Health inspection·January 15, 2025

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 interview and record review, the facility failed to follow physician's hospital discharge order and apply a wound vac and coordinate care for an abdominal wound for 1 (R2) of 4 residents reviewed for quality of care/treatment in the sample of 4. Residents Affected - Few Findings include: R2's Face Sheet documents he was initially admitted to the facility on [DATE] post recent abdominal surgery, multiple ostomies and lower bowel ishchemia. R2's Hospital Discharge Paperwork, dated 12/4/2024 documents R2 is to have a wound vac to abdominal wound to be restarted on 12/4/2024. R2's Health Status Note, dated 12/5/2024 at 12:11 AM, documents wound vac ordered. R2's Nurtritional Progress Note, dated 12/5/2024 at 2:21 PM, documents open surgical abdominal wound has order for wound vac. R2's Physician's Order Sheet (POS) dated 12/2024 documents a physician's order for 12/5/2024 External Debridement Ointment apply to abdomen topically two times a day for dressing change cleanse wound with wound cleanser apply santyl to base of wound gently pack with Dakins moistened kerlex cover with ABD (abdomen) pad and midipore tape change BID (twice a day) and PRN (as needed) use this order if wound vac is off. R2's Medication Administration Record (MAR) dated 12/5/2024 through 12/12/2024 staff documented the above physician's treatment order was administered to R2's abdominal wound. R2's POS, dated 12/11/2024 documents a physician's order cut white foam to fill wound bed cut black foam to fit over white foam and apply - abdomen, check wound vac for proper functioning. Setting maintain at 125 mmHg, change wound vac dressing 3 times per week and PRN (when necessary) or malfunction and change wound vac canister weekly and PRN filling. R2's Treatement Adminstration Record dated 12/12/2024 staff documented the wound vac was applied and started per physicians orders dated 12/11/2024. On 1/14/2025 at 1:45 PM, V16 Wound Nurse, LPN stated when R2 was initially admitted to the facility she read on his hospital discharge paperwork that he was to have a wound vac on his abdominal wound but she spoke with V15, Wound Care Specialist and he said to discontinue the wound vac order and to (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 2 Event ID: 145651 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 145651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Alton 3490 Humbert Road Alton, IL 62002 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)