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 5 of 9 145290 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 6 of 9 145290 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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** 50908

Residents Affected - Few Based on interviews, observations, and record reviews the facility failed to prevent development of additional pressure injuries for 1 of 3 residents, (Resident R1) reviewed for treatment/services to prevent/heal pressure ulcers in

a sample of 16. This failure resulted in Resident R1 developing two new Stage 2 pressure injuries.

Findings include:

Resident R1's Face Sheet, documented Resident R1 was admitted to the facility on [DATE REDACTED] with diagnosis of, in part, paranoid schizophrenia, pressure ulcer stage 3, and atherosclerotic heart disease.

Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED], documented he is moderately cognitively impaired and required partial/moderate assistance with toileting hygiene; substantial/maximal assistance with showering/bathing and all transfers; and partial/moderate assistance with rolling left to right in bed.

Resident R1's Care Plan dated 1/24/25 documented he is at risk for skin complications r/t (related to) psychotropic medications and impaired independence with activities of daily living functions. Stage 3 Pressure ulcer to Coccyx on 6/18/25 interventions to assess and document of progress of areas weekly. On 1/10/25 intervention to assist and encourage resident to turn and reposition every one to two hours and as needed. Resident R1's care plan also documented he has a self-care deficit in bed mobility related to decreased ability to position or reposition self in bed/ turn from side to side; on 11/29/23 a halo bar was placed above the resident's bed for turning and repositioning and to assist with transfers; on 11/29/23 position and reposition resident in bed for comfort, joint support, and skin integrity.

On 3/25/25 this surveyor observed Resident R1 to be on his left side at 8:25 AM, 8:35 AM, 8:49 AM, 8:55 AM, 9:10 AM, 9:11 AM, 9:23 AM, 9:35 AM, 9:50 AM, 10:01 AM, 10:16 AM, 10:28 AM. Resident R1's door was left closed from 10:32 AM until 11:22 AM.

On 3/25/25 this surveyor observed Resident R1 still on left side at 11:22 AM and 11:33 AM.

On 3/24/25 at 9:50 AM, Resident R1 had a sign above his bed stating, turn schedule.

On 3/24/25 at 1:50 PM V7, Licensed Practical Nurse (LPN) stated she was not sure how long Resident R1 has had his pressure ulcer but thinks it should be improving with the wound vac, he is typically compliant with that.

On 3/24/25 at 2:00 PM, V8, Wound Nurse, stated Resident R1's pressure ulcer was in house acquired and Resident R1 has had it for about 6 months, it started out as moisture associated because he likes to pour liquids on himself leaving him wet. V8 stated the ulcer had slough around it at first and was small but then went to the hospital and came back with it debrided and a lot larger. V8 stated he emphasizes implementing care plans and following interventions to improve patient care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 145290 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 On 3/25/25 at 1:17 PM, V8, provided Resident R1 wound care to his stage 4 pressure injury while he was on his left side. After pressure ulcer care was completed, V8 got V11, Certified Nursing Assistant (CNA) to come assist Level of Harm - Actual harm him with peri care on Resident R1. While V11 turned Resident R1 on to his right side, two pressure ulcers with no dressings on them were noticed. V8 stated these were new, facility acquired pressure ulcers. The pressure ulcer to Resident R1's Residents Affected - Few left ischial had approximately 5-6 centimeters of erythema surrounding a darken red wound bed of granulation tissue that was approximately 2 centimeters in diameter with a skin flap peeled open, this part of

the wound did not blanch when V8 applied pressure to it. V8 stated he would call this an open blister. Resident R1's new pressure ulcer to his left hip had erythema covering approximately 4 centimeters in width by 1.5 centimeters in length with a patch of open excoriated skin in the center approximately 0.5 centimeter in diameter. V8 stated that the hip pressure ulcer was from Resident R1's catheter tubing being underneath him while on his left side, it has the exact indentation of it. V8 stated it could have been caused by excessive time being

on top of the tubing without being repositioned. V8 preceded to take pictures of both the wounds, applied skin prep to them and a bordered foam dressing to the left ischial and an island dressing to the left hip. V8 stated he would notify the wound nurse practitioner and get new orders for care. At 2:23 PM, V11 and V8 turned Resident R1 back on to his left side. V11 and V8 stated they turned Resident R1 on his left side again because he won't stay on his right side. V11 and V8 stated we can turn Resident R1 on his right side and show that he won't stay there. Resident R1 was turned to his right side by V11 and V8 cooperatively without complaints or refusal.

Resident R1's Skin and Wound assessment dated [DATE REDACTED] documented an in-house acquired blister to his left ischial tuberosity involving 100% granulation to the wound bed and to have erythema surrounding it. On 3/25/25, a second Skin and Wound Assessment documented a new in-house acquired skin tear to Resident R1's rear left trochanter (hip) with 100% granulation to the wound bed and erythema surrounding.

On 3/26/25 at 8:41, AM, Resident R1 stated he doesn't mind being turned and doesn't refuse unless the staff reposition him roughly because his butt hurts. Resident R1 stated the staff will sometimes drag my butt when they turn me and it hurts a lot but if they are gentle, I don't care what side I'm on. Resident R1 stated no one asked or offered to turn me yesterday. Resident R1 stated he was on his left side for most of the day 3/25/25.

On 3/26/25 at 3:53 PM, Resident R16, Resident R1's roommate, stated he doesn't see staff come in and turn him frequently.

On 3/26/25 at 12:30 PM, V16, LPN, stated residents are on turn schedules to prevent break down of the skin, if a resident is non-compliant V16 stated she would try to at least offer a wedge under one side to turn even slightly.

On 3/26/25 at 1:20 PM, V5 CNA stated turning schedules prevent skin break down and wounds from worsening, typically occurring every 1-2 hours. V5 stated if a resident is noncompliant with turning, a wedge can be used to turn them slightly and offer encouragement. V5 stated if a resident is not turned it is likely to cause a sore.

On 3/27/25 at 1:05 PM, V2, Assistant Director of Nursing, stated she expects the nursing staff to be turning residents that require it at least every two hours, if they do not turn a resident within that timeframe, they are at risk for causing skin break down. V2 stated she does not expect a resident to be lying on top of a catheter tube, this could cause skin sores.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 145290 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 The facility's Turning and Reposition Policy dated 8/2024 documented all residents at risk of, or with existing pressure injuries, will be turned and repositions, unless it is contraindicated due to a medical condition. In Level of Harm - Actual harm this case, small shifts in repositions with be employed. Repositioning techniques in bed includes avoiding positioning the resident onto medical devices or other foreign objects and avoid positioning residents on Residents Affected - Few surfaces with existing pressure injuries, including persistent redness. Repositioning techniques in chair include if the resident is unable to make position changes, reposition every hour.

The facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy dated 10/2024 documented for management of tissue loads, pressure redistribution devices offer an effective means of reducing interface pressure but because they cannot provide pressures consistently less than 25 to 32 mm/HG (millimeters of mercury), a turning schedule should be implemented as well.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 145290