Health inspection·March 7, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the RT (Respiratory Therapist), made a verbal threat to (R2), diagnosis, quadriplegia, after the resident made a verbal threat to the RT. The RT was immediately suspended. The resident was assessed. There were no signs of injury or emotion distress. The (local police department) was contacted and came to interview the resident. The MD (Medical Director) was notified, as well as the residents' POA. Investigation initiated. Final to follow. Final Investigation: Upon investigation it was reported that the nurse, heard the resident say, don't give me that man and don't speak to me like that [NAME]. The nurse reported that she approached the door to the resident's room and overheard the resident threaten the RT while he was suctioning him if you try and hurt me again, I'm going to have my family come up here and f*** you up, (V5). The RT was heard telling (R2) don't threaten mother f****er! Again, (R2) stated if you try to hurt me again, I will call my family and they will f*** you up! The nurse stated she entered the room and the RT stated, don't threaten me again, I will choke the hell out of you! The nurse immediately got the RT out of the room and the resident was assessed and provided further care from nursing staff. Upon the administrator coming to the facility the RT stated that the resident is going to make him lose his job due to him threatening his life. This administrator spoke to the RT about his actions and the way he handled himself in the situation. The RT was terminated due to poor customer services r/t resident rights. R2's Progress Note dated 02/25/25 at 5:18 AM documents About 15-20 minutes before midnight the CNA alerted the RT that the resident was requesting suctioning. this nurse was at the nurses' station and overheard the RT make a statement to the resident that was don't give me that man. don't speak to me like that [NAME]. this nurse got up and went and stood outside the resident's room to listen to the conversation between the resident and RT. as soon as I approached the door this nurse heard the resident shout at the RT, and make a verbal threat to the RT. The RT then made a verbal threat to the resident. this nurse went to intervene, and the resident again made a verbal threat to the RT and the RT again made a verbal threat to the resident. this nurse shouted for the RT to stop and leave the room, the RT again made a threat to the resident, this time bending over and gesturing with his hands what he was going to do. this nurse walked closer and again shouted at the RT and ordered him to get out of the room. this nurse also called the other nurses into the room to help separate the two and to calm the resident down. this nurse suctioned the resident and another nurse saws to his personal needs and both of us looked over resident to make sure he wasn't injured in anyway. this nurse then left the room to make calls to the administrator, and on call. per resident's request and per administrator (local police department) was called to obtain a report. the resident mother was also called to be advised of the verbal altercations that took place. the resident is resting quietly at this time. will continue to monitor. On 03/07/25 at 9:13 AM, R2 stated that (V5) was rough while suctioning. He stated V5 was fired once before for rough suctioning and threatening to kill a nurse. He stated that they rehired (V5). He stated that (V5) was not supposed to suction him. (V5) was allowed to check the vent but not suction him because he was rough before. He stated that nurse was supposed to suction him. He stated that night he had a lot of secretions and needed to be suctioned more often. He stated that night (V5) started off being cool with him. He stated that after asking to be suctioned for 3rd time, (V5) started complaining about being the only RT working and that he did not have time to keep come in there to suction him. R2 stated that (V5) started ramming the suction catheter into his throat and leaving the suction on for too long causing him to not be able to breath. He stated that he did threaten (V5) that if he ever did that again that he would have his family come to the facility and f*** (V5) up. He stated that him and (V5) went back with verbal threats. He stated that (V5) threatened to kill and put his hands around his throat about inch away like (V5) was going to choke him. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145241 If continuation sheet Page 2 of 3 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 03/07/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that nurse came into the room and told (V5) to get out but (V5) ignored her. He stated that she left and came back with a male staff. He stated that while the nurse was gone that (V5) had bawled up his fist and pressed his fist into face near his nose and eye socket. He stated that the nurse told (V5) again and this time he listened because she had a male staff with her. He stated that he issues with a nurse named (V7). He stated she was supposed to change his wound dressing after the Aids gave him a bed bath. He stated that after they had finished giving him a bath, he was lying there with a gown and sheet covering him only. He stated that it took her long time to come do his wound care. He stated that when she got done, he asked to wrap his lower leg because the bandage falls off and get blood on his bed. He stated that (V7) told him that he did not need it to be wrapped. He stated that told her the reason why and she left. He stated that it was around 6pm because staff was feeding him dinner that (V7) and wrapped his leg. He stated that when she was leaving the room, she said you're welcome but he ignored her and continued eating. He stated that when she got the door, she turned around again and said, you're welcome He stated that he told her that he heard her and did not have to say thank you for doing your job. He stated that she walked back over to bed and flip the blanket off his leg. He stated that she unwrapped the dressing and that she had just put on. He stated that she then threw the dressing in the trash. He stated that later on that evening that (V7) back into the room to do something for his roommate and (V7) said something about she was working the weekend and that they were going to have a good time. He stated that he took as a threat and asked if she was threatening him. He stated that she said no and that she was just saying that were going to have a good time this weekend. On 03/07/25 at 1:55 PM, V3, LPN (Licensed Practical Nurse) stated that she was sitting at the nurses' station and could hear (R2) and (V5), RT yelling at each other. She stated that she got up and went down the hall to investigate. She stated that she heard (V5) say, don't start that shit with me. She stated that she then heard (R2) say, if you suction me hard like that again, I am going to have my family come here and f*** you up. She stated that she heard (V5) tell (R2) twice that he was going to choke him to death. She stated that the second time he said it to (R2), that (V5) was leaning over (R2) with his hands close to (R2's) throat like he was going to choke him. She stated that she yelled at (V5) to leave (R2's) room and (V5) did not, so she went and got (V4), another nurse. She stated that by the time she got (V4), (V5) had left the room. On 03/07/25 at 2:16 PM, V1, Administrator stated that she thinks both incidents involving (R2) was out of frustration. She stated that (R2) uses his words to push people. She stated that she does not think that (V5) should have said what he said to (R2). She stated that she tells staff that they have the ability to walk away if (R2) is pushing their buttons. She stated that ultimately her job is to protect the residents so that is why is terminated (V5) and (V7). Facility's Abuse Prevention Policy dated 9/29/22 documents This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145241 If continuation sheet Page 3 of 3