Health inspection·January 27, 2026

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 complete indwelling urinary catheter changes as ordered, failed to follow urology physician orders as directed, and failed to verify hospital discharge orders for 1 of 3 residents (R2) reviewed for quality of care in the sample of 4. This failure resulted in R2 developing a urinary tract infection with sepsis that required hospitalization and IV (intravenous) antibiotics. Findings Include:R2's admission Record, print date of 1/22/26, documented R2 has diagnoses including cerebral infarction, osteomyelitis, diabetes mellitus, peripheral vascular disease, urinary tract infection, dysuria, stage 4 pressure ulcer, chronic kidney disease, congestive heart failure, and diabetic polyneuropathy. R2's MDS (Minimum Data Set) dated 12/2/25 documented R2 is cognitively intact, has an indwelling urinary catheter, and is dependent on staff for mobility.R2's Care Plan, initiation date of 12/9/25, documented R2 was diagnosed with a UTI (urinary tract infection) while at outside hospital. R2's urology consult progress notes and order, dated 7/8/25, documented [AGE] year old male with history of hypertension, hyperlipidemia, diabetes, neuropathy, peripheral vascular disease, neurogenic bladder managed with an indwelling urinary catheter, left AKA (above knee amputation), coccygeal wound with osteomyelitis, who presents today for follow-up following a hospitalization where urology was consulted for scrotal swelling. It continues, (R2) states that his indwelling urinary catheter has not been changed at his facility but that the facility is able to do that and just needs an order. It continues, Assessment/Plan: [AGE] year-old male with scrotal edema likely secondary to underlying comorbidities and a neurogenic bladder currently managed with an indwelling urinary catheter. We discussed his situation in some detail and recommended scrotal support for his scrotal edema. I do recommend he get his catheter changed every month at this facility. This can also be done on a PRN (as needed) basis if he has any issues with the catheter not draining. I plan on following up with him in 6 months for re-evaluation. Sooner, should he have any issues. Order for facility: (indwelling urinary) catheter change today and every month indefinitely.R2's progress note, dated 7/8/25 at 6:22 PM, documented resident went to urology appointment today, came back with a new order to change (indwelling urinary catheter) today and monthly after.R2's TAR (Treatment Administration Record), dated October 2025, documented change (indwelling) monthly every night shift starting on the 8th and ending on the 8th of every month. This TAR does not document R2's indwelling urinary catheter was changed as ordered on 10/8/25. R2's progress note, dated 10/9/25 at 3:15 PM, documented this writer was notified by aid that patient had bleeding from penis. Resident due yesterday for monthly (indwelling urinary) catheter change. This writer deposed of old (indwelling urinary catheter) extracting 30 cc (cubic centimeters) of water from balloon. Writer sterilized area and inserted new (indwelling urinary catheter) inputting 30 cc in balloon, met with urine return of clear yellow color. No complaints of pain or discomfort, patient thanked writer. R2's progress note dated 10/20/25 at 1:35 AM documented UA (urinalysis) collected. R2's progress noted dated 10/23/25 at 2:54 PM documented nitrofurantoin microcrystal capsule 100 MG (milligrams), give 1 capsule by mouth every 6 hours for UTI (urinary tract infection) for 7 days.R2's progress note dated 11/4/25 at 7:09 PM documented IM (intramuscular) ABT (antibiotic) continues r/t (related to) UTI. R2's TAR (Treatment Administration Record), dated November 2025, documented change (indwelling) monthly every night shift starting on the 8th and ending on the 8th of every month. This TAR does not document R2's indwelling urinary catheter was changed as ordered on 11/8/25. R2's progress note, dated 12/3/25 at 10:26 AM, documented upon entering resident's room to check morning BS (blood sugar) resident was observed to be shaky with elevated temperature and pulse. Vitals were taken and pulse was tachycardia at 134. Resident was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145668 If continuation sheet Page 2 of 4 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 145668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Belleville 150 North 27th Street Belleville, IL 62226 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 0684 Level of Harm - Actual harm Residents Affected - Few alert and able to tell me that he was not feeling well. BS was 319, resident received 10 units of sliding scale insulin. Resident had emesis before EMS (emergency medical services) arrived. R2's progress note, dated 12/4/25 at 2:52 AM, documented Pt (patient) admitted to (local) hospital for sepsis. R2's hospital History and Physical, dated 12/3/25, documented patient presented from (facility) with complaint of abdominal pain to the lower abdomen with nausea and vomiting. Patient has an indwelling urinary catheter. He states he noticed sediment in his urine recently. He reports they just changed his indwelling urinary catheter 3 days ago, but it had been over 40 days since it had been changed, and the patient reports he had been telling them about it. This morning, he had a fever of 102.3, he also had shaking chills. He does not have much of an appetite and currently rates his abdominal pain at 3/10. He is having some discomfort to his left side. It continues, Assessment and Plan: Patient presented meeting sepsis criteria with a white blood cell count of 20500 with over 4+ leukocytes in urine and 50 white blood cells in his urine and 6-10 red blood cells. I ordered a lactate which is pending but he initially had a fever of 103 upon arrival as well as a heart rate of 110 and an increased respiratory rate at 22. This is a severe medical condition. R2's hospital after visit summary, dated 12/8/25, documented future appointment, follow up with (regional) urology on 4/29/26 with the same medical provider who ordered R2's indwelling urinary catheter to be changed every month. On 1/6/2026 at 3:45 PM R2 stated he's had an (indwelling urinary) catheter for years and prior to moving to the facility he used to have his catheter tubing and bag changed every month and he didn't get UTIs now the facility for whatever reason doesn't change his catheter bag or tubing and he stated he has a physician's order to change both tubing and bag every month. R2 stated he is very frustrated because he's been hospitalized twice within the last few months, and he received IV antibiotics, and the ER physician told him he is getting the really bad UTIs because the facility isn't changing the catheter monthly and the bugs are growing and that's why he's getting the UTIs that require IV antibiotics. R2 stated the UTI was uncomfortable and the second UTI he felt throbbing in his groin. R2 stated he wished the staff would follow physician's orders and change his foley catheter as they should monthly, because if not he is going to get another UTI and he doesn't want another one because it hurts and he hates having to go to the hospital. R2 stated he doesn't know why staff don't change his foley catheter monthly to prevent him from getting UTIs. R2 stated he felt this was neglect.On 1/22/26 at 9:55 AM V18 Case Manager at local hospital stated R2 was hospitalized in July of 2025, the Urology Department followed R2 and ordered his indwelling urinary catheter to be changed monthly. V18 stated R2 was hospitalized for a UTI in December 2025 and R2 stated the facility had not been changing his indwelling urinary catheter every month as ordered. V18 stated the physicians again ordered the catheter to be changed every month.On 1/22/26 at 10:25 AM V16 LPN (Licensed Practical Nurse) stated R2's indwelling urinary catheter is supposed to be changed every month because he was hospitalized in December 2025 with a UTI. On 1/22/26 at 12:10 PM V1 Administrator stated she assumes if an indwelling catheter change is not documented on the TAR then it wasn't completed but she would have to check with V2 DON (Director of Nursing).On 1/22/26 at 1:12 PM Surveyor requested the physician order for R2's indwelling urinary catheter to be changed PRN and not monthly as directed by R2's urologist on 7/8/25. V2 DON stated she must go through 600 pages of documents to find the order. Surveyor asked V2 if it is professional standard to follow the orders from R2's urologist. V2 stated the facility did not receive the order from R2's urologist dated 7/8/25 to change R2's indwelling urinary catheter every month and PRN indefinitely. Surveyor asked if it is standard practice for the facility nurses to call the doctor after a resident sees a specialist to clarify if there are any new orders. V2 replied the facility does not do indefinite physician orders and the urologist's orders are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145668 If continuation sheet Page 3 of 4 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 145668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Belleville 150 North 27th Street Belleville, IL 62226 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete no longer in effect once a resident goes into the hospital.On 1/22/26 at 1:28 PM V2 DON stated she cannot find the order nor physician notification for R2's indwelling urinary catheter to be changed PRN instead of monthly. V2 stated R2's indwelling urinary catheter was not changed as ordered in October nor November of 2025.On 1/27/26 at 8:38 AM R2 stated the last time he was in the hospital the hospital nurse changed his indwelling urinary catheter, and the doctor informed him the catheter needs changed every month. R2 stated the facility does not clean around his catheter site every day and that he rarely gets it cleaned.On 1/27/26 at 10:07 AM V19 Wound Care Nurse stated R2's indwelling urinary catheter is ordered to be changed on night shift. V19 stated if it wasn't signed off then it wasn't documented so it wasn't done. V19 stated R2's urologist ordered R2's catheter to be changed monthly, when R2 was readmitted from the hospital the nurse should have restarted the orders so it should have been activated at that time. V19 stated the nurses restart the previous orders unless specified otherwise for consistency with the orders. The facility's Catheterization of Urinary Bladder policy, dated 6/2015, documented a catheter is placed in the bladder when it is needed to prevent urinary retention, when a resident needs to produce a sterile specimen, when a resident has a stage 3 or 4 pressure ulcer, for accurate intake and output or when the resident is at the end of life and moving them is uncomfortable. It continues, 21. The catheter is changed PRN when it is not draining. This policy does not address following physician orders for indwelling urinary catheter changes. Event ID: Facility ID: 145668 If continuation sheet Page 4 of 4