Memorial Care Center
MEMORIAL CARE CENTER in BELLEVILLE, IL — inspection on March 5, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
provide appropriate care for a resident with a feeding tube.
interview, observation, and record review, the facility failed to flush a gastric-tube (g-tube) after
reviewed for proper g-tube management in the sample of 34.The findings include:R67's Face Sheet, undated, documents R67 was admitted to the facility on [DATE] with diagnosis of Gastrostomy status, malnutrition, dysphagia oropharyngeal and pharyngoesophageal phase, and status post-surgery on the circulatory system - Coronary Artery Bypass Graft. R67 was discharged on the evening of 3/2/26. R67's Minimum Data Set (MDS), dated [DATE], documents R67 is cognitively intact and is dependent on staff for feeding. R67's Care Plan, dated 2/16/26, documents R67 is on tube feeding post open-heart surgery.
Interventions: Osmolite 1.5, 275 ML (milliliters) 4 times a day, 115 ML water flushes 4 times per day. 2/26/26: given my weight drop from 125 lbs (pounds) before hospital stay down to 116.8 lbs on 2/25, my tube feeding amount will be increased from 325 ML of Osmolite 1.5 4/day to 350 ML of Osmolite 1.5 4/day. R67's Physician Order, dated 2/13/26, documents Tube feeding water bolus 115 ML Q (every) 6hr (hours).R67's Physician Order, dated 2/13/26, documents Patient Isolation: Enhanced Barrier Precaution (EBP).
Risk for MDRO (Multidrug-Resistant Organisms) r/t (related to) G-tube.R67's Physician Order, dated 2/26/26, documents My Dining Tube Feeding.
Osmolite 1.5 Cal (calorie) 350 ML QID (4 times day).On 3/2/26 at 9:55 AM, R67 was seen lying in bed with V19, Licensed Practical Nurse (LPN), observed turning off R67's tube feeding, disconnected the feeding line from his g-tube, and then plugging the tube. V19 stated R67 gets 350 ML bolus feeding and then it gets turned off.
When asked about flushing R67's g-tube after disconnecting the feeding, V19 stated that R67 gets flushed four times a day and she had already done it this morning so she will do later. R67's tube feeding bottle is dated 3/1/26 with no time indicated when it was hung or started.
The bottle had Osmolite written on the bottle with no rate of infusion.
There was no PPE (Personal Protective Equipment) seen at the entrance to the room and V19 did not don PPE prior to taking care of R67's G-Tube. On 3/5/26 at 10:00 AM, V22, LPN, stated if she is giving a feeding through the g-tube, she always flushes it after the feeding. V22 stated the feeding bottle should have the date and time it was hung or started along with the rate. V22 stated if any resident has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown, gloves, and a mask when caring for that resident. On 3/5/26 at 10:06 AM, V11, LPN, stated she always flushes a g-tube before and after giving a feeding. V11 stated the bottle of g-tube feeding should have the resident's name, date and time it was started and the rate of infusion. V11 stated if anyone has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown, gloves, and a mask to care for that resident. On 3/3/26, at 3:35 PM, V2, Director of Nursing (DON), stated if giving a bolus of feeding, you should flush the tube with 30 ML of water afterwards. V2 stated she would expect the staff to be following the policies on EBP and tube feedings via g-tube.On 3/3/26 at 3:36 PM, V1, Administrator, stated after giving a resident a feeding through the g-tube, they should be flushed with at least 30 ML of water.The Facility's Tube Feeding and Pump Operation/Kangaroo E-Pump Policy, dated 9/2024, documents in part Purpose: To provide guidelines for proper enteral nutrition and the use of the Kangaroo E-Pump to provide optional fluid and nutrition. 1.
Obtain physician's order, per dietician's recommendation, which includes tube feeding formula and the TOTAL volume needed to assure caloric needs are met.
Order should also include the rate and flush volume/frequency. If tube feeding is to be off for certain activities, order must specify such. 14. Be sure tube feeding bottle/tubing are dated and initialed.
Tube feeding bottle/bag must be labeled with the resident's name, formula and rate of instillation.
Hang time for closed system is 48 hours.
and staff should be wearing a gown, gloves, and a mask to care for that resident. V11 stated hand
going on.
On 3/5/26 at 11:05 AM, V2, Director of Nursing (DON), stated she would expect the staff to be following the policies on EBP, tube feedings via g-tube, and hand hygiene when passing medications.
The Facility's Infection Control - Standard and Transmission-Based Precautions Policy, dated 2/2024, documents in part It is the policy of (facility) residences to utilize Standard and Transmission-Based Precautions to reduce the potential for infections and disease transmission.
Hand Hygiene remains the single most effective means of preventing infections and controlling disease transmission.
Wash hands before passing medications or performing treatments and when each resident's care is completed.
Transmission-Based Precautions are always used in addition to Standard Precautions.
Infection risks will be balanced with the need for more than one occupant in a room.
Considerations include but are not limited to: Cohorting residents with the same pathogen, the presence of risk factors that increase the likelihood of transmission (i.e., indwelling devices; pressure injuries or open wounds; immunocompromised.
Information regarding the precaution to be utilized will be communicated through verbal reports, written in-house communication forms, and signage.
Signage is to be placed in a conspicuous place outside the resident's room with precaution instructions.
Appropriate PPE shall be readily available near the entrance to the resident's room.
The Facility's Infection Control - Enhanced Barrier Precautions Policy, dated 2/2024, documents in part It is the policy of (facility) to implement enhanced barrier precautions to prevent transmission of novel or targeted multidrug=resistant organisms as defined by CDC to residents, staff, volunteers, visitors or any other individuals providing services under a contractual agreement.
Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).
Clear signage will be posted outside of the resident's room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of gown and gloves.
Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders.
Make gowns and gloves available immediately outside of the resident's room.
Face protection may also be needed if performing activity with risk of splash or spray. 6.R11's Facesheet documented she was admitted to the facility on [DATE].
On 3/3/26 at 8:01 AM, V10 registered nurse (RN) administered R11 her IV (intravenous) daptomycin 400 mg (milligram) via PICC (peripherally inserted central catheter) line to her RUA (Right Upper Arm) without completing hand hygiene prior to gloving up after entering her room. 7.R57's Facesheet documented she was admitted to the facility on [DATE].
On 3/3/26 at 8:22 AM, V13 licensed practical nurse (LPN) administered R57 without completing hand hygiene prior to gloving up after entering her room.
145102 03/05/2026
Memorial Care Center 4315 Memorial Drive Belleville, IL 62226