Health inspection·November 26, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for physical abuse in the sample of 3. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, depression, abnormalities of gait and mobility, and pain. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, ambulated via wheelchair, and was independent with bed mobility and transfer. R2's Care Plan updated 11/26/24 documents R2 is at risk for abuse and neglect. The Facility's Initial Report sent to the (State Agency) on 11/16/24 at 10:15 PM documents V1, Administrator, was notified on 11/16/24 at 10:00 PM that R2's CNA (Certified Nursing Assistant) became agitated with her during care and touched her face in a [NAME] way. The CNA was suspended pending investigation. R2's Progress Note by V5, Licensed Practical Nurse (LPN), on 11/16/24 documents, CNA reported to this nurse that the resident slapped her. I went down to talk to the resident and she stated that she did not slap the CNA, the CNA slapped her. Resident stated she were (was) in the bathroom and rocked her wheelchair back, the CNA asked her to stop, the resident stated she did not know what she was talking about. Resident stated she must have ran (run) over her toe because she heard her say ouch. Resident stated, then the CNA slapped her really hard. V5's Hand-Written statement dated 11/16/24 documents, CNA came and reported to this nurse, that a resident slapped her. Another CNA pulled the night nurse to the side and stated that the CNA was lying she witnessed her slapping (R2). I went down to talk to the resident and she stated the CNA did slap her. I ask what happen, resident said she was rolling back and ran over the CNA foot, she heard the CNA say ouch. Resident stated she was turning around and the CNA slapped her. On 11/26/24 at 11:00 AM, V5 stated, I was at the nurse's station when (V3) came and told me (R2) slapped her. I was walking down to (R2)'s room, and on the way down there (V4, CNA) told me something different. I went into (R2)'s room and (R2) stated, '(V3) slapped me really hard.' (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145241 Printed: 05/15/2026 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 145241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 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)