Integrity Hc Of Belleville

F-F401's Initial Incident Report with incident date of 5/9/2025 at 7:00 AM, document, It was alleged resident to resident altercations occurred. Investigation initiated. Final to follow.

Resident R401's Final Incident Report with incident date of 5/9/2025 at 7:00 AM, document, Upon investigation, the facility is unable to substantiate the res (resident) to resident complaint. The residents both were unable to communicate any information to interviewer. Staff were inconsistent with statements due to them not being able to fully see what had taken place down the hall. All staff were in-serviced on abuse and neglect, process of reporting and protective oversight. No injuries noted on either resident. (Resident R401) was sent out due to some change in conditions with communicating with staff.

Statement dated 5/9/2025 documents, At about 6:30 I was bringing my resident from the dining room, and I saw (Resident R401) punching on (Resident R402) across the head. Me and 2 other staff went down there to stop him, he walked away as if he didn't do anything. Signature of author was not readable.

Resident R401's Abuse Investigation folder only had three statements from staff. The above statement dated 5/9/2025 documents there were a total of three staff members but does not document their names and there were no additional statements to review.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 145290 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145290 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belleville Healthcare Center 727 North 17th Street Belleville, IL 62226

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 0610 Statement from V3, Certified Nursing Assistant (CNA) stated, So around 6 o'clock I was coming out of the bathroom I see (Resident R401) trying to push (Resident R402) to the wall me and (V11, CNA) stopped him, I put (Resident R401) back Level of Harm - Minimal harm or in his room and moved (Resident R402) off the hall. I go back in the bathroom to wash hands only to see (Resident R401) potential for actual harm hitting (Resident R402) on the head.

Residents Affected - Few On 5/16/2025 at 2:03 PM, V10, Certified Nursing Assistant (CNA) stated, I had never seen (Resident R401) and (Resident R402) at odds with each other before this day. (Resident R401) was in a motorcycle accident and can't talk and (Resident R402) is hard of hearing so it is hard to know what was happening between the two. They were roommates and I know after the incident they were separated. I saw (Resident R401) trying to push (Resident R402). I know (Resident R402) has a history of taking (Resident R401's) stuff, especially his food. I don't know what set (Resident R401) off, but he was pushing (Resident R402) and I saw it and went and immediately separated the two and (V11) was with me helping to separate

the two. I thought everything was okay but then about five minutes later as I was leaving the bathroom and washing my hands I see (Resident R401) hitting (Resident R402). He made contact and was hitting him in the head. I gave a statement to (V1) and separated them again and contacted (V1, Administrator).

Resident R401's Incident Abuse Investigation does not have any statement from V11.

On 5/16/2025 at 2:13 PM, V1, Administrator stated, I did not substantiate the tag because when I asked staff when (Resident R401) hit (Resident R402) did he have an open hand or a closed hand they could not tell me. I felt the staff were inconsistent with their statements, so it was impossible to determine if abuse occurred. I know some of my staff will lie.

The Facility Abuse Policy dated 9/2017 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment by anyone, but not limited to, facility staffing other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 145290 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145290 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belleville Healthcare Center 727 North 17th Street Belleville, IL 62226

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45302

Residents Affected - Few Based on observation, interview and record review the facility failed to assess and document a head to toe skin assessment upon readmission to the facility for 1 (Resident R44) of 1 resident reviewed for pressure wounds in

the sample of 39. This failure resulted in the deterioration of the pressure ulcer from a stage II to a stage III.

Resident R44's Undated Face Sheet documents initial admitted [DATE REDACTED] diagnoses of spina bifida and pressure ulcer of sacral region unspecified stage.

Resident R44's Annual Minimum Data Set (MDS) dated [DATE REDACTED] documents she is alert and no pressure ulcers, not at risk for pressure ulcers, no unhealed pressure ulcers.

Resident R44's Care Plan, addresses resident at risk for skin complications r/t (related to) skin spina bifida. Goal: area to right buttock will remain stable/heal. Interventions: assess and document progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN (when needed) and skin assessment weekly.

Resident R44's Hospital Discharge Paperwork, dated 8/14/2024 documents sacral stage 2 pressure ulcer.

Resident R44's Nurses Note, dated 8/14/2024 at 6:12 PM, documents resident returned to the facility at 6p via ambulance. Resident transferred from stretcher to bed by 2 EMT workers. No c/o pain or discomfort at this time. Resident has a Foley catheter, suprapubic catheter, and cecostomy tube. The resident has a breakdown to her right butt. 97.6 120/74 20 82. Resident laying in bed with call light within reach. No documentation of readmission skin assessment documented.

Resident R44's Braden Scale for Predicting Pressure Ulcer Risk dated 8/15/2024 documents moderate risk.

Resident R44's Dietary Note, dated 8/15/2024 at 2:59 PM documents resident readmitted on [DATE REDACTED]. Per staff, resident has 2 pressure wounds on buttocks. Recommend Prostat BID (twice a day) r/t wound healing.

Resident R44's NRSG Admission Observation, dated 8/15/2025 documents no skin assessment.

Resident R44's Dietary Evaluation, dated 8/15/2024 documents no skin issues and recommend Prostat 30 ml (milliliters).

Resident R44's Medication Administration Record (MAR) dated 8/15/2024 documents no physician's order for Prostat BID.

Resident R44's Treatment Administration Record (TAR), dated 8/17/2024 through 8/31/2024 documents staff initial treatment administered to buttocks one time a day and PRN to promote wound healing calcium alginate, medihoney wound gel and foam bordered dressing.

Resident R44's Skin Screen dated 8/20/2024 documents stage 3 pressure ulcer. No other assessment documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 145290 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145290 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belleville Healthcare Center 727 North 17th Street Belleville, IL 62226

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 0686 Resident R44's Wound Evaluation, dated 8/20/2024 documents stage 3 pressure ulcer right ischial tuberosity 6 days old present on admission measured 6.11 centimeters (cm) x 3.01 cm x 2.77 cm. Wound bed assessment: Level of Harm - Actual harm 60% slough, 40% eschar, no exudate (drainage), periwound area attached, surrounding tissue intact.

Residents Affected - Few Resident R44's Wound Assessment Report, dated 8/21/2024 documents right ischium Stage 3 pressure ulcer date wound acquired 8/14/2024, present on admission. Wound status: 90% granulation, 10% slough, wound edges attached, periwound: intact, exudate: moderate, exudate amount: serosanguineous drainage, no odor. Treatment: daily and PRN (when needed) cleanse with wound cleanser, medical grade honey, collagen particles, calcium alginate and bordered foam.

Resident R44's Physician's Order Sheet (POS), dated 8/2024 documents staff administered wound treatment start date 8/16/2024 calcium alginate, medihoney and a foam dressing apply to buttocks topically one time a day/PRN (when needed) to promote wound healing. No physician's order for Prostat 30 ml twice a day documented.

Resident R44's POS dated 9/2024 documents a physician's order dated 9/4/2024 Prostat two times a day for wound healing 30 ml. Staff documented it was administered 9/5/2024 through 9/30/2024.

On 3/12/2025 at 8:36 AM V12, Wound Nurse/LPN provided wound care to Resident R44. V12 entered room washed hands and donned gloves. He assisted Resident R44 to roll to her left side and removed the intact dressing to her right buttocks/ischium area. Wound bed was approximately 30% slough and had serosanguinous drainage that measured approximately 4.0 centimeters (cm) x 5 cm. No concerns regarding infection control noted during treatment. Resident R44 lying on a low air loss mattress and had a wedge pillow under her left side.

The Facility's Pressure Injuries Policy, last reviewed date 4/2024 the facility will ensure that all residents have necessary assessments completed in a timely manner at the point of admission in order to provide the best possible, person-centered care. All new and re-admissions that have been out of the facility longer than 24 hours should be assessed within 1 day of arriving to the facility by a licensed nurse to ensure stability and safety of resident. Within 24 hours of admission, the following forms should be completed NRSG: Admission

Observation, Braden's Scale for Predicting Pressure Sore Risk and NRSG: Interim Baseline Care Plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 145290 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145290 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belleville Healthcare Center 727 North 17th Street Belleville, IL 62226

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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 45302

Residents Affected - Many Based on observation, interview and record review, the facility failed to employ a full-time Director of Nurses DON to oversee the facility's nursing department. This failure has the potential to affect all 126 residents residing in the facility.

Findings include:

On 3/11/2025 at 9:05 AM V6, Registered Nurse Consultant stated the facility does not have a Director of Nurses at this time and the Assistant Director of Nurses (ADON) just started working at the facility a day ago.

On 3/13/2025 at 3:16 PM V6, Registered Nurse Consultant stated the former DON's last day was 2/11/2024.

Facility Assessment Tool dated 3/5/2025 documents, no name for the Director of Nurses on the Facility Assessment Tool.

Resident Census and Conditions of Residents form CMS-671 dated 03/11/2025 documents a census of 126.

The Facility's Nursing Services - Registered Nurse RN Policy last reviewed 9/2024, documents it is the intent of the facility to comply with registered nurse staffing requirements. The facility will designate a registered nurse to serve as the Director of Nursing on a full-time basis. The Director of Nursing may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 145290 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145290 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Belleville Healthcare Center 727 North 17th Street Belleville, IL 62226

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 25071 potential for actual harm Based on observation, interviews, and records review, it was determined that the facility failed to ensure Residents Affected - Many garbage in the facility dumpster was covered. This has the potential to affect all 126 residents residing in the facility.

The findings include:

Review of the facility's policy Disposal of Garbage and Refuse with a review date of 10/2024, revealed, Procedure: 1. The facility will assure all garbage and refuse containers are in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lids and covered.

Observation on 03/11/2025 at approximately 09:03 AM revealed two dumpsters for garbage located behind

the kitchen. One dumpster lid was missing while the second lid was completely open to the environment and observed to be approximately half full of garbage bags and other trash.

During an interview on 03/11/2025 at approximately 09:03 AM, V21 Dietary Aide verified the observation and stated These lids should be closed. That is how we keep the animals out of the trash.

During an interview on 03/12/2025 at 12:50 PM V1 Administrator stated The operator of the garbage truck ripped the lid off and never worried about replacing it. I've contacted the company and was told they will replace the entire unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 145290