Health inspection·September 19, 2025

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 physical abuse did not occur for 2 of 3 residents (R1) and R3) reviewed for abuse in the sample of 7. 1-R1's Physician Order Sheet for August 2025 documents a diagnosis of nontraumatic subarachnoid hemorrhage, moderate protein calorie malnutrition, mucopurulent chronic bronchitis, weakness, major depression disorder, acute diastolic heart failure, pleurisy, anxiety disorder and spinal stenosis of the cervical region. R1's Minimum Data Set (MDS) dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. No impairments on the upper or lower extremities and independent on most tasks and does not need assistance with some tasks. R1's Initial Incident Report dated 8/21/2025 at approximately 1:35 PM, there was an altercation between (R1) and (R3). There was no injury to either resident. The two were immediately separated. The Administrator was notified. A full investigation and a final report sent when complete. R1's Care Plan document under Abuse with the date initiated of 12/10/2024 documents, (R1) had verbal/physical altercation with another resident (no injuries) on 7/9/2025. The Care Plan does not address the resident-to-resident altercation on 8/21/2025. R1's Progress Notes do not address the resident-to-resident altercation on 8/21/2025. A Statement from V8, Certified Nursing Assistant (CNA) dated 8/21/2025 documents, I (V8) was bringing (R3) from the dining room pushing her to the room. Once there another resident was in her room. She asked (R1) to not move her curtain, then (R1) said ‘wait Bitc*' to (R3) then (R3) rode down on (R1) and punched her in the back, then (R1) turned around and punched (R3) in the face, then I pulled (R3) back then everything was over. On 9/19/2025 at 2:11 PM, a phone message was left for V8, but she never returned the call during this survey. A statement from V7, Infection Control Preventionist (ICP) dated 8/21/2025 documents, Around 1:15 PM, I heard a CNA screaming while standing at the back nursing station. I turned around and saw CNA (V8) holding (R3) hand and resident punched (R3) in her face. Placed myself in between both residents. Calmly asked Resident (R1) to remove herself from the room. (R1) grabbed her walker and walked out. Called (R3) a bitc*. On 9/19/2025 at 11;21 AM, V7, Infection Control Preventionist stated, I had just got to the nurse's station, and I heard a staff yelling and I turned around and saw (V8, CNA) with (R3) and saw (R1) punch (R3) in the face. I put myself between the residents and tried to calm them down. I am not aware of either one of them being aggressive. All I know is that (R1) was going into (R3's) room because she is friends with (R3's) roommate. On 9/19/2025 at 11:39 AM, R1 stated, I was friends with (R7) and she shared a room with (R3). I liked to spend time with (R7) we are friends. (R3) was upset because she would pull the curtain, and she was upset with me because I was in her room, and she called me a name and hit me in the back, so I hit her back in the face. 2-R3's August POS 2025 documents a diagnosis of type 2 diabetes morbid obesity, chronic respiratory failure, major depression disorder, anemia, hyperparathyroidism and chronic kidney disease. R3's MDS dated [DATE] document R3 was cognitively intact for decision making of activities of daily Page 1 of 2 145668 145668 09/19/2025 Bria of Belleville 150 North 27th Street Belleville, IL 62226

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few living. R3 has impairment on both her upper and lower extremities, she uses a walker and wheelchair; She requires minimal assist to supervision for most ADL's (activities of daily living). R3's Care Plan: Abuse with a revision date of 8/28/2024 document, (R3) is at risk for abuse and neglect r/t (related to) DM (diabetes mellitus), neuropathy, morbid obesity, CKD3, cardiomegaly/HTN. R3's altercation on 8/21/2025 was not addressed on her care plan. On 9/19/2025 at 11:40 AM, R3 stated, I used to be in another room. I liked to have the curtain pulled all the way. At that time (R7) was my roommate and she was friends with (R1). (R1) liked to push (R7) in her wheelchair and every time she would come into the room she would move the curtain. I told her to stop moving the curtain and she would not listen and the next time she came in the room and moved the curtain I got mad and smacked her one because she would not listen. R3's Final Report document (R3) is a [AGE] year-old female resident. She admitted (Facility) on 8/26/2024. She is alert and oriented x 4. Her BIMS (brief interview for mental status) score is 15 (15/15). She is able to ambulate short distances with a walker, but primary mode of locomotion is a wheelchair. She requires minimal assist to supervision for most ADL's (activities of daily living). Her diagnosis includes type 2 diabetes morbid obesity, chronic respiratory failure, major depression disorder, anemia, hyperparathyroidism and chronic kidney disease. On 8/21/225 at approximately 1:35 PM residents were involved in a verbal disagreement which resulted in one resident making physical contact with the other residents. Staff intervened immediately, both residents were interviewed and assessed by staff. Neither resident had any injures and both stated they feel safe in the facility. (V8) reported that she was taking (R3) back to her room and there was another resident (R1) in the room. (R3) told (R1) not to move her curtain. (V7) stated that she heard a CNA hollering and she turned and saw (V8) holding back resident (R3). (V7) placed herself between the two residents and calmly asked (R1) to remove herself in the room. (R1) grabbed her walker and left the room. The Facility Abuse Policy 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5). 145668 Page 2 of 2