Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. 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 - 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 ensure coordination of care with residents'
community-based physician including preventative care to maintain the highest practicable physical
well-being for 1 of 6 residents (R3) reviewed of quality of care in the sample of 6.
Residents Affected - Few
Findings include:
R3's admission Record, not dated, documents R3 was admitted [DATE].
R3's Brief Interview for Mental Status, dated 5/3/2024, documents R3 is cognitively intact.
R3's Progress Note, effective date 6/11/2024 at 12:30 PM, documents created dated 6/14/2024 at 11:57
AM Late Entry: Note Text: Resident was concerned over his Cologuard being sent out and asked what time
the mail ran. I informed him they picked up at around 2pm and he had time to get it ready. He then stated
he did not need to go now, and he would have to wait until Wednesday.
On 6/12/2024 at 9:40 AM R3 stated he was admitted to the facility on [DATE]nd. R3 stated shortly after he
went to his primary physician which is outside of the facility. R3 stated he saw his physician and was
informed he needed a colonoscopy. R3 stated because of his breathing issues his physician did not feel it
was safe to put him under. R3 stated a (non-invasive, at home prescription stool DNA test) was then
ordered. R3 stated when he returned to the facility, he notified the nurse about it. R3 stated he waited for
the stuff to be delivered. R3 stated he asked about it but was told and no one had seen it. R3 stated on
6/7/2024 he was giving his box of supplies. R3 stated the box was delivered on 5/24/2024. R3 stated he
was upset because he had another appointment following Monday and his primary physician wanted the
results. R3 stated he was very upset and voiced this to the nursing staff. R3 stated V4, Unit
Manager/Licensed Practical Nurse, LPN, spoke with him about it. R3 stated V4 came up with a plan for it to
be sent out on Tuesday and but it is still here on Wednesday.
On 6/12/2024 at 9:40 AM a delivery box with stool specimen equipment, dated 4/24/2024 at 5:33 AM,
observed in R3's room.
On 6/12/2024 at 11:24 AM V2, Director of Nursing, stated she was not aware of the box being delivered. V2
stated R3 makes his own appointments and does not communicate with the facility. V2 stated she became
aware of it on Friday 6/7/24. V2 stated R3 is alert and able to do it himself.
On 6/12/2024 at 11:26 AM V3, Assistant Director of Nursing, stated she became aware of the issue on
6/7/2024 and stated she tried to speak with R3. V3 stated R3 was upset. V3 stated the box should have
been delivered when it arrived. V3 stated they are working with R3 to get it done.
(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
06/17/2024
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
On 6/12/2024 at 11:30 AM V5, LPN, stated it was her fault. V5 stated there were some problems with R3's
medication and they were waiting to get them in the mail. V5 stated when the box was sitting back there it
was not the medication, so she didn't think too much of it.
On 6/12/2024 at 11:36 AM V8, Medical Assistant, stated R3 was seen by V7, Physician, on 5/8/2024. V8
stated at that time V7 ordered the Cologuard test to be performed. V8 stated the Cologuard was ordered to
rule out colon and rectal cancer. V8 stated on his visit on 5/8/2024 they were not aware R3 was at a skilled
facility and was not notified by the skilled facility. V8 stated because of this the communication was with R3.
V8 stated they are now aware of R3 residing at a skilled facility. V8 stated they send the order to the
company and the company contacts the facility and/or patient.
On 6/17/2024 at 9:43 AM V11, Licensed Practical Nurse (LPN), stated when a resident returns from a
doctor's appointment they return with paperwork. V11 stated this paperwork is given to the nurse. V11
stated they must verify any new orders or follow up appointments. V11 stated sometimes the residents
come back and don't have paperwork. V11 stated they talk with the resident and family.
On 6/17/2024 at 9:50 AM V10, LPN, stated she works for the facility. V10 stated when a resident goes to
the doctor V6 (Transportation Aide) goes with them. V10 stated paperwork is sent with them. V10 stated the
paperwork is given to the resident if they are alert or V6 if they are not. V10 stated when the resident
returns the nurse is notified and the paperwork is then given to the nurse. V10 stated they must verify there
aren't new orders or follow up appointments. V10 stated the nurse will speak with the resident and the
family if they went along.
On 6/17/2024 at 9:54 AM V9, LPN, stated she is an employee of the facility. V9 stated when a resident goes
to the doctor paperwork is sent with the resident. V9 stated they have a staff member goes with the
residents if needed. V9 stated when the resident returns the paperwork is given to the nurse. V9 stated they
do have residents keep their paperwork. V9 stated if they don't receive any paperwork, they call the office to
make sure there isn't any new orders or follow up appointments. V9 stated if a resident receives a delivery
they first check to see if its medication and then the box is given to the resident.
On 6/17/2024 at 10:14 AM V6, Transportation Aide, stated she took R3 to his doctor's appointment on
5/8/2024. V6 stated R3 had recently admitted to facility and notified her of his appointment. V6 stated she
was able to fit R3 in the schedule and went with him. V6 stated she waited for R3 in the waiting area. V6
stated R3 is alert and did not want V6 to go into the exam with him. V6 stated when R3 returned to the
waiting room she asked if he had any paperwork and R3 stated he didn't. V6 stated when returning to the
facility V6 notified the administrator and the nurse R3 had returned. V6 stated when taking a resident to the
doctor V6 makes copy of paperwork. V6 stated she copies the face sheet with insurance and physician
order sheet. V6 stated usually the resident has a summary that is provided by the office.
On 6/17/2024 at 10:35 AM V12, Receptionist, stated when a resident gets mail or delivery those items are
taken to the nurse's station and given to the nurse. V12 stated those items are not given directly to the
resident.
The Residents' Rights for people in Long-Term Care Facilities, dated 11/18, documents, You have the rights
to choose your own doctor. Your facility must deliver and send your mail promptly.
The facility's Physician Orders for Resident Appointments policy dated 7/6/2023, documents on the
(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
06/17/2024
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 - Minimal harm
or potential for actual harm
day of the scheduled appointment, the resident's nurse will document a progress note when the resident
leaves facility, with any required information, and then a second progress note upon the resident's return to
the facility, with any required information.
Residents Affected - Few
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 June 17, 2024 survey of La Bella of Caseyville?
This was a inspection survey of La Bella of Caseyville on June 17, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at La Bella of Caseyville on June 17, 2024?
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.