Inspection·July 21, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents (R22) reviewed for PASARR's in the sample of 21. Findings Include: R22's PASARR, as provided by the facility, dated 11/1/19 documents no Developmental Disability or Mental Illness diagnoses during this evaluation, therefore not requiring a level II screening. Review of R22's Continuity of Care with a created date of July 20, 2023 documents active diagnosis of Delusional Disorders with an effective date of 05/27/2022. This same document also lists a diagnosis of Major depressive disorder, single episode, moderate with an effective date of 06/23/2023. No PASARR re-evaluation is documented as being completed after these diagnoses were added. On 07/20/23 at 09:28 AM, V5 (Social Services) stated that residents only receive a PASARR screening when they are admitted to the facility, and are not referred back for re-evaluation should new diagnoses be added. V5 confirms that R22 was not referred back for a PASARR Level II screening after a having serious mental disorder diagnoses added. Review of the facility policy titled Resident Assessment: Coordination with PASARR Program with a revision date of October 2017 stated, 6. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the State mental health or intellectual authority for a level II resident review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 2 of 6 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 07/21/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide the required supervision to prevent a fall for 1 of 7 residents (R31) reviewed for falls in the sample of 21. Findings include: On 7/28/23 at 12:45pm, R31 was observed in the dining room during lunch service. R31 was in a specialty high backed wheelchair, and was being fed by staff. R31 was noted to be contracted in all limbs and was very spastic, making frequent involuntary jerking movements. R31's Face Sheet listed an admission Date of 3/31/22, and diagnoses including Huntington's Disease and Dysphagia. R31's Fall Risk assessment dated [DATE] documented that R31 is at high risk for falls. R31's Minimum Data Sets dated 1/6/23, 4/5/23, and 6/15/23 all documented that R31 requires extensive assistance from at least 2 staff for transfers, locomotion on the unit, and personal hygiene, and is totally dependent on two plus staff for bathing. R31's Care Plan with a start date of 7/11/22 and the most recent review date of 7/19/23 documented, Resident at risk for falls. History of falls. Relies on staff for all transfers. (Specialty) Wheelchair is primary mode of transportation. Primary diagnosis Huntington's disease. She has uncontrolled movement of legs and arms, with a corresponding intervention,Never leave resident unattended in the shower chair, which was added on 1/28/23. A Nursing Progress Note for R31 dated 1/28/23 documented, At (9:33pm), this nurse was alerted to resident's room by CNA (Certified Nursing Assistant). CNA had just given resident a shower and was needing assistance transferring her to bed from the shower chair. CNA had turned her back on resident long enough to holler out the door and resident tipped shower chair, landing resident on the floor . A Fall Investigation report for R31 dated 1/28/23 documented,Root Cause Analysis: At (9:33pm) this nurse was alerted to resident's room by CNA. CNA had just given resident a shower and was needing assistance transferring her to bed from the shower chair. CNA had turned her back on resident long enough to holler out the door and resident tipped shower chair, landing resident on the floor. Resident was assessed, no bumps or bruises noted, no shortening or internal/external rotation. Resident was asked if she was okay and she was able to verbalize that she was. When asked if anything hurt she verbalized no .She is in bed now resting comfortably and will continue to monitor. The Investigation documented that physical exam showed no injuries, that R31's vital signs were within normal limits, and that her Primary Care Physician and Power of Attorney were notified. On 07/21/23 at 08:35 AM, V1, Administrator, stated that after the above referenced fall, staff were re-educated to not leave R31 unsupervised while in the shower chair, and to always have at least two staff members are with R31 during showers. The facility's Fall Prevention Management Policy dated 3/15/18 documented, It is the policy of (the facility) to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 3 of 6 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 07/21/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to have a Registered Nurse (RN) for at least 8 consecutive hours, 7 days a week. This has the potential to affect all 38 residents who reside at this facility. This past non-compliance occurred between 1/14/23 and 5/20/23. Findings include: On 7/20/2023 at 2:00 pm, V6 (Regional Director of Operations) stated that for the following dates in January 2023 (1/14/23 and 1/28/23), February 2023 (2/25/23), and May 2023 (5/20/23) there was no Registered Nurse (RN) coverage for those days. On 7/20/23 at 2:15 pm, V1 (Administrator) stated that the nursing agency RN's had picked up these shifts to cover the hours and then did not show up for the actual shift. The facility at this time did not have many RN's on staff and many were working on finishing their schooling. As of July 1, 2023 the facility has only RN's on staff with the exception of a new hire (Licensed Practical Nurse) as of 7/20/23. A facility document titled Resident Census and Condition dated 7/20/23 documents there are currently 38 residents living in the facility. Prior to the survey date, the facility implemented the following actions to correct the deficient practice: 1. The facility currently has 8 full time RN's, and Minimum Data Set Coordinator (MDS) and the Director of Nursing which are RN's. 2. A Quality Assurance Performance Improvement Meeting was held on 1/26/23 and 4/27/23 to discuss the reason the facility had days of no RN coverage, which included the low amount of RN's on staff and the agency staff not showing up for shifts they had signed up for. It was determined the facility needed to have more RN's on staff. 3. Schedules show since the last date of 5/20/23 without RN coverage, they have not had this issue. The Licensed Practical Nurses (LPN's) on staff have all became RN's with the exception of a new hire providing more room to schedule a nurse to cover 8 consecutive hours 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 4 of 6 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 07/21/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one resident of five residents (R4) reviewed for unnecessary medications in the sample of 21. Findings include: R4's Face Sheet documented an admission date of 2/1/23, a date of birth indicating R4 is [AGE] years of age, and diagnoses including Hypertension, Diabetes Type 2 and Developmental Disorder of Scholastic Skills, unspecified. R4's Behavior Tracking for May, June, and July 2023 documented that R4 has displayed no behaviors in that time. R4's July 2023 Physician Order Sheet documented an order for Zoloft 50 mg (milligrams) one tablet daily, Seroquel 25mg one tablet every morning, and Seroquel 50mg one tablet at bedtime, all with a start date of 2/1/23. R4's AIMS (Abnormal Involuntary Movement Scale) dated 5/10/23 documented that R4 is not experiencing any side effects from atypical antipsychotic use. R4's Psychiatric Initial Diagnostic Interview dated 2/16/23 authored by V7, Advanced Practice Nurse, Psychiatry, documented,(R4) .was admitted to the facility on [DATE] .He has a history of Major Depressive Disorder, as well as a developmental disorder. His sister reports that he is intellectually disabled, she reports this has been (present) his whole life .He is currently on Seroquel 25mg in the morning and 50mg at bedtime .She reports he has been on these medications for years. Assessment: (Diagnoses): Major Depressive Disorder, Recurrent, Unspecified (and) Developmental Disorder of Scholastic Skills .Recommend that he continue his current psychotropic medications. R4's Medical Record documented that R4 saw V7 on 2/23/23, 3/10/23, 3/29/23, 4/27/23, 5/19/23, 6/8/23, and 6/15/23, each evaluation documenting no changes in diagnoses, treatment, or medications. According to https://pdr.net/drug-summary/Seroquel-quetiapine-fumarate-2185.6108, Indications (for use): Bipolar Disorder Schizophrenia Neurocognitive symptoms associated with Borderline Personality Disorder Refractory Obsessive Compulsive Disorder Refractory Depression. Elderly patients (over 65) may be more sensitive to the sedative, anticholinergic, orthostatic effects, and QT prolongation associated with quetiapine. There was no indication listed for the treatment of behaviors related to Intellectual/Developmental Disability. On 7/19/23 at 9:45am, R4 was interviewed in his room. R4 was alert and oriented to person place and time. R4 presented as developmentally delayed and with a flattened affect and lack of general fund of knowledge. R4 was pleasant and cooperative with the interview. On 7/21/23 at 9:32am,V1, Administrator, stated that R4 has displayed no maladaptive behaviors at the facility. V1 stated V7 quit 3 weeks ago and has not yet been replaced. V1 stated V7 was made aware numerous times that R4 did not have diagnoses supporting the use of Seroquel, but V7 stated she did not want to add a mental health diagnosis such as Schizophrenia for R4 as she feared the Department citing a deficiency at F658, which V1 stated V7 felt would reflect negatively on V7. The facility's Antipsychotic Medication Policy dated October 2017 documented, Antipsychotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 5 of 6 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 07/21/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm medication therapy shall be used only when it is necessary to treat a specific condition, based on a comprehensive assessment of the resident. Only those medications required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications are important considerations for all residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 6 of 6