents Affected - Few
On 11/16/2023 at 11:00AM, V12 (LPN), stated R3 was a new patient to them with recent suprapubic
catheter. V12 stated R3 presented to them with significant urethral erosion which was caused by the
catheter. V12 stated that type of wound does not occur immediately, but over time. V12 stated the wound
could occur in as short as a couple of months. V12 stated this injury was caused by the catheter. V12 stated
depending on how the catheter was anchored, pulled and pressure of the catheter. V12 stated it is like a
pressure ulcer. V12 stated this area does not reposition or move often and needs the catheter to be moved
when repositioning the patient to relieve the pressure off the penis.
The facility's Skin Ulcer-Wound Policy, dated 10/12/2023, documents Assessment Protocols: 2.
Measurements must be completed weekly by the same licensed person when at all possible. 3. At the time
a skin issue is discovered it must be measured.
The facility's Indwelling Urinary Catheter & Catheter Care, dated 2/6/2023, documents Urinary Catheter
Maintenance: 1. Catheter care: Performed daily by nursing staff, and is part of routine perineal care,
performed after each bowel incontinence, and/or as needed if secretions build around the urinary meatus
after.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145585
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2023 survey of La Bella of Caseyville?
This was a inspection survey of La Bella of Caseyville on November 16, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at La Bella of Caseyville on November 16, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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.