F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
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 provide showers twice a week to 2 of 4 residents (R1 and
R8) reviewed for bathing in the sample of 11.
Residents Affected - Few
Findings include:
1. R1's Bath and Skin Report sheet dated April 2025 documents bath or shower preference to be done AM
on Monday and Thursday. R1's bath and skin report does not document a shower being given from
4/14/2025- 4/23/2025.
R1's Face Sheet dated 4/23/2025 documents in part a diagnosis of Quadriplegia, Dysphagia, Speech and
Language Deficits following Cardiovascular Disease.
R1's Care Plan dated 7/9/2022 documents R1 has an Activity Daily Living (ADL) self-care performance
deficit related to Cerebrovascular Accident (CVA), Weakness. R1's care plan documents interventions R1
currently requires assistance for bathing total 2. R1's Care plan documents R1 has bowel incontinence
related to immobility. R1's Minimum Data Set (MDS) dated [DATE] document unable to do Brief interview for
Mental status due to R1's cognitive impairment.
2. R8's Bath and Skin Report sheet dated April 2025 documents shower preference AM. R8's sheet
documents Tuesday and Friday as shower days. R8's Bath and Skin Report Sheet does document R8 had
a shower on 4/4/2025, and next documented shower 4/15/2025. R8's Bath and Skin Report does not
document R8 receiving a shower from 4/4/2025-4/15/2025. R8's Bath and skin report does not document
R8 receiving a shower from 4/15/2025- 4/21/2025 with last documented shower on 4/22/2025.
R8's Care Plan dated, 6/19/2024 documents R8 has a ADL self-care performance deficit needs and
participation may vary. R8's Care Plan documents the following interventions; R8 currently requires
assistance with ADL's , Bathing physical help of one staff
On 4/22/2025 at 1:23PM V5, Maintenance stated a circualtion pump had been down at the facility. V5
stated there was no hot water on Friday. V5 stated he did repairs and was called back in on Saturday for no
hot water. V5 stated he called (outside contractor) and they helped him trouble shoot. V5 stated parts were
ordered and he got them on Monday and installed. V5 stated water temps were not high enough to gives
showers at that time. V5 stated after parts installed took about 2 hours for holding tank to fill to get temps
up.
On 4/23/2025 at 10:25AM V2, Director of Nursing (DON) stated residents are expected to get showers
twice a week or more if soiled or incontinent.
(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
04/24/2025
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
The facility policy Bath/shower/tub dated revised February 2018 documents the purpose is to promote
cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy
documents documentation; the date and time the shower/tub bath was performed, if the resident refused
the shower/tub bath the reason why and intervention taken. the signature and title of the person recording
the data.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145846
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
145846
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2025
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)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observation, interview and record review the facility failed to change dressing and provide skin
care daily to Gastrostomy (G ) tube for 1 of 3 residents (R2) reviewed for enteral feeding tubes in the
sample of 11.
Findings include:
1. On 4/22/2025 at 9:03 AM R2's Gastrostomy (G) tube dressing in place with date of 4/18/2025 as verified
by V3, Licensed Practical Nurse (LPN).
R2's Care plan dated 3/21/2025 documents R2 requires tube feeding related to oropharyngial dysphagia
after Cerebrovascular Accident (CVA). R2's care plan documents intervention; provide skin care to insertion
site daily and as needed (PRN).
R2's Physician Order (PO) dated 4/22/2025 documents G-tube site care - cleanse site and apply dry split
gauze dressing every night after 12 AM.
On 4/22/2025 at 9:03 AM V3, Licensed Practical Nurse (LPN) stated R2's gtube is to be cleaned and
dressing changed daily.
The facility policy Gastrostomy/Jejunostomy Site Care dated revised April 2025 documents the purpose of
the procedure is to promote cleanliness and to protect the gastrostomy or Jejunostomy irritation,
breakdown and infection. The policy documents to verify there is PO for the procedure, review the resident's
care plan and provide for any special needs for the resident. The policy documents person performing the
procedure should record the following information in the resident's medical record which would include date
and time procedure was formed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145846
If continuation sheet
Page 3 of 3
