Health inspection·March 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plan interventions were appropriately in place for 2 out of 4 residents (R2, R7) reviewed for accidents in a sample of 18. Findings include: 1. R2's admission Record, dated 3/5/24, documented that R2 was admitted on [DATE]. R2's admission record documented that R2's diagnoses are fracture of T11-T12 vertebra, type 2 diabetes mellitus with diabetic nephropathy, narcolepsy, hypertensive heart disease with heart failure, venous insufficiency, obstructive and reflux uropathy, depression, anemia, chronic kidney disease, obstructive sleep apnea, neuromuscular dysfunction of bladder, essential hypertension, hypothyroidism, mixed hyperlipidemia, benign prostatic hyperplasia and gastro-esophageal reflux disease. R2's MDS (Minimum Data Set), dated 2/1/24 documented that R2 is severely cognitively impaired and is dependent on staff for all ADLS (activities of daily living). R2's Care Plan, dated 11/9/23, documented that R2 requires a mechanical lift for all transfers. R2's Fall Risk Assessment, dated 12/19/23, documented that R2 is at high risk for falls. The facility's Incidents by Incident Type document, dated 3/4/24, documented that R2 had falls on 12/18/23, 1/24/23, and 2/2/24. R2's Care Plan, dated 11/9/23, documented that R2 is at risk for falls and is to have the following interventions in place: anticipate and meet resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, monitor/encourage appropriate footwear prn (as needed) it continues frequent monitoring of resident to ensure safe positioning and needs are met, keep bed in lowest position acceptable by the resident when the resident is in bed, remind to request assistance when getting up if needed, apply bolsters to bed, mat to right side of bed, it continues scoop mattress to bed. On 3/4/24 at 3:45 pm V10, CPC (Care Plan Coordinator) stated that (R2) is care planned to have a scoop mattress and a floor mat next to the bed. On 3/4/24 at 3:50 pm V10 and writer entered (R2's) room and (R2) was resting on an air mattress without a scoop, nor bolsters. (R2's) floor mat was folded up and leaning against the nightstand. At this time, V10 stated that she would expect (R2) to have a scoop mattress on his bed and that the mat should be on the floor next to the bed. (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: 145846 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 145846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Edwardsville 6277 Center Grove Road Edwardsville, IL 62025 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)