La Bella of Mascoutah: Wound Care Failures Cause Harm - IL
The wounds were stage 3 pressure ulcers, meaning they had already eaten through the full thickness of the skin and into the tissue below. A wound assessment completed on August 25, 2025 measured the left posterior thigh ulcer at 12.0 centimeters by 12.0 centimeters and the right at 12.0 centimeters by 15.0 centimeters. Both were 0.3 centimeters deep.
A physician had ordered a specific treatment protocol for both wounds back on June 17. Staff were to cleanse each wound with normal saline or wound cleanser, apply Dakin's Solution at 0.5 percent, then hydrocortisone cream, then collagen, then calcium alginate, and cover the whole thing with a bordered foam dressing. That was to happen every day shift, without exception.
It did not happen that way.
The facility's own treatment administration records show the left thigh wound went untreated on June 26, June 27, July 2, July 23 through July 26, August 1, August 2, and August 6. The right thigh wound missed the same dates. That is at least fourteen documented failures to complete a daily treatment on open stage 3 wounds, spread across a period when the resident had no documented alternative care in place for those days.
Federal inspectors who arrived on September 3, 2025 in response to a complaint rated the violation as causing actual harm.
The Director of Nursing, identified in the inspection report as V2, acknowledged the obvious when inspectors asked about it that morning. She stated that wound treatments should be given as ordered and documented in the treatment administration record at the time they are given.
They were not.
What makes the gap between that statement and the records so stark is its repetition. A single missed treatment might reflect a chaotic shift, a staffing emergency, something that slipped. Fourteen missed treatments across eight separate dates, affecting both legs of the same resident, over the course of ten weeks, is a different kind of failure. It is a pattern that nobody caught, or nobody acted on, while the wounds persisted.
Stage 3 pressure ulcers do not heal on their own. The multi-step protocol the physician ordered, with its specific sequence of cleanser, antimicrobial solution, steroid cream, collagen, and alginate dressing, exists because these wounds require consistent, layered intervention to prevent infection and promote closure. Each skipped treatment is not a neutral event. The wound simply sits, unaddressed, for another day.
The inspection report does not describe what the resident experienced during those gaps. It does not say whether anyone noticed, whether the resident asked about their care, or whether family members were aware that the ordered treatments were not being completed. The records simply show the blank spaces where documentation should be.
The facility's own wound care policy, last revised in November 2019, instructs staff to document treatment. That policy was apparently not enough to produce documentation, or the treatment itself, on at least fourteen occasions.
By the time inspectors arrived in early September, the wounds had been open and measurable for at least ten weeks. The August 25 assessment captured their dimensions in precise centimeters. What it could not capture was the accumulation of days when the ordered care did not come.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Bella of Mascoutah from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
La Bella of Mascoutah in MASCOUTAH, IL was cited for violations during a health inspection on September 3, 2025.
The wounds were stage 3 pressure ulcers, meaning they had already eaten through the full thickness of the skin and into the tissue below.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.