Inspection·May 17, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm 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 and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 37 residents living at the facility. Residents Affected - Many Findings include: On 5/15/24 at 8:30am, V1 (Administrator) stated the current resident census is 37. V1 stated since the facility received a staffing citation from IDPH (The Illinois Department of Public Health) on 4/19/24, the facility signed a contract with a staffing agency. V1 stated the agency currently has nurses available which the facility is utilizing, but no CNAs (Certified Nursing Assistants) are available. On 5/15/24 at 9:15am, V3 (Power of Attorney/POA) of R1, stated on Tuesday 5/7/24 from about 3:30pm to about 6:00pm, the only CNA working was V11 (CNA). V3 stated during that time, she tried to find V11 for help transferring R1 into the wheelchair from the recliner and back again, but V11 was busy with other residents, and V3 stated she transferred R1 by herself although it takes two people to transfer R1. V3 stated the facility has an ongoing problem with being short staffed. V3 stated because of this, she has decided to have R1 discharged to home with in home care at the end of May 2024. On 5/15/24 at 10:45am, R4 was alert and oriented. R4 stated there are ongoing issues with staffing. R4 stated call lights can take up to an hour to be answered especially on overnight shift (10pm-6am), and there have been times in past month where only one CNA and one nurse were the only two staff in the building on overnight shift. R4 stated V7 (Registered Nurse [RN]/Minimum Data Set[MDS]/Care Plan Coordinator[CPC]) works as a floor nurse and sometimes as a CNA almost every weekend, in addition to her Monday through Friday job duties. On 5/15/24 at 11:00am, R2 was alert and oriented. R2 stated call lights take up to an hour especially on evening shift (2:00pm to 10:00pm) and overnight shift on weekends. R2 stated in the past month there have been times on the overnight shift when there is only one nurse and one CNA for the whole building, and she has noticed some of the CNAs working doubles due to the oncoming shift not relieving them. On 5/15/24 at 11:20am, R3 was alert and oriented. R3 stated she doesn't use the call light so she can't say how long it might take to get answered. R3 stated sometimes on night shift there are only two staff in the building, one CNA and one nurse, and sometimes the CNAs are working doubles because nobody is coming in to relieve them. On 5/15/24 at 2:20pm, V9 (CNA) stated in the past month, she has at times been the only CNA in the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145807 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 05/17/2024 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)