Inspection·August 24, 2022

F 0692 Level of Harm - Actual harm Residents Affected - Few noon meal. At 1:20 PM, V9 (Certified Nurse Aide/CNA) came in to assist R9 with her meal. R9 stated the meal was cold and she didn't feel like eating. R9 was not encouraged to eat, offered a different tray, nor offered to reheat the cold food. R9's Weight Record documents the following weights: 131.2lbs (pounds) on 6/1/22, 127.4lbs on 7/1/22, and 116.6lbs on 8/11/22. This documents a 14.6 pound weight loss since June 2022, which calculates to an 11.1% weight loss in 3 months. R9's Registered Dietician Note dated 8/18/22 documents: Current weight of 117# (pounds) is down 10#-1 mo, down 18#-3 mo, down 8#-5 mo. Res is within weight standards per BMI (Body Mass Index) of 21.32. No recent labs. No open skin areas per report. Resident is on regular diet and meal intake average varies. Receives supplement 2x daily. Recently went hospice care. Related to weight loss and varied intakes, receives super cereal at breakfast. Continue to monitor. 2. R10's Care Plan documents an admission date of 7/26/22 and lists diagnoses including, but not limited to: Alzheimer's disease, unspecified (Primary), Unspecified dementia with behavioral disturbance, Anxiety Disorder, unspecified, Chronic kidney disease, stage 3 unspecified, Transient cerebral ischemic attack, unspecified, Anemia, unspecified, Essential (primary) hypertension, Vitamin D deficiency, unspecified, Other specified abnormalities of plasma proteins, Nontoxic single thyroid nodule, Mixed hyperlipidemia, Gastro-esophageal reflux disease without esophagitis. R10's MDS dated [DATE] documents in Section C that R10 has a BIMS score of 5, indicating R10's cognition is severely impaired, and she has short term and long-term memory impairment. This same MDS documents in Section G, Eating, that R10 requires supervision and setup assistance from the staff. R10's Care Plan also documents a problem category of Nutritional Status with a start date of 7/26/22 and states Resident has experienced weight loss R/T (related to) fair/poor food and fluid intake. Currently on mechanical soft diet. Receives supplements. Has own teeth. Relies on staff for set up and cueing during meals. Other factors include dementia, anemia, GERD, age. Approaches dated 7/26/22 include to Provide setup help and cueing assistance for meals encourage oral intake of food and fluids, and provide supplements as ordered. On both 8/15/22 and 8/16/22 at 12:30 PM, R10 was observed sitting in her recliner asleep, with her noon meal tray on the bedside table that had been placed in front of her. R10's meal tray sat in front of R10 for over 40 minutes during continuous observation and no staff went into R10's room to wake her up and encourage R10 to eat her lunch. R10's tray went back to the kitchen untouched both days on 8/15/22 and 8/16/22. R10's Weight Record documents the following weights: 125lbs in February 2022, 121lbs on 4/1/22, 118lbs on 5/1/22, 118.6lbs on 6/1/22, and 115lbs on 7/1/22. These records document that R10 had a 6lb weight loss in 4 months and a 10lb weight loss since February 2022 (8% loss in 6 months). 3. R12's Care plan documents an admission date of 5/14/21 and lists diagnoses including, but not limited to: Parkinson's disease (Primary), Unspecified dementia with behavioral disturbance (Admission), Unspecified macular degeneration, Depression, unspecified, Hallucinations, unspecified, Essential (primary) hypertension, Unspecified glaucoma, Anemia, unspecified, Other constipation, Nausea. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 2 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 0692 Level of Harm - Actual harm Residents Affected - Few R12's MDS dated [DATE] documents in Section C that R12 has a BIMS score of 8, indicating R12 can communicate, but has impaired short term and long term memory. This same MDS documents in Section G, Eating, that R12 is extensive assist of 1 person with her meals. R12's Care Plan also documents a problem category of Nutritional Status with a start date of 8/18/22 and states Resident has experienced weight loss. Currently on mechanical soft diet with supplements. Has dentures. Relies on staff for food and fluid intake. Other factors may include poor intake, Parkinson's, dementia, glaucoma, macular degeneration, depression, hallucinations, hypoparathyroidism, anemia. Approaches dated 8/18/22 include to encourage oral intake of food and fluids, to provide physical assistance for meals and provide supplements as ordered. There was no reproducible evidence presented from the facility that Nutritional Status had been addressed in R12's care plan as an issue prior to 8/18/22. On 8/16/22 at 1:00pm, R12 received her noon (lunch) tray. V9 (Certified Nurse Aide/CNA) was assisting R12 to eat, but R12 stated she didn't like the food because it was cold. R12's food was not offered to be re-heated, and she didn't receive another tray. R12 only ate 35% her noon meal. On 8/16/22 at 1:25 PM, V9 and V10 (CNAs) both stated they try to pass out the trays as soon as they come out, and it takes a long time to assist residents who need to be fed or encouraged to eat their meal. V10 stated when there are only 2 people passing out trays and assisting with the meals, it's hard to get everyone fed before their food is cold, and it takes time to go to the kitchen for another tray. On 8/18/22 at 2:30 PM, V1 (Administrator) stated she was wanting to get staff members who weren't Certified Nurse Aides or Nurses trained so they could assist with the meals. V1 stated it's hard for just 2 or 3 Certified Nurse Aides to get all of the feeding assistance done. V1 stated if other staff members could assist with the mealtimes, the residents who need help with their meals would receive that service efficiently, and the meals wouldn't be cold. The facility's undated policy on Assistance with Meals documents in line #3. Residents Requiring Full Assistance: a. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. b. Nursing staff will feed those residents needing full assistance. c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Line #5. For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. The facility's policy on Weight Management Program dated 7/2014 documents under Policy; It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions. Line #2; On the first through the fifth days of the month the Certified Nurses Aide will take the weights for all monthly weights. Weekly weights will be obtained for any resident determined by the Weekly committee. Line #10; The Director of Nursing or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake, pressure ulcers, chewing or swallowing problems, receive tube feedings, all new admissions, all readmissions, or abnormal lab results will be given to the registered dietician for assessment and recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 3 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the physician ordered diet for three (R1, R15 and R34) of 12 residents in a sample of 27. Residents Affected - Few Findings Include: The facility diet spreadsheet dated, Cycle Day: 9, Monday 06/06/2022 documents: Regular diet: oven baked fish 1 fillet, parsley noodles 4 ounces, tossed salad 1 cup, breadstick 1 each and strawberry ice cream 1 each. Mechanical soft diet: ground oven fish #6 (4.75 ounces) scoop with 2 ounces gravy, parsley noodles 4 ounces, shredded lettuce 1 cup, breadstick 1 each, strawberry ice cream. The Pureed diet: Pureed fish #8 scoop, pureed parsley noodles #8 scoop (0.5 cup), pureed green beans #16 scoop (2 ounces), pureed bread 2/3 slice and vanilla pudding #8 scoop. On 08/15/22, in reference to the menu above dated 06/06/22, V8 (Dietary Manager) stated that it is the correct menu, it is on the next cycle of the menu, that is why the date is not correct, it has not been updated. The recipe #681 documents: fish oven baked ground: 2. Remove amount of cooked fish and place in a food processor. Grind to desired texture. 3. Serve a #6 scoop (4.75 ounces) with 2 ounces gravy. 1. R1's Physician Order Sheet dated 08/01/22 documents: Diet: Regular, Consistency: Pureed, Fluid consistency: Regular with a start date of 06/10/2022. On 08/15/22 at 12:05 PM, R1 received puree diet did not receive any pureed bread or pudding. On 08/15/22 at 12:10 PM, V19 (Cook) stated she did not give R1 the pudding because she received a nutritional ice cream and V19 did not realize R1 was supposed to get both. On 08/15/22 at 12:10 PM, V8 (Dietary Manager) stated, the pureed bread and pudding were missed for R1, they will send them out shortly. 2. R15's Physician Order Sheet dated 08/01/22 documents: Diet: Regular, Consistency: Mechanical Soft, Fluid consistency: Honey with a start date of 06/14/2022. On 08/15/22 at 12:05 PM during kitchen observation, V8 (Dietary Manager) used a fork to cut up a breaded fish patty into pieces approximately 0.5 inches by 1.0 inches for R15's lunch. R15 then received that breaded fish patty for lunch. 3. R34's Physician Order Sheet dated 08/01/22 documents: Diet: LCS (Low Concentrated Sweets), Consistency: Mechanical Soft, Fluid consistency: Thin with a start date of 07/01/2022. On 08/15/22 at 12:05 PM during kitchen observation, V8 (Dietary Manager) used a fork to cut up a breaded fish patty into pieces approximately 0.5 inches by 1.0 inches for R34's lunch. R34 then received that breaded fish patty for lunch. On 08/18/22 at 11:10 AM, V7 (Minimum Data Set/Care plan coordinator) stated, meat cut up with a fork into pieces, including 1 inch by 1 inch pieces is the same as the mechanical soft diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 4 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 0803 On 08/18/22 11:10 AM V1 (Administrator) stated, meat cut up with a fork into pieces, including 1 inch by 1 inch pieces is the same as the mechanical soft diet. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 5 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 Based on interview, observation, and record review the facility failed to provide food at palatable, hot temperatures for 4 (R15, R29, R31 and R3) of 4 residents reviewed for cold food in a sample of 37. Residents Affected - Some Findings include: On 08/16/22 at 9:30 PM - 10:30 AM, during resident council meeting R15, R29, R31 and R3, all alert and orientated, stated, the food is cold, especially at breakfast. The Summer 2022 Regular Week 2 menu for 08/16/22 documents: Teriyaki Chicken, white rice, sugar snap peas, wheat bread, peanut butter brownies and margarine. On 08/16/22 at 11:00 AM, the surveyor's metal stemmed digital thermometer was calibrated using the ice point method. On 08/16/22 at 1:05 PM, a test tray was received off of the hall cart and was temped with the metal stemmed thermometer. The chicken was 98.0 degrees Fahrenheit, the rice was 98.1 degrees Fahrenheit, and the peas were 100.1 degrees Fahrenheit. All items on the plate tasted cold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 6 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 - Some 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. Based on observation, interview and record review the facility failed to ensure residents were offered snacks and that snacks were distributed per the facility policy for 4 (R15, R29, R31 and R3) of 4 residents reviewed for providing snacks in a sample of 37. Findings include: On 08/15/22 at 9:30 AM, the snack cart was observed behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of grapes. On 08/15/22 at approximately 3:00 PM the snack cart was taken back to the kitchen without ever leaving the nurse's station. All food items still appeared to be present on the cart except for half a sandwich, which R18 came to the nurse's station and asked for at 2:15 PM. On 08/16/22 at 9:30 AM, the snack cart was observed behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of cake. On 08/16/22 at approximately 3:00 PM, the snack cart was taken back to the kitchen without ever leaving the nurse's station with all food items appearing untouched. On 08/16/22 between 9:30 AM and 3:00 PM, continuous observation of the snack cart revealed no snacks being distributed to residents in their rooms. On 08/17/22 at 9:30 AM the snack cart was located behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of cake. On 08/17/22 at approximately 3:00 PM the snack cart was taken back to the kitchen without ever leaving the nurse's station. All items were still intact, appearing untouched. On 08/17/22 between 9:30 AM and 3:00 PM there were no observations of residents being taken snacks to their room. On 08/16/22 between 9:30 AM and 10:30 AM, during resident council meeting R15, R29, R31 and R3, all alert and orientated, stated, they do not get snacks. R15, R29, R31 and R3 stated the staff are usually too busy and they have not received any snacks since they have had Covid-19 in the facility again. On 08/18/22 at 11:00 AM V10 (Certified Nurse Aide) stated, she is not really for sure when snacks are to be given to the residents, she believes maybe 9:30 AM and 2:00 PM, she has not taken the cart down the hall or went down the hall and asked the residents about snacks, she is not sure who does it. The Facility policy titled, Meal Service & Snack Times dated December 2016 documents: Dietary shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 7 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 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. Procedure(s) 3. Snacks shall be provided at: 10:00 AM, 2:30 PM and 7:00 PM. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 8 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 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 ensure dishes in the dishwasher were being properly sanitized. This has the potential to affect all 37 residents residing in the facility. Residents Affected - Many Findings include: On 08/15/22 at 10:55 AM, V19 (Cook) stated she did not know how to check the sanitizer in the dish machine. V19 asked V8 (Dietary Manager) how to test the sanitizer and V8 handed her the quaternary ammonia test strips and told her how to test it. After three attempts of trying to test it, V19 was asked what kind of sanitizer the machine used and what kind of test strip she was using. V19 (Cook) read the label stating sodium hypochlorite and realized the test strips and sanitizer where not compatible. After finding the correct strips, tested the sanitizer in the machine and it read 20 parts per million (PPM) Chlorine. On 08/15/22 at 10:58 AM, V8 (Dietary Manager) stated she checked the machine this morning and it read 100 ppm Chlorine. On 08/15/22 at 11:40 AM, V20 (Cook) started doing dishes again and when asked to check the sanitizer in the dish machine, she stated she did not know how. V8 (Dietary Manager) told her how to do it and handed her the quaternary ammonia test strips. After attempting to test it three times, V20 was asked what kind of sanitizer the machine used and what kind of test strip she was using. V20 read the label stating sodium hypochlorite and realized the test strips and sanitizer where not compatible. After finding the correct strips, V20 tested the sanitizer in the machine and it read 20 ppm Chlorine. On 08/15/22 at 11:45 AM, V20 started doing dishes again and eight more racks of dishes were washed and put away, including the food processor. On 08/15/22 at 12:57 PM, V8 (Dietary Manager) stated she tested the machine that morning and it tested 100 ppm (while pointing to the 100 color area on the quaternary ammonia test strip). After being told by surveyor the dish machine uses a chlorine based sanitizer, so that was not the correct test strip, V8 (Dietary Manager) said, oh, I will call the dish machine guy tomorrow. On 08/15/22 at 1:00 PM, V20 (Cook) started doing dishes again. On 08/15/22 at 1:15 PM, V1 (Administrator) stated that is not good, especially with having Covid-19 in the building, she assumed the dietary staff was checking the machine every day. She will go into the kitchen and see what can be done about sanitizing the dishes. The www.FDA.gov/FDAFoodCode2017 documents: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; chlorine sanitizer: Concentration range mg/l (ppm) 50-99 with a minimum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 9 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 temperature of 100 degrees Fahrenheit. Level of Harm - Minimal harm or potential for actual harm The facility Resident Census and Condition of Residents dated 08/15/22 documents 37 residents residing in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 10 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 0880 Provide and implement an infection prevention and control program. 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 utilize Personal Protective Equipment (PPE) in accordance with professional standards of practice and failed to utilize and/or correctly apply approved disinfectants to prevent the spread of Covid-19. This has the potential to affect all 37 residents that reside at the facility. Residents Affected - Many Findings Include: On [DATE] at 9:00 AM, V2 (Director of Nursing) provided the Facility document titled, Daily Census Report: [DATE] this document was marked with the Covid-19 residents and date of positivity by V2. This list documented that R2, R16 and R32 were positive for Covid-19. On [DATE] at 11:35 AM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) was assisting delivering residents lunch trays with her N95 respirator on. The bottom strap of the N95 mask was not worn properly, as the bottom strap was hanging down in front of her mask. On [DATE] 11:46 AM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) was still wearing her N95 mask improperly with the bottom strap hanging down in front of her mask and entered R16's room. R16's door had signage posted to indicate it was a Covid-19 positive resident's room, documenting contact and droplet transmission-based precautions should be utilized. V7 then entered R32's room, which also had signage posted on the door to indicate it was a Covid-19 positive resident's room, also documenting contact and droplet transmission-based precautions should be utilized. V7 also did not change the N95 upon exiting R16's room, or don a surgical mask over the N95 prior to entry of either room. On [DATE] at 11:10 AM, V1 (Administrator) stated, all infection control measures are supposed to be followed and all staff members are to wear their N95 properly, covering both their nose and mouth, with both straps behind the head. V1 (Administrator) stated, all personal protective equipment (PPE) should be doffed upon exiting any Covid-19 positive room. According to https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html#:~:text=Put%20on%20the%20N9 How to Use Your N95 Respirator updated [DATE], step 3 documents the following: Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted. On [DATE] at 1:45 PM, R2's door had signage posted to indicate it was a Covid-19 positive resident's room, documenting contact and droplet transmission-based precautions should be utilized. V12 (Housekeeping) was in R2's room wiping down surfaces, spraying door handles and mopping the floor of R2's room. The surfaces that were sprayed were wet approximately 3 minutes. The disinfectants utilized for surfaces and the floor were located on the housekeeping cart and were noted to be Expose and Diversey Revive plus SC. On [DATE] at 2:10 PM V12 (Housekeeping) stated, she uses Expose (EPA 70627-6) to wipe down surfaces including door handles, beds, and light switches. V12 said she will leave the disinfectant on the surface for approximately 5 minutes and then wipe the surface off. She further stated she uses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 11 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Diversey Revive plus SC on the floors and will leave it on for a couple minutes when she mops. V12 stated she has not been trained with contact times for Covid-19. The EPA N List (www.epa.gov/Nlist) documents: Expose (EPA 70627-6) as having a 10-minute contact time to kill Coronavirus, and the Diversey Revive plus SC was not registered as an EPA N listed cleaner for Coronavirus. The facility document titled Infection Prevention and Control Program Policies and Procedures: General Statement dated [DATE] documents: The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidenced based approaches to infection prevention. The facility policy titled, Covid-19 Resident Monitoring, Assessment and Management Policy dated [DATE] documents: Planning: The administrator will create a plan to isolate infected residents to 1 area of the facility. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. The facility should have designated staff to care for residents on the Covid-19 unit when the time comes. In the event of a facility outbreak, the administrator/designee will institute outbreak management protocols. The facility will document efforts to obtain necessary PPEs and supplies. If this occurs the nurse must- place the resident in contact/droplet isolation and close the door (If safe to do so).All staff must wear full PPE. Isolation signage and supplies should be placed outside of resident room. If testing results are positive, the resident must be moved to a Covid-19 designated area. Staff/Resident Management: Place residents in private rooms on standard, contact, droplet precaution and keep resident room door closed. Cohort residents identified with Covid-19 confirmation, Implement consistent assignment of employees and allow only essential staff to enter rooms/wings with appropriate PPE and respiratory protection. PPE includes: gloves, gown, N95 and eye protection will be used. Eye Protection that covers both the front and sides of the face. Remove before leaving resident room. Reusable eye protection will be cleaned and disinfected according to manufacturer's recommendation. The Resident Census and Conditions of Residents dated [DATE] documents 37 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 12 of 13 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 145807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Newton 300 S Scott Street Newton, IL 62448 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, record review and interview, the facility failed to provide a safe, functional and sanitary environment for the folding and storage of clean clothes. This has the potential to affect all 37 residents residing at the facility. Findings Include: On 08/18/22 at 2:15 PM during inspection of the laundry facility, the room was noted to be rectangular with the washers and dryers on the opposite wall from the entrance. There were clean clothes noted across from the washers and dryers, as well as on the wall next to the entrance. Directly above the washers was a 6 foot by 6 foot hole in the drywall ceiling. Insulation was observed hanging down from the hole. There was visible mold on the insulation. There were dust and drywall particles falling onto the floor from the ceiling. Above the entrance there was another 3 foot by 4 foot hole in the ceiling with insulation and mold hanging down. There was a lot of airflow from the air conditioner vents blowing the drywall particles and insulation around the room. The residents clothes were exposed to these dust particles, insulation and mold. On 08/18/22 at 2:15 PM during the above inspection of the laundry facility, V17 (Laundry) stated the holes in the ceiling have been there for a couple months, they started out much smaller but keep getting bigger. When it rains, hard water does come inside. V17 stated she had moved inside the facility to fold the clean clothes, but with Covid-19 in the facility she had to move back out to the laundry facility. The Resident Census and Conditions of Residents dated 08/15/22 documents 37 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 13 of 13