Health inspection·February 14, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections for 3 of 4 residents (R3, R4, R5) reviewed for incontinent care in the sample of 8. Findings include: 1. R3's Face Sheet, print date of 2/14/25, documents that R3 was admitted on [DATE] with diagnoses of flaccid hemiplegia affecting the right dominant side and a personal history of urinary tract infections. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact, requires partial to moderate assistance with toileting, always incontinent of urine, and frequently incontinent of bowel. On 2/14/25 at 4:15 AM, V9 Certified Nurse Assistant (CNA), transferred R3 from the bed, to the wheelchair, and then to the toilet. V9 removed the incontinent brief. The brief was slightly soiled with urine. When R3 finished, she stood up, V9 washed her rectal area with a soapy towel. V9 pulled up the incontinent brief and R3's pants. R3 was transferred back to the wheelchair. V9 failed to cleanse the labia and urethra and failed to dry R3. 2. R4's Face Sheet, Print date of 2/24/25, documents R4 was admitted on [DATE] and has a diagnosis of an anoxic brain injury. R4's MDS, dated [DATE], documents R4 is severely cognitively impaired, is dependent on staff for activities of daily living, is always incontinent of urine, and frequently incontinent of bowel. On 2/14/25 at 4:25 AM, V9 checked R4 for incontinence. R4 was not soiled but V9 provide pericare. With a soapy towel, V9 cleansed the groins, labia and the urethra. V9 failed to flip the towel to a clean portion of towel. V9 rolled R4 over onto her side and cleansed the rectal area and the buttocks with the same portion of the towel. V9 placed a new incontinent brief on R4. V9 failed to dry R4. 3. R5's Face Sheet, print date to 2/14/25, documents R5 was admitted on [DATE] and has diagnoses of history of urinary tract infection and Alzheimer's Disease. R5's MDS, dated [DATE] documents that R5 is severely cognitively impaired, is dependent on staff for activities of daily living, has an indwelling urinary catheter, and is always incontinent of stool (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 02/14/2025 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)