Health inspection·October 8, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to call emergency medical services, EMS, in a timely manner for 1 (R2) of 3 residents reviewed for delay in treatment in the sample of 10. This delay in treatment resulted in R2 experiencing a low oxygen level and later expiring at the the hospital from an unknown cause.Findings Include: R2's Face sheet documents an admission date of 7/30/2025. Diagnosis include Multiple Fractures of Ribs, Right Side, Wedge Compression Fracture of T11-T12 Vertebrae, Dysphagia, Severe Protein Calorie Malnutrition, Acute Thrombosis of Left Femoral Artery. R2's MDS dated [DATE] documents R2 is cognitively impaired.R2's care plan dated 7/31/2025 documents R2 is at risk for altered nutrition and hydration related to diagnosis of Pulmonary Embolism, Fracture of Thoracic Vertebra, Lumbar Fracture, Hyperlipidemia, Dementia.R2's progress notes dated 9/14/2025 at 3:12PM document Note Text: R2 sent to hospital due to possible aspiration and shortness of breath. Oxygen Saturation at 65%. R2 placed on Oxygen with rebreather mask until Emergency Medical Services, EMS, arrived. Blood Pressure cuff continued to read error, unable to obtain Blood Pressure. Emergency contact made aware of transfer.R2's progress notes dated 9/14/2025 at 5:30PM Telehealth Visit Chief Complaints: Emergency Department, ED, Transfer (R2 left building) Comments: R2 sent to ED at 3:12PM. Shortness of Breath, possible aspiration, Oxygen Saturation 65%, R2 placed on Oxygen. Lungs with audible crackles, unable to obtain vital signs. sent to hospital.No documentation of when change of condition began. No documentation of time EMS called. No SBAR, Situation, Background, Assessment, Recommendation, Assessment form completed. No documentation of notification of Physician during change of condition or before EMS being called.On 9/24/2025 at 12:10PM V2, Director of Nursing, DON, stated this happened on a Sunday. The nurse working said this was an acute change in condition. R2 had been fine all day and suddenly was having trouble breathing. R2 was immediately sent out. The nurse did not even call telehealth before calling Emergency Medical Services, EMS.On 9/24/2025 at 12:20PM V4, Certified Nursing Assistant, CNA, stated I was working the day (R2) was sent out to the hospital. When I came in the morning, I cleaned her up and fed her breakfast. (R2) ate all her breakfast and was not coughing or choking at all. She was on a pureed diet. I also fed her lunch. She took most of her lunch and drank all her drinks. I am not sure what time I checked on her next. I want to say 12:00PM-1:00PM. I noticed she was wheezing. I got (V5), Licensed Practical Nurse, LPN, and (V5) got (V3), Assistant Director of Nursing, ADON.On 9/30/2025 at 10:30AM V4, CNA, stated On 9/14/2025 I had started collecting the lunch trays after residents were finished with lunch. That is around the time I checked on (R2) and heard her breathing and rattling. It would've been 12:30PM to 1:00PM. When asked V4 if R2 was alert during the change in condition, V4 stated Her eyes were glazed over.On 9/24/2025 at 1:30PM V5, LPN, when asked about the change of condition on 9/14/2025 regarding R2, stated What about (R2)? (R2) had been fine all day. She ate fine. (V4), CNA, came and got me and told me (R2) was not the same. (R2) had shortness of breath and crackles that were audible. We got the oxygen tank, and I got (V3), Residents Affected - Few Page 1 of 2 145668 145668 10/08/2025 Bria of Belleville 150 North 27th Street Belleville, IL 62226

F 0684 Level of Harm - Actual harm Residents Affected - Few ADON. We then called 911. It happened very fast, so I don't know the exact time everything happened. I was focusing on (R2). I don't know what time (V4) came and got me. I don't know what we called EMS or what time EMS got there.On 9/24/2025 at 1:50PM V3, ADON, stated V5, LPN, came to get me for a change in condition in R2. R2 had audible crackling. She was alert. We put her on 2 liters of Oxygen. We can't go past 4 liters. We called 911 from R2's room because her Oxygen would not stay up. She had been fine until then. We stayed with R2 the whole time. She was never left alone. V5 even called 911 from her personal cell phone. It all happened so fast that there was no change of condition to report to the Physician. EMS put a mask on R2 to help R2 breathe. I don't know the exact time everything took place or what time EMS were called.On 9/24/2025 at 3:00PM V6, Emergency Medical Technician, EMT, stated We were dispatched for a resident having a change in condition. Staff met us in the hallway. I didn't get the nurse's name, but the nurse said, The resident aspirated and now she isn't acting right. When we went in the room I saw the resident. She was unresponsive and very tachypneic in the 130s. She had vomited and it had pooled on her neck and gown. I had to wipe it away. The nurse told me all this started at 1:15PM and then everyone left the room. We put R2 on a high flow oxygen mask and loaded her in the ambulance. She was never responsive, and her lungs were full. I was in the room in the Emergency Department when she passed away.On 9/25/2025 at 11:50AM V2, DON, and V3, ADON, stated This is the time EMS was called for R2 on 9/14/2025. EMS was called at 1:51PM on 9/14/2025. These times are from V4's cell phone.On 9/30/2025 at 12:02PM V6, EMT, stated EMS was called from facility at 1:53PM and arrived at facility at 2:06PM.On 9/30/2025 at 12:30PM V12, Nurse Practitioner, stated I am Monday through Friday and the change of condition for (R2) occurred on a Sunday. I still would've expected one of the on-call Providers to be notified of a transfer to the hospital. I see there is no note saying telehealth was called until after the R2 was transferred. They should've called the on-call provider. When V12 was asked if he would've expected to be notified of R12's change in condition and for 1 hour to have gone by between R2's change of condition and EMS being called V12 stated They should've called the on call provider.Facility policy dated 9/2024 states It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Nursing will notify the resident's physician or nurse practitioner when: There is a significant change in the resident's physical, mental or emotional status. 145668 Page 2 of 2