Health inspection·March 2, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide twice weekly showers and bed linen changes for 2 of 2 dependent residents (R19, R57) reviewed for ADL (Activities of Daily Living) care in the sample of 45. Residents Affected - Few Findings include: 1. On 02/26/23 at 11:28am, R19 was alert and oriented to person, place and time. R19 stated she is not getting twice weekly showers as she is supposed to be. R19 stated her bed linens are also supposed to be changed on shower day. R19 stated, I haven't had a shower in about two weeks, and since my bed linens haven't been changed, they are stinking so bad I have to spray deodorant on them. R19's Minimum Data Set (MDS) dated [DATE] indicated that R19 requires physical help from at least one staff member for bathing. R19's January and February Shower Sheets documented that on the week of 2/12/23, R19 got a shower once that week, on 2/14/23. As of 2/27/23, there was no documentation to indicate R19 had received a shower after 2/14/23. There was no documentation to indicate R19 had refused any showers in February 2023. 2. On 02/26/23 at 12:16pm, R57 was alert and oriented to person, place, and time. R57 stated she is not getting twice weekly showers as she is supposed to. R57's bottom bedsheet was observed to be streaked with feces. When the surveyor asked about it, R57 stated the sheets are changed on shower day, and R57 stated she had not had a shower in a week, therefore the sheets have not been changed. R57 stated a visitor saw the condition of the bottom sheet and had offered to try to change her bed for her, but she refused as she feels it is not the visitors job to change bed linens. R57's Shower Sheets for January and February 2023 documented that on the week of January 29th, R57 got one shower, on 2/1/23. These sheets further document that on the week of 1/19/23, R57 got one shower, on 2/20/23. As of 2/27/23, R57 had not been showered past 02/20/23. There was no documentation to indicate R57 had refused showers within these weeks. R57's MDS dated [DATE] documented that R57 requires physical help from at least one staff member for bathing. On 03/01/23 at 8:34am, V16 (Certified Nursing Assistant/CNA), confirmed residents are to receive two showers per week. V16 confirmed that bed linens are changed on shower day and should be changed as needed in between. V16 stated when she is scheduled as the only CNA on the A Hall, which is where R19 and R57 live, it is very hard to get all the showers and linen changes done. On 03/01/23 at 10:20am, V3 (Director of Nurses) confirmed residents are to get two showers per week with a bed linen change on shower day and in between as needed. V3 confirmed that when residents refuse a shower, it is to be documented on the shower sheets. A Bathing a Resident Policy dated July 2014 documented, It is the policy of (the facility) that residents will receive a shower/bath (to) be scheduled regularly and PRN (as needed). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 2 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide range of motion (ROM) exercises per physicians orders for 3 of 3 residents (R50, R1, R38) reviewed for ROM in the sample of 45. Findings include: 1. R50's February 2023 Physicians Order Sheet documented an order for, Restorative therapy for PROM (Passive Range of Motion) 6-7 times per week, twice a day. R50's Diagnosis List documented diagnoses including Hemiplegia and Hemiparesis to the dominant right side. R50's Minimum Data Set (MDS) dated [DATE] documented that R50 has impairment to one side of the body as well as both upper and lower extremities. R50's Care Plan with a review date of 3/1/23 documented a problem area of, Resident requires PROM to all extremities 6-7 days per week, with a corresponding intervention, Provide PROM to all extremities 3-5 repetitions per joint. R50's Point of Care History for February 2023 documented that R50 did not receive ROM at all on 2/8/23, and received ROM only once per day on 2/4/23, 2/5/23, 2/12/23, 2/15/23, 2/16/23, 2/17/23, 2/18/23, 2/20/23,2/22/23, 2/24/23, and 2/28/23. There was no documentation to indicate R50 refused ROM on any of the above referenced dates. On 02/27/23 at 2:47pm, V21 (Certified Nursing Assistant/CNA) was observed performing ROM exercises with R50. R50 was alert but could only say yes and no repeatedly in a nonsensical fashion. When asked how often R50 is getting ROM, V21 stated, I'm not sure, but probably daily. V21 began with R50's ankles, dorsi-plantar flexing each ankle once. R50 did not resist or show any signs of pain. V21 did not attempt to further exercise either ankle. V21 did not attempt to move R50's toes on either foot. V21 moved through the lower and upper extremities, doing three repetitions to each joint, skipping the neck. V21 stated she was finished with the procedure and covered R50 back up with the blanket. The surveyor asked V21 if she intended to exercise R50's neck, to which V21 replied she was not sure if the surveyor had wanted her to do that. V21 then exercised R50 neck giving only one repetition to each side and one repetition up and down, with R50 showing no signs of pain or refusal to cooperate. 2. R1's February 2023 Physician Order Sheet documented an order for, Restorative therapy program for PROM (Passive Range of Motion) 6-7 times per week twice a day. R1's Diagnosis List documented diagnoses including Cerebral Palsy, Muscle Weakness, and Abnormal Posture. R1's MDS dated [DATE] documented that R1 has one sided impairment to the upper and lower extremities. R1's February 2023 Point of Care History documented that R1 did not receive ROM at all on 2/8/23, and received ROM only once daily on 02/02/23, 02/04/23, 02/05/23, 02/12/23, 02/15/23, 02/16/23, 02/17/23,02/18/23, 02/20/23, 02/22/23, 02/24/23, and 02/28/23. There was no documentation to indicate R1 refused ROM on any of the above referenced dates. On 02/28/23 at 11:01am, V17 (CNA/Transporter/Medical Records staff) was observed performing ROM for R1. V17 stated she primarily does transport and medical records and helps on the floor when needed. R1 was alert and oriented to person, place, and time. R1 was noted to have a contracted left arm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 3 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and hand. R1 stated, I haven't been moved this way in forever, it sure feels good to be stretched like this. R1 stated it has been a while since he has had any range of motion. R1 stated, When would these girls (staff) even have time to do it? They don't have enough help around here. 3. R38's February Physicians Order Sheet documented an order for, Restorative therapy program for PROM (Passive Range of Motion) 6-7 times per week three times a day. R38's Diagnosis list documented diagnoses including Quadriplegia. R38's 1/9/23 MDS documented that R38 has impairment to her upper and lower extremities on both sides. R38's February 2023 Point of Care History documented that on 02/05/23, 02/06/23, and 02/17/23, R38 did not receive ROM at all, received ROM once per day on 02/01/23, 02/02/23, 02/08/23, 02/18/23, 02/19/23, 02/20/23, 02/24/23, and 02/28/23, and received ROM twice per day on 02/03/23, 02/07/23, 02/09/23, 02/10/23, 02/12/23, 02/13/23, 02/14/23, 02/16/23, 02/21/23, 02/23/23, 02/25/23, 02/26/23, and 02/27/23. There was no documentation to indicate R38 refused ROM on any of the above referenced dates. On 02/26/23 at 12:09pm, R38 was alert and oriented to person, place, and time. R38 stated she is not engaged in physical therapy and does not get ROM services. On 02/28/23 at 11:27am, R38 stated she would not allow the surveyor to observe her ROM. On 02/28/23 at 12:40pm, when asked about the report from the above referenced residents, V3 (Director of Nurses) stated she does not believe residents are not getting ROM as ordered. V3 stated she believes there may be an issue with it not being documented. V3 stated the Restorative Aid quit about three weeks ago and has not yet been replaced, therefore it is the responsibility of the CNAs on the floor to do the ROM on their halls. A Restorative Nursing ROM Exercises Policy dated '2011' stated, Passive (ROM) (Purpose): To preserve the range of motion in joints and stimulate circulation in the unconscious, paralytic, or very weak patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 4 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview, observation, and record review, the facility failed to provide sufficient nursing staff to ensure resident's care needs were being met in a timely manner. This failure has the potential to affect all 70 residents living in the facility. On 02/26/23 at 10:20am, R40 was alert and oriented to person, place, and time. R40 stated call lights can take up to two hours to be answered, and evening shift is the worst for this issue. On 02/26/23 at 10:25am, R19 was alert and oriented to person, place, and time. R19 stated she is not getting twice weekly showers and bed linen changes. On 02/26/23 at 10:35am, R17 was alert and oriented to person, place, and time. R15 stated it is rarely less than 30 minutes for his call light to be answered. On 02/26/23 at 10:50am, R125 was alert and oriented to person, place, and time. R125 stated call light wait times can be up to two hours. On 02/26/23 at 12:16pm, R57 was alert and oriented to person, place, and time. R57 stated she is not getting twice weekly showers and linen changes' bed linens were observed to be streaked with feces. R57 stated she has not had a shower in a week. R57 stated she regularly waits up to an hour for her call light to be answered. R57 stated the facility does not have enough staff on any shift. On 02/28/23 at 11:01am, R1 was observed receiving range of motion exercises. R1 stated he is not getting range of motion done regularly. R1 stated, When would these girls (staff) have time to do it? They don't have enough help around here. On 12/28/23 at 12:40pm, V3 (Director of Nurses) stated she does not believe residents are not getting range of motion regularly as she believes there is an issue with staff not documenting it. Resident Council Meeting Minutes documented the following issues: 10/27/22: Waiting too long for call lights. (Staff) hurrying in and hurrying out of the room (without meeting the resident's needs). 1/26/23: Taking too long to answer call lights. 2/23/23: Call lights take too long to answer. On 03/01/23 at 8:34am, V16, (Certified Nursing Assistant/CNA), stated getting all the showers and linen changes done can be very difficult, especially when she is assigned as the only CNA on A Hall. On 03/02/23 at 10:10am, V3, stated the facility is meeting the State of Illinois' minimum staffing requirements. V3 stated she did not believe it takes up to two hours for call lights to be answered. V3 stated it was probably the residents perception that it was taking that long. The facility's Staffing Policy dated November 2017 documented, Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 5 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0725 staffing on each shift to ensure that our residents needs and services are met. Level of Harm - Minimal harm or potential for actual harm The facility's Answering the Call Light Policy dated July 2014 stated, Purpose: The purpose of this procedure is to respond to the residents needs and requests .8. Answer the residents call light as soon as possible. Residents Affected - Many The facility Resident Census and Conditions Form dated 02/26/23 documented a total of 70 residents living at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 6 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, observation and record review the facility failed to administer ordered medications per current standards of practice for 1 of 4 residents (R12) reviewed for medication administration in a sample of 45. Findings include: R12's Face Sheet documents diagnosis includes: Heart failure, Dementia, Anxiety Disorder, Atherosclerotic heart disease of native coronary artery without angina pectoris, Polyosteoarthritis, Paroxysmal atrial fibrillation, Hyperlipidemia, Angina pectoris, Hypothyroidism, Cognitive communication deficit, Presence of coronary angioplasty implant and graft, Essential (primary) hypertension, Edema, Pain, Depression. R12's Physician's Order sheet dated 02/01/23 to 02/28/23 document orders for: Atorvastatin 80 mg tablet to be given 6:00 AM - 10:00 AM, Carvedilol 3.125 mg 1 tablet to be given 6:00 AM - 10:00 AM, Furosemide 20 mg to be given 6:00 AM - 10:00 AM, Meloxicam 7.5 mg to be given 6:00 AM - 10:00 AM, Potassium Chloride 20 mg to be given 6:00 AM - 10:00 AM, Sertraline 100 mg to be given 6:00 AM - 10:00 AM. On 02/28/23 at 9:30 AM a cup of seven pills were observed located on R12's night stand. On 02/28/23 at 10:30 AM, R12 who was alert to person, place and time, stated these are her pills, she needs to take these pills still. She stated she knows what some of the pills are for, the big one is her Potassium and she thinks that tiny one is for her heart, she drops that one a lot. On 02/28/23 at 11:45 AM, V15 (Licensed Practical Nurse) identified the pills that were still left in the cup as: Atorvastatin 80 mg tablet, Carvedilol 3.125 mg, Furosemide 20 mg, Meloxicam 7.5 mg, Potassium Chloride 20 mg, Sertraline 100 mg. V15 then stated she handed R12 the pills and she had them in her hand when her roommate asked her to look at something so she walked over to her and R12 must have put the pills back into the cup. She did not realize she did not take them right then. V15 stated, she usually watches the residents take their medications. She stated, she knows they are supposed to watch them take their medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 7 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food to residents that was palatable and at a preferred temperature. This has the potential to affect all 70 residents residing at the facility. Residents Affected - Many Findings include: 1. On 02/26/23 at 11:05 AM, R125 who was alert to person, place and time stated the food is frequently cold, it does not matter if he eats in his room or the dining room. On 02/27/23 at 11:35 AM, R4 stated sometimes the food is cold, especially breakfast. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 12 (moderately impaired). On 02/26/23 at 12:40 PM, R19 stated the food is cold and that it is frequently a problem. R19's MDS dated [DATE] documents a BIMS of 15 (cognitively intact). On 02/27/23 at 12:12 PM, R7 stated the food is cold, he does not like the scrambled eggs, the sausage was cold this morning, especially this far down the hall. R7's MDS dated [DATE] documents a BIMS of 14 (cognitively intact). On 02/27/23 at 12:45 PM, R49 who was alert to person, place and time stated the food can be cold and it makes it taste not so great. On 02/27/23 at 11:29 AM, R65 stated the food is not hot, sometimes even cold, it is not very good and sometimes she cannot even eat it. R65's MDS dated [DATE] documents a BIMS of 15 (cognitively intact). On 02/27/23 at 12:17 PM, R72 stated the food is cold, but it is ok, usually breakfast is the coldest. R72's MDS dated [DATE] documents a BIMS of 09 (moderately impaired). 2. On 03/01/23 at 8:15 AM Breakfast menu documents: Wednesday 03/01/23 choice of cereal, choice eggs 1 egg, biscuits, and gravy 1 biscuit and 1 ounce gravy, margarine 1 each, juice of choice 6 ounces, 2% milk 8 ounces, coffee or tea 6 ounces. On 03/01/23 at 8:15 AM a metal stemmed thermometer was calibrated using the ice point method. On 03/01/23 at 8:15 AM a test tray from the food cart for the D hall was observed and had the temperature measured of the hot item on the tray, the breakfast consisted of cereal, biscuits and gravy, orange juice 6 ounces, milk 6 ounces and coffee. The biscuits and gravy were 109 degrees Fahrenheit using a calibrated metal stemmed thermometer. At that time the biscuits and gravy tasted bland with a cool temperature. On 03/02/23 at 11:20 AM, V8 (Dietary Manager) stated she does not know why the food was cold and that she was sure the food was at least at the holding temperature on the steam table. 3. Resident Council minutes dated 01/26/23 and 02/23/23 document: the food tasting awful and food being cold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 8 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete The facility policy dated 12/2016 titled menus and food preparation documents: Food shall be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs. Food shall accommodate resident allergies, intolerances, and preferences. Food and drinks served shall be palatable, attractive and at a safe and appetizing temperature. The Resident Census and Conditions of Residents dated 02/26/23 documents 70 residents residing at the facility. Event ID: Facility ID: 145388 If continuation sheet Page 9 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on interview, observation and record review the facility failed to provide supplements as ordered by the physician for 1 of 4 residents (R7) reviewed for nutrition in a sample of 45. Residents Affected - Few Findings include: R7 records document R7 has an admission date of 09/19/22 with diagnosis including: fracture of the tibia, type II Diabetes, Hypertension, fracture of the T12, Chronic Kidney Disease, and Coronary Artery Disease. R7's Physician Order sheet dated 12/01/22 documents an order with a start date of 12/20/22 stating offer nutritional ice cream with lunch and supper. R7's Progress Note dated 02/27/2023 at 5:58 AM by V25 (Registered Dietician) documents: R7's current body weight is 178.2 pounds and body mass index is 23.8 (within normal limits). He intakes a mechanical soft diet including diet condiments/beverages along with an evening snack, double protein with breakfast and lunch and he is offered a nutritional ice cream with lunch and supper. He is at risk for weight loss as evidenced by the acute disease stress, and the inflammatory nature of the diagnoses. R7's weights and vitals document: on 01/16/23 at 1:47 PM R7's weight was 184.2 pounds on 02/20/23 at 1:38 PM R7's weight was 178.2 pounds. On 02/26/23 at 12:10 PM, R7's lunch tray did not contain a nutritional ice cream supplement. On 02/27/23 at 12:15 PM, R7's lunch tray did not contain a nutritional ice cream supplement. On 03/02/23 at 11:20 AM, V8 (Dietary Manager) stated they have not been out of any nutritional supplements, she does not know why R7 did not receive has nutritional supplement as ordered. On 03/02/23 at 4:20 PM, V25 (Registered Dietician) stated, she would expect R7 to receive the supplement she has recommended for him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 10 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide snacks to the residents. This has the potential to affect all 70 residents residing at the facility. Findings include: 1. On 02/26/23 at 2:40 PM, R70 stated, they do not receive evening snacks. R70's MDS dated [DATE] documents a BIMS of 12 (moderately impaired). R70's Progress Note dated 01/25/23 at 4:11 PM by V25 (RD) documents: R70's current body weight is 142 pounds; her body mass index is 21.5 (Underweight). She intakes a regular diet along with an evening snack. She is at risk for weight loss as evidenced by the acute disease stress and the inflammatory nature of the diagnoses. 2. On 02/26/23 at 3:00 PM R7 stated, they do not receive evening snacks. R7's MDS dated [DATE] documents a BIMS of 14 (cognitively intact). R7's Progress Note dated 02/27/2023 at 5:58 AM by V25 (RD) documents: R7's current body weight is 178.2 pounds and body mass index is 23.8 (within normal limits). He intakes a mechanical soft diet including diet condiments/beverages along with an evening snack, double protein with breakfast and lunch and he is offered a magic cup with lunch and supper. He is at risk for weight loss as evidenced by the acute disease stress, and the inflammatory nature of the diagnoses. 3. On 02/26/23 at 1:30 PM R54 shook his head no when asked if receives a snack in the evening. R54's progress note dated 02/27/2023 at 6:32 AM by V25 (RD) documents R54's current body weight is 146.6 pounds-down 6% x1 month; 9% since admission. R54's body mass index is 23.66 (within normal limits). He is in facility for rehab from surgery. He intakes a regular diet including prostat@30cc's two times a day, and an evening snack. He is at risk for weight loss as evidenced by the acute stress of disease and the inflammatory nature of the diagnoses. 4. On 02/26/23 at 2:20 PM R4, stated they do not bring them snacks, especially evening snacks. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 12 (moderately impaired). 5. On 02/27/23 at 12:10 PM, R72 stated they do not receive evening snacks. R72's MDS dated [DATE] documents a BIMS of 09 (moderately impaired). R72's progress note dated 02/03/23 at 3:38 PM by V25 (Registered Dietician) documents: R72 's current body weight is 171 pounds and his body mass index is 23.19 (within normal limits). R72 intakes a regular diet along with an evening snack. Continue R72's current diet and encourage intake. 6. On 02/27/23 at 11:30 AM, R58 who was alert to person, place and time stated they do not get evening snacks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 11 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 02/27/23 at 12:35 PM. R65 stated they do not get evening snacks and she thought they were supposed to if it was more than 14 hours between evening meal and breakfast. R65's MDS dated [DATE] documents a BIMS of 15 (cognitively intact). On 02/26/23 at 12:00 PM, V8 (Dietary Manager) stated, that breakfast was at 7:30 AM, lunch is around 11:30 AM and dinner is 4:30 - 5:00 PM. On 03/02/23 at 11:15 AM, V20 (Licensed Practical Nurse) stated she does not know why they are not given snacks to deliver to the residents in the evening, sometimes she will be given some peanut butter and jelly sandwiches for some of the diabetic residents. She would have to guess that they would come from the kitchen. On 03/02/23 at 4:20 PM, V25 (Registered Dietician/ RD) stated she expects the residents to receive an evening snack. She has the evening snack written into her dietary recommendation for several residents due to their potential for weight loss. On 03/02/23 at 11:20 AM, V8 stated they are supposed to get evening snacks, she does not know why they are not taking them to them. Resident Council Minutes dated 01/26/23 and 02/23/23 document, no evening snacks are being given to residents. The untitled undated facility Policy documents: Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. An H.S. (evening) snack shall be provided by Dietary and offered to the residents by nursing. Additional snacks shall be provided between meals as ordered by the physician or per resident's request. Dietary shall be responsible for all food preparation including snacks and shall deliver meals (with assigned assistance) to the residents or to the nursing units. Snacks shall be delivered to the nursing units by dietary personnel. Nursing shall be responsible for distributing snacks to the residents. 5. Dietary shall deliver nourishments to the nursing units. Nursing shall be responsible for distribution of snacks. The Resident Census and Conditions of Residents dated 02/26/23 documents 70 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 12 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, observation and record review, the facility failed to sanitize dishware according to minimum sanitary guidelines and failed to serve drinks and utensils using sanitary methods. This has the potential to affect all 70 residents residing at the facility. Findings include: 1. On 02/26/23 at 09:30 AM the facility did not have any Chlorine test strips to test the dish machine that was using a chorine-based sanitizer, pool test strips were on top of the dish machine. V24 (Dietary) tested the dish machine by dipping the pool test strip into the water of the dish machine and comparing it to the color range on the container. V8 (Dietary Manager) stated, it is fine, see it is in the ideal range, when surveyor asked what the matching color for ideal would convert to it parts per million (PPM) V8 stated she is not good at math. On 02/26/23 at 10:30 AM, V24 (Dietary) stated, the dish machine has not been tested yet today, they do not have any test strips besides the pool strips. On 02/26/23 at 10:50 AM, V24 tested the dish machine after acquiring some chlorine test strips, the test strip read 10 ppm chlorine. On 02/26/23 at 11:00 AM, V8 stated this is the first time they have tested the dish machine today, it is reading 10 ppm chlorine. She stated she will have to see if they have another jug of dish soap or rinse. On 02/26/23 at 11:10 AM it was observed that the container of sanitizer for the dish machine had been exchanged for a different container of sanitizer. On 02/26/23 at 11:15 AM, V8 checked the dish machine again, it was still running and dishes were being washed, and the test strip read 25 ppm. V8 stated, the dish machine is good now. When the surveyor asked what the range the dish machine was supposed to be reading as, V8 stated, she could not find that information on the test strip container. On 02/26/23 at 11:17 AM, V8 observed the blank dish machine log sheet in the kitchen that states the minimum level of chlorine needed to sanitize dishware as 50 ppm, V8 stated, Oh, I guess it is low, we will have to see what we can do. I guess we could sanitize the dishes in the three-compartment sink. At 11:25 AM dishes were still being washed and put away with no sanitization via a three-compartment sink. At 12:20 PM dishes were still being washed and put away with no sanitization via a three-compartment sink. The facility policy dated 01/2012 titled, Machine Ware Washing documents: 1. Employees that use the ware washing machine will be responsible for knowing how to use the machine, document its use, and properly maintain it after use. Steps include: Check sanitizer concentration using appropriate test strips. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 13 of 14 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 145388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Olney 410 East Mack Olney, IL 62450 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. On 02/26/23 during lunch service between 11:40 AM and 1:00 PM, V23 (Dietary) touched several resident's silverware by the eating portion and several resident's drink ware by the rim after touching: wheelchair handles, the chairs in the dining room, the handle of the cart, and her eyeglasses. V8 (Dietary Manager) carried resident's drinks up against her shirt and carried several resident's drinks by the rim and after touching the cart handle, resident's chairs, the refrigerator door, the milk container, her mask, her shirt, her pants. The facility policy dated 01/2012 titled, Machine Ware Washing documents: 1. Employees that use the ware washing machine will be responsible for knowing how to use the machine, document its use, and properly maintain it after use. Steps include: Check sanitizer concentration using appropriate test strips. The Resident Census and Conditions of Residents Form dated 02/26/23 documents there are 70 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145388 If continuation sheet Page 14 of 14