Helia Southbelt Healthcare

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

POA's, and local police were notified.Resident R3's Psychiatry Initial Evaluation Note, dated 4/17/2025 at 12:09 PM, documents the following: Chief Complaint: Initial Assessment. History of Present Illness: 71 y/o (Year Old) Male with Dementia and Agitation. History obtained from patient and staff. Patient pleasant and cooperative with assessment with intermittent confusion. Patient was recently involved in an altercation due to his wandering behaviors, where he was assaulted by another elderly dementia patient for wandering into his room. Patient was not seriously injured, treated and readmitted after being sent to the hospital. Patient can be difficult to redirect, and staff report he can then become easily agitated. Pleasant at time of assessment with some confusion and nonsensical talk. Patient diagnosed with Alzheimer's Disease, psychosis, dementia, GAD (Generalized Anxiety Disorder), MDD (Major Depressive Resident R3's Progress Note dated, 7/17/2025 at 9:40 AM, documents the following: The Identified Offender was assessed using the Identified Offender Risk Assessment and scored a 9, indicating a compromised risk level. The resident continually exhibits significant cognitive impairment and consistent disorientation related to a diagnosis of dementia.

The resident has a documented history of behavioral disturbances, including verbal aggression and sexually inappropriate behavior directed toward staff and other residents. The resident also has been known to frequently display wandering and rummaging behaviors. It has been highly recommended that ongoing monitoring and implementation of appropriate interventions should be continued to maintain the safety and well-being of all individuals within the facility.On 8/13/25 at 9:25 AM, V1, Administrator, stated he was not employed by the facility when the altercation between Resident R3 and Resident R8 took place. On 8/13/25 at 9:52 AM, V10, Resident R3's Physician, stated he does not recall the incident between Resident R3 and Resident R8. The Abuse Prevention Policy, dated 9/29/22, documents the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. As part of

the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict.

Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse for these residents.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Helia Southbelt Healthcare

101 South Belt West Belleville, IL 62220

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

himself, but no one knew he left. Resident R7 stated H*** No, he would never do this again. Resident R7 stated his wheelchair is working fine. Resident R7 stated did go to the hospital after the incident. Resident R7's Progress Note, dated 8/2/2025 at 9:04 PM, documents the following: Resident allowed skin assessment once in bed. Resident has open areas noted to bilateral legs and left elbow. Areas cleansed with dressings applied. Wound care team made aware. Spoke with POA about incident and POA stated he will speak with resident about leaving facility unattended.Resident R7's Progress Note, dated 8/4/2025 at 5:29 PM, documents the following: Fall f/u (Follow Up) day 2, resident c/o (complains of) pain to bilateral legs/back/bottom, x-rays completed to legs, no fractures noted. MD made aware of increased pain r/t fall, new order for Norco PRN (as needed), order entered, script received by pharmacy.Resident R7's Progress Note, dated 8/5/2025 at 3:09 PM, documents the following: Resident requested ER (Emergency Room), stated he wanted to get checked out r/t previous fall. Sent to local ER for further evaluation. MD notified. Attempted to notify POA twice, left voicemail.Resident R7's Progress Note, dated 8/6/2025 at 12:17 AM, documents the following: Resident returned to the facility and was placed to bed by 2 EMTs (Emergency Medical Technician) via stretcher. New order for Cephalexin 500 mg PO (by mouth) daily for 10 days r/t wound. Resident resting in bed, call light and side table within reach, VS (Vital Signs) WNL (Within Normal Limits).Resident R7's Elopement Evaluation, dated 3/7/25, documents Resident R7 is not at risk for elopement. There were no recent Elopement Evaluations in Resident R7's record for review. Resident R7's Fall Event, dated 8/2/25, documents Resident R7 had an unwitnessed fall. Resident R7 attempted to leave the facility unattended and fell. Resident R7 is to remain on safe pathways around facility entrances and not to attempt to leave facility in his wheelchair. On 8/12/25 at 12:30 PM, V1, Administrator, stated Resident R7 is able to go outside by himself and he likes to sit out in front of the facility. V1 stated Resident R7 was outside, got onto the grassy area in front of the facility and fell out of his wheelchair. V1 stated Resident R7 stated he was going to get cigarettes. V1 stated Resident R7 still likes to go out front to sit, but they prefer and ask him to go out on the back patio, which he does. On 9/13/25 at 9:20 AM, V1, Administrator, stated Resident R7 has is an activity care plan, documenting his desire to participate in activities of his choosing. V1 stated there is not an assessment to determine if Resident R7 is safe to leave the property without supervision. On 8/13/2025 at 9:20 AM, V9, Registered Nurse (RN), stated Resident R7 is not an independent smoker and is not to be outside by himself. V9 stated he would not be safe outside the facility by himself. On 8/13/2025 at 9:23 AM V8, CNA, stated Resident R7 is not supposed to go outside and smoke by himself, but he still does it. V8 stated Resident R7 is not safe to leave the facility by himself but doesn't see Resident R7 has a flight risk.On 8/13/25 at 9:52 AM, V10, Resident R7's Physician, stated if Resident R7 is competent enough to enter the code to exit the building, then he is capable to go out by himself, Resident R7 is disabled but not mentally incompetent. On 8/13/25 at 9:55 AM, V11, Resident R7's Brother/POA, stated Resident R7 is able to go outside to smoke and leave the facility property by himself. V11 stated this was an unusual situation of him going down the grassy hill instead of using the concrete or road. V11 stated the facility has policies in place to address this sort of thing. V11 stated on that particular day, he didn't make a safe decision even though his mind is with it. V11 stated it could have been worse, Resident R7 could have gotten ran over and killed. The Elopement Prevention Policy, dated 1/2018, documents the following: It is the policy of the facility to provide a safe and secure environment for all residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Helia Southbelt Healthcare

101 South Belt West Belleville, IL 62220

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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

don't know of him getting into (Resident R2's) bed.On 8/8/2025 at 2:30PM, V7 CNA, stated Resident R3 thinks everyone's bed is his bed. He messes with (Resident R2's) snack.The Dementia Clinical Protocol policy, dated 11/2011, documents

the following: The staff and physician will review the current physical, functional, and psychosocial status of each individual with Dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Individuals with Dementia can also have a personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions, or other conditions causing or contributing to impaired cognition and problematic behavior. For the individual with confirmed Dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of Dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc.

Event ID:

Facility ID:

If continuation sheet