Health inspection·May 21, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's right to privacy when privacy curtains were not present in their rooms for 4 of 4 residents (R1, R2, R4, and R12) observed in a sample of 23 residents observed for privacy curtains. Residents Affected - Some Findings include: 1.R1's undated face sheet documented diagnoses of Cerebral infarction, asthma, diabetes, gait abnormalities, left hip pain, encephalopathy, sleep apnea, hyperlipidemia, restless leg syndrome, cerebral palsy, and chronic pulmonary embolism. R1's minimum data set (MDS) dated [DATE] documented that she is alert and cognitively oriented. R1 requires substantial assistance for personal hygiene and is dependent for upper and lower body dressing. R1 is always incontinent of bowel and bladder. R1's care plan dated 4/17/2025 documented problems including, assistance with activities of daily living (ADLs), brace on her right lower leg and self-care transferring deficit. Interventions include provide with one or two staff assistance with ADL, provide peri care following incontinence episodes, and staff to help as needed with dressing, toileting, hygiene, and bathing. On 5/19/2025 at 10:25 am, R1 was observed to have one privacy curtain between her bed and the wall that was not pulled during care. It was hanging between the wall and her bed and a few of the hooks were not attached at the top and hanging loosely. There were two knocks on the door and V6 (CNA) called out patient care. One staff member entered anyway and needed the gait belt. V8 (CNA) also knocked and opened the door to see if she was needed. On 5/19/2025 at 3:45 pm, R1 stated that she is missing the privacy curtain on the right side of her bed, between her and the window and she would like to have that. R1 stated that sometimes someone will walk by the window outside and if she is changing it feels rather personal and she feels exposed. 2.R2's undated face sheet documented diagnoses of paraplegia, diabetes, asthma, schizophrenia, hypertension, hyperlipidemia, anxiety disorder, depression, dementia, Injury at unspecified level of cervical spinal cord. R2's MDS dated [DATE] documented she was admitted to the facility on [DATE]. She is cognitively alert and oriented. She requires moderate assistance for lower body dressing and substantial assistance for personal hygiene. R2 is frequently incontinent of bowel and bladder. Page 1 of 3 145290 145290 05/21/2025 Nexus Pavilion at Belleville 727 North 17th Street Belleville, IL 62226

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R2's care plan dated 5/12/2025 documented R2 requires assist with daily care needs related to being paralyzed. The intervention is the staff will anticipate and meet all the resident's needs daily. The interventions include assist resident with ADLSs. On 5/19/2025 at 10:50 am, R2 stated she was wanting the privacy curtain around her bed put back up. R2 stated this had been down for two months. It makes her feel uncomfortable that it is not up there. There were no privacy curtains observed in the room. 3.R4's undated face sheet documented she has diagnoses including psychosis, chronic obstructive pulmonary disease, hypertension, depressive disorder, and an anxiety disorder. R4's MDS dated [DATE] documented she is moderately cognitively impaired and requires use of a walker and a wheelchair for mobility. She requires setup for oral hygiene and requires supervision for all other activities of daily living. She is frequently incontinent of bowel and bladder. R4's Care plan dated 4/14/2025 documented problems including moderate to extreme anxiety, mood distress/depression, dressing self-care deficit, hallucinations/delusions, and mood alteration. She also requires ADL assistance from staff for going to the bathroom. The goal for this is she will maintain current level of ADL function. The interventions are to allow resident sufficient time to perform ADL's, assess and monitor resident's abilities and attention, observe frequently to anticipate, and meet needs and provide 1-2 assist with ADLs as needed. R4's psychotropic notes dated 4/1/2025 documented she is alert and oriented x3 with intermittent confusion. She self-propels in wheelchair and requests ice water and assistance with change of briefs. On 5/19/2025 at 8:15 am no privacy curtains were noted in R4's room. R4 stated it had been a while since she had a privacy curtain. R4 stated that it bothered her not to have a privacy curtain. R4 stated that she was used to having something over there as barrier. On 5/19/2025 at 8:15 am V6 (CNA) came to R4's room with wash basins, towels, and gloves. V7, (CNA) came in to assist V6 with R4's care. V6 instructed R4 to sit on the bed and she told her she couldn't because she was wet. V7 went to get a pad and placed it on the bed. Incontinent brief is slightly wet. No privacy curtain present. 4. R12's undated face sheet documented diagnoses including schizophrenia, chronic obstructive pulmonary disease, diabetes, and hyperlipidemia. R12's MDS dated [DATE] documented he is cognitively alert and oriented. He requires use of a walker for ambulation and requires supervision for all ADL's. He is always continent of bowel and bladder. R12's care plan dated 3/13/2025 documented problems including that he experiences visual/auditory hallucinations, schizophrenia, occasional care refusal, occasional ADL assist, mood alteration and COPD. On 5/19/2025 at 8:45 am there were no privacy curtains noted in R12's room. On 5/21/25 at 8:05 am, R12 stated that not having privacy curtains was a concern for him. R12 stated that the staff would change his roommate in the first bed and there was no barrier for his roommate or himself while the personal care was occurring. 145290 Page 2 of 3 145290 05/21/2025 Nexus Pavilion at Belleville 727 North 17th Street Belleville, IL 62226

F 0583 Level of Harm - Minimal harm or potential for actual harm On 5/19/2025 at 11:05 am, V7 (CNA) stated that she doesn't know why the privacy curtains are down in some rooms. On 5/19/2025 t 11:10 am, V8, (CNA) stated she doesn't know why some of the privacy curtains. She stated she didn't remember when, but they took them down not that long ago. Residents Affected - Some On 5/19/2025 at 11:40 am, V11 (CNA) stated she doesn't know why any of the privacy curtains are down. On 5/19/2025 at 12:50 pm, V14, (Housekeeping/Laundry Supervisor) stated that the facility had bed bugs in a few of the rooms. Due to this the privacy curtains were removed from the affected room, and the rooms on each side of that room about 1-2 week ago. V14 stated that she didn't want to hang the privacy curtains in these affected rooms until she felt comfortable doing so and that the bed bugs were completely gone. V14 stated she has the privacy curtains ready to go. V14 stated she inspects the rooms herself and had planned on hanging the privacy curtains on Wednesday. On 5/21/25 at 10:30 am, V2 (Director of Nursing) stated that the housekeepers are cleaning certain rooms and are doing this on a schedule. V2 stated in the morning meeting, they discuss which rooms they are cleaning. When V2 was asked about the resident' dignity while the curtains are down, she stated they should only remove one curtain at a time. Facility policy titled Activities of Daily Living Dependent Residents last reviewed 8/2024 documented that with the hygiene procedure, privacy is provided for the resident. With the shower or bed bath, provide privacy (close curtains, doors). With elimination privacy is provided to each resident. 145290 Page 3 of 3