Health inspection·August 13, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete POA's, and local police were notified.R3's Psychiatry Initial Evaluation Note, dated 4/17/2025 at 12:09 PM, documents the following: Chief Complaint: Initial Assessment. History of Present Illness: 71 y/o (Year Old) Male with Dementia and Agitation. History obtained from patient and staff. Patient pleasant and cooperative with assessment with intermittent confusion. Patient was recently involved in an altercation due to his wandering behaviors, where he was assaulted by another elderly dementia patient for wandering into his room. Patient was not seriously injured, treated and readmitted after being sent to the hospital. Patient can be difficult to redirect, and staff report he can then become easily agitated. Pleasant at time of assessment with some confusion and nonsensical talk. Patient diagnosed with Alzheimer's Disease, psychosis, dementia, GAD (Generalized Anxiety Disorder), MDD (Major Depressive R3's Progress Note dated, 7/17/2025 at 9:40 AM, documents the following: The Identified Offender was assessed using the Identified Offender Risk Assessment and scored a 9, indicating a compromised risk level. The resident continually exhibits significant cognitive impairment and consistent disorientation related to a diagnosis of dementia. The resident has a documented history of behavioral disturbances, including verbal aggression and sexually inappropriate behavior directed toward staff and other residents. The resident also has been known to frequently display wandering and rummaging behaviors. It has been highly recommended that ongoing monitoring and implementation of appropriate interventions should be continued to maintain the safety and well-being of all individuals within the facility.On 8/13/25 at 9:25 AM, V1, Administrator, stated he was not employed by the facility when the altercation between R3 and R8 took place. On 8/13/25 at 9:52 AM, V10, R3's Physician, stated he does not recall the incident between R3 and R8. The Abuse Prevention Policy, dated 9/29/22, documents the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse for these residents. Event ID: Facility ID: 145241 If continuation sheet Page 2 of 7 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 08/13/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to adequately assess and provide supervision to prevent elopement for 1 of 5 residents (R7) reviewed for supervision in the sample of 8.Findings Include:On 8/13/25 at 11:00AM, R7 observed up in his electric wheelchair exiting the facility through the front door. R7 was able to enter the code and stayed in front of the facility.R7's Face Sheet, undated, documents R7 has the following diagnoses: Hemiplegia and Hemiparesis following a Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction, Vascular Dementia, and Acquired Absence Below the Knee of Right and Left Legs.R7's Minimum Data Set, MDS, dated [DATE], documents R7 has a BIMS (Brief Interview of Mental Status) score of 12, indicating R7 has moderate cognitive impairment.R7's Care Plan, dated 1/27/23, documents R7 is limited in physical mobility R/T hemiplegia and amputation. R7 utilizes an electric w/c (wheelchair). R7's electric w/c seat belt damaged.R7's Care Plan, dated 7/18/25, documents R7 is limited in physical mobility R/T (Related To) bilateral amputation, chair bound, and hemiplegia.R7's Care Plan, dated 8/12/25, documents R7 is at risk for falls CVA (Cerebrovascular Accident) with left side hemiparesis, CAD (Coronary Artery Disease), MI (Myocardial Infarction), HTN (Hypertension), NIDDM (Non-Insulin Dependent Diabetes Mellitus), DJD (Degenerative Joint Disease), Depression and Debility secondary to CVA. R7's Progress Note, dated 7/5/2025 at 5:01 PM, documents the following: A visitor notified writer of resident being outside leaning over in wheelchair and unable to get back in the building. Staff went to assist resident and reminded resident that he is not an independent smoker and that he is supposed to follow facilities supervised smoking times due to safety concerns. Resident verbalized understanding and continued to go outside multiple times alone throughout the day.R7's Progress Note, dated 7/8/2025 at 7:20 PM, documents the following: Resident was once again outside in the front smoking, reminded him again that he is not an independent smoker and that he is supposed to follow facilities supervised smoking times due to safety concerns. Resident was upset and asked to be left alone. He continues to knowingly break smoking policy often.R7's Progress Note, dated 8/2/2025 at 5:50 PM, documents the following: Resident had fall in grassy area. Offered ER (Emergency Room) r/t fall; resident refused. Resident was educated on risks of leaving facility unattended, verbalized understanding - stated he needed cigarettes. MD (Medical Doctor) made aware. Attempted to notify POA (Power of Attorney) twice with no answer.R7's progress note, dated 8/2/2025 at 6:12 PM, documents the following: Intervention for fall-educated to remain on safe pathways around facility entrances and to not attempt to leave the facility in his chair alone.On 8/13/25 at 8:41 AM, R7 was observed in bed, eating breakfast. R7 has had both feet amputated. R7 is alert and oriented to person, place, time, and situation. R7 stated he was in his electric wheelchair and went down the hill at a decent speed, on the grass, and hit tire tracks in the grass and the whole chair flipped over his head. R7 stated his right leg had scratches from it. R7 stated he left the facility to go get cigarettes at the gas station. R7 states a black man and a white women stopped to help get him back in his wheelchair. R7 stated he then went back to the facility by himself and told staff what happened. R7 stated if he did make it down the street, he would have crossed by an open opportunity and crossed the street to get to the gas station. The road R7 is referring to is a busy 2 lane road with a center turn lane, at the end of the street, there is a stop light and pedestrian cross walk directly across from the gas station R7 was attempting to go to. R7 states he was pretty close to the road when he fell out of his wheelchair. R7 stated he was scared and could have been killed. R7 stated he did not tell anyone he was leaving the facility and stated, Why would I, I've done it before? R7 stated he is allowed to leave the facility by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145241 If continuation sheet Page 3 of 7 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 08/13/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete himself, but no one knew he left. R7 stated H*** No, he would never do this again. R7 stated his wheelchair is working fine. R7 stated did go to the hospital after the incident. R7's Progress Note, dated 8/2/2025 at 9:04 PM, documents the following: Resident allowed skin assessment once in bed. Resident has open areas noted to bilateral legs and left elbow. Areas cleansed with dressings applied. Wound care team made aware. Spoke with POA about incident and POA stated he will speak with resident about leaving facility unattended.R7's Progress Note, dated 8/4/2025 at 5:29 PM, documents the following: Fall f/u (Follow Up) day 2, resident c/o (complains of) pain to bilateral legs/back/bottom, x-rays completed to legs, no fractures noted. MD made aware of increased pain r/t fall, new order for Norco PRN (as needed), order entered, script received by pharmacy.R7's Progress Note, dated 8/5/2025 at 3:09 PM, documents the following: Resident requested ER (Emergency Room), stated he wanted to get checked out r/t previous fall. Sent to local ER for further evaluation. MD notified. Attempted to notify POA twice, left voicemail.R7's Progress Note, dated 8/6/2025 at 12:17 AM, documents the following: Resident returned to the facility and was placed to bed by 2 EMTs (Emergency Medical Technician) via stretcher. New order for Cephalexin 500 mg PO (by mouth) daily for 10 days r/t wound. Resident resting in bed, call light and side table within reach, VS (Vital Signs) WNL (Within Normal Limits).R7's Elopement Evaluation, dated 3/7/25, documents R7 is not at risk for elopement. There were no recent Elopement Evaluations in R7's record for review. R7's Fall Event, dated 8/2/25, documents R7 had an unwitnessed fall. R7 attempted to leave the facility unattended and fell. R7 is to remain on safe pathways around facility entrances and not to attempt to leave facility in his wheelchair. On 8/12/25 at 12:30 PM, V1, Administrator, stated R7 is able to go outside by himself and he likes to sit out in front of the facility. V1 stated R7 was outside, got onto the grassy area in front of the facility and fell out of his wheelchair. V1 stated R7 stated he was going to get cigarettes. V1 stated R7 still likes to go out front to sit, but they prefer and ask him to go out on the back patio, which he does. On 9/13/25 at 9:20 AM, V1, Administrator, stated R7 has is an activity care plan, documenting his desire to participate in activities of his choosing. V1 stated there is not an assessment to determine if R7 is safe to leave the property without supervision. On 8/13/2025 at 9:20 AM, V9, Registered Nurse (RN), stated R7 is not an independent smoker and is not to be outside by himself. V9 stated he would not be safe outside the facility by himself. On 8/13/2025 at 9:23 AM V8, CNA, stated R7 is not supposed to go outside and smoke by himself, but he still does it. V8 stated R7 is not safe to leave the facility by himself but doesn't see R7 has a flight risk.On 8/13/25 at 9:52 AM, V10, R7's Physician, stated if R7 is competent enough to enter the code to exit the building, then he is capable to go out by himself, R7 is disabled but not mentally incompetent. On 8/13/25 at 9:55 AM, V11, R7's Brother/POA, stated R7 is able to go outside to smoke and leave the facility property by himself. V11 stated this was an unusual situation of him going down the grassy hill instead of using the concrete or road. V11 stated the facility has policies in place to address this sort of thing. V11 stated on that particular day, he didn't make a safe decision even though his mind is with it. V11 stated it could have been worse, R7 could have gotten ran over and killed. The Elopement Prevention Policy, dated 1/2018, documents the following: It is the policy of the facility to provide a safe and secure environment for all residents. Event ID: Facility ID: 145241 If continuation sheet Page 4 of 7 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 08/13/2025 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide revise interventions/approaches for behaviors in a resident with Dementia related to wandering for 1 of 1 resident (R3), reviewed for Dementia Care in the sample of 8.Findings include:On 8/13/25 at 1:00PM, R3 was observed ambulating independently on the hallway he resides. R3 was wandering on the hallway, stopping at various doors but did not enter. R3 is alert to self only.R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, Restless and Agitation, Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia.R3's Minimum Data Set, MDS, dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 2, indicating R3 has severe cognitive impairment.R3's Care Plan, with a review date of 7/22/25, documents R3 is exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. He invades other's spaces without intention, gets confused where his room is. Interventions include: approach resident in a calm manner and to calmly que and redirect. There were no revised or added resident centered interventions since 4/20/25 on the care plan.R3's Progress Note, dated 4/4/2025 at 2:17 AM, documents the following: Resident very confused. Wants to go back home, goes in others' rooms, got into verbal fight with (previous resident) in room [ROOM NUMBER] because (R3) kept going into the (previous resident's) room. Got into room [ROOM NUMBER], refused to get out of the female resident's room. Hit CNA (Certified Nursing Assistant), kicked me, the nurse. Together 3 CNAs got him into his room. Will keep monitoring.R3's Progress Note, dated 4/4/2025 at 5:13 AM, documents the following: Slept for 90 minutes, still going into other rooms, up and down, monitored behavior.R3's Progress Note, dated 4/7/2025 at 2:39 AM, documents the following: CNA informed this nurse (R3) wandered in another resident room and was attacked by resident. This nurse went in to check on (R3) and he was laying in bed, c/o (complaining of) back and neck pain. This nurse observed bruising and lacerations on his upper back and showers (shoulders). Resident AOx1 (Alert and Oriented to Self) and not able to describe what happened. Resident sent to (local hospital) for evaluation. Bed hold policy and all appropriate documents sent with resident.POA (Power of Attorney) called and informed of incident. MD (Medical Doctor) made aware.R3's Progress Note, dated, 4/07/2025 at 6:32 AM, documents the following: Resident returned to facility. NNO (No New Orders) staff will continue to monitor. No signs of distress. No c/o pain or discomfort.R3's Progress Note, dated 4/13/2025 at 7:40 AM, documents the following: Resident was seen by staff sitting on the sides of several residents' beds and was getting aggressive towards staff when asked to get out of their rooms. Resident was given PRN (As Needed) pain and anxiety medication with no results. EMS (Emergency Medical Services) were called and R2 was sent to (local hospital) for further psychiatric evaluation.R3's Progress Note, dated 4/14/2025 at 1:30 AM, documents the following: Resident had some behaviors this shift going in other resident's room. With a lot of redirecting resident finally resting in room, call light within reach. NO (New Order) from MD to increase the dose of following medications: Citalopram 20 mg (milligram) po (by mouth) daily and Rexulti 1 mg (milligram) po (by mouth) daily.R3's Psychiatry Initial Evaluation Note, dated 4/17/2025 at 12:09 PM, documents the following: Chief Complaint: Initial Assessment. History of Present Illness: 71 y/o (Year Old) Male With Dementia and Agitation. History obtained from patient and staff. Patient pleasant and cooperative with assessment with intermittent confusion. Patient was recently involved in an altercation due to his wandering behaviors, where he was assaulted by another elderly dementia patient for wandering into his room. Patient was not seriously injured, treated and readmitted after being sent to the hospital. Patient can be difficult to redirect, and staff report he can then become easily agitated. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145241 If continuation sheet Page 5 of 7 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 08/13/2025 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Pleasant at time of assessment with some confusion and nonsensical talk. Patient diagnosed with Alzheimer's Disease, psychosis, dementia, GAD (Generalized Anxiety Disorder), MDD (Major Depressive Disorder), insomnia, and history of alcohol dependence.R3's Progress Note dated, 4/16/2025 at 7:09 AM, documents the following: Resident had some behaviors this shift going in other resident's room. With a lot of redirecting resident finally resting in room, call light within reach.R3's Progress Note dated 4/16/2025 at 6:03 PM, documents the following: Resident continues behaviors, so I spoke with the doctor today, New Order for Zyprexa 2.5mg daily PRN and recently was placed on Rexulti 1mg, Doctor stated he will have to place the resident on these meds first before he changes medications. Resident resting in chair and cont. (continue) to monitor. R3's Progress Note, dated 4/19/2025 at 6:07 PM, documents the following: This resident continue to go into another resident's room, resident was redirected and will cont. to monitor.R3's Progress Note, dated 5/7/2025 at 5:30 PM, documents resident cont. (continued) behaviors, entering into other residents' room, prn (as needed) meds was given, resident resting in chair and cont. with care.R3's Progress Note, dated 6/19/2025 at 12:09 PM, documents the following: Pt (Patient) found wandering in another resident room. Pt went to sit on the bed and slipped and slid down to the floor. Fall was witnessed. Pt didn't hit his head, no injuries noted VSS (Vital Signs Stable), MD aware. Notified POA immediate intervention was redirecting pt. to dining room.R3's Progress Note dated, 7/17/2025 at 9:40 AM, documents the following: The Identified Offender was assessed using the Identified Offender Risk Assessment and scored a 9, indicating a compromised risk level. The resident continually exhibits significant cognitive impairment and consistent disorientation related to a diagnosis of dementia. The resident has a documented history of behavioral disturbances, including verbal aggression and sexually inappropriate behavior directed toward staff and other residents. The resident also has been known to frequently display wandering and rummaging behaviors. It has been highly recommended that ongoing monitoring and implementation of appropriate interventions should be continued to maintain the safety and well-being of all individuals within the facility.R3's Hospital AVS (After Visit Summary), dated 4/7/25, documents R3 was seen in the emergency room due to being an assault victim. R3's Abuse Investigation Final Report, dated 4/7/25, documents the following: A resident-to-resident altercation was reported to the Administrator that took place to between residents R3 and R8 (Former Resident). It was reported that R8 stormed R3 due to him trying to get into his (R8's) room. R8 was seen hitting, kicking, and scratching, R3 with scissors. The residents were immediately separated. R3 was assessed and was found to have scratches and was sent to the local emergency room for further assessment and treatment. He returned the same day with NNO's. The scissors were taken from R8, and he was sent to the local hospital for a psychiatric evaluation. Upon his admission to the hospital, he was given an emergency discharge from the facility. R8's state guardian was notified of the decision. The facility MD, POA's, and local police were notified.R3's Behavior Tracking, dated June 2025, documents there were10 times redirection and one on one care was provided and was not effective.R3's Behavior Tracking, dated July 2025, documents there were 3 times redirection and one on one care was provided and was not effective. On 8/8/2025 at 11:59 AM, R2 stated There is a man (R3) that's confused and gets into my bed. He just got in to bed with me twice this week on Tuesday 8/5/2025 and Wednesday 8/6/2025. I am paraplegic so I don't know if he touches me. He walks in and is scary. He is a lot bigger than me. When I told him to get out, he said ‘Where is the exit?' Then he went out the door. I have seen him go through my bathroom door and go into another lady's room. On 8/8/2025 at 2:20PM, V5, CNA, stated R3 is a wanderer and is all over. He gets into (R2's) snacks and she puts him out. I haven't heard of him getting into her bed. On 8/8/2025 at 2:25PM, V6, CNA, stated R3 is very busy. He goes all over, and he goes into rooms. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145241 If continuation sheet Page 6 of 7 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 08/13/2025 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete don't know of him getting into (R2's) bed.On 8/8/2025 at 2:30PM, V7 CNA, stated R3 thinks everyone's bed is his bed. He messes with (R2's) snack.The Dementia Clinical Protocol policy, dated 11/2011, documents the following: The staff and physician will review the current physical, functional, and psychosocial status of each individual with Dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Individuals with Dementia can also have a personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions, or other conditions causing or contributing to impaired cognition and problematic behavior. For the individual with confirmed Dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of Dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc. Event ID: Facility ID: 145241 If continuation sheet Page 7 of 7