Inspection·September 13, 2024

F 0640 Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. 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 2 of 10 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 09/13/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility has failed to update comprehensive care plans for 2 of 12 residents (R15 and R21) reviewed for care plans in a sample of 41. Residents Affected - Few The Findings Include: 1. R15's Face sheet documents an admission date of 2/9/21. R15's Face sheet includes the following diagnosis: major depressive disorder, cognitive communication deficit, depression, unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, vascular dementia with agitation. R15's Current care plan documents a problem area of falls. The goal for this problem area is that resident will remain free from injury. The approach to this problem area include: therapy to evaluate and treat if POA (Power of Attorney) approves, provide proper well maintained footwear, staff assess pressure alarm is functioning when providing care, lock brakes of wheelchair when resident is not in it, non skid strips placed on the floor next to the bed, observe frequently and place in supervised area when out of bed, resident will be monitored when in the dining room and escorted back to her room when dining is complete, assure resident is wearing eyeglasses and are clean and in good repair, assure the floor is free of glare, liquids, and foreign objects, encourage resident to assume a standing position slowly, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach, leave night light on in room, provide proper maintained footwear, provide environment free of clutter, and provide toileting assistance every 2 hours and as needed. On 9/11/24 at 2:30PM, V1 (Administrator) stated that R15 should have her call light within reach at all times to call for assistance. On 9/11/24 at 2:36 PM, V5 (Certified Nurse Assistant/CNA) stated that the family does not like R15 to have a call light due to the risk of her choking herself with the cord. V5 stated that they just check on her more often, that they do not have any other form of call light system for R15 to use. On 9/11/24 at 2:45 PM, V1 stated that the care plan is not updated to reflect the need for R15 to have an alternate type of call light/alert system to let the staff know assistance is needed, nor is the behavior/request of family in the care plan requesting to not use the standard call light. 2. R21's face sheet documents an admission date of 10/21/2022. The following diagnosis are included on the face sheet: Parkinson's disease, anxiety disorder, depression, and major depressive disorder with psychotic features. R21's current month physician orders include an order for Seroquel 50 milligram tablet once daily at bedtime with a start date of 4/9/2024. R21's Current care plan has a problem area category of psychotropic drug use resident receives antidepressant medication. The goal for this problem area is that the resident will not exhibit signs of drug related sedation, hypotension, or anticholigenic symptoms. The approach to this problem area is that they will assess/record effectiveness of drug treatment, monitor signs and symptoms of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 3 of 10 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 09/13/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sedation, hypotension, or anticholinergic symptoms and to monitor resident mood and response to medication. On 9/13/21 at 12:30 PM, V2 (Minimum Data Set Coordinator/Care Plan Coordinator) stated that the care plan had not been updated to include the anti-psychotic medication that was started on 4/9/24 or any individualized non pharmalogical interventions when behaviors are occurring. V1 did not provide a care plan policy and procedure on updating comprehensive care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 4 of 10 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 09/13/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review and interview the facility failed to implement fall precautions by placing the call light within reach for 1 of 2 (R15) residents reviewed for falls in a sample of 41. Residents Affected - Few Findings Include: R15's face sheet documents an admission date of 2/9/21. This same document includes the following diagnosis: muscle weakness, other abnormalities of gait and mobility, and vascular dementia. R15's care plan has a problem area category of falls that has a start date of 8/18/22 and an edited date of 8/27/24. The goal for this problem area with a long term goal target date of 11/29/24 is that the resident will remain free from injury. An approach to this problem area with a start date of 8/18/22 is to keep the call light in reach at all times. R15's most recent recent quarterly MDS (Minimum Date Set) dated 5/20/24 documents in Section C a BIMS (Brief Interview of Mental Status) of 6, indicating R15 is severely impaired with cognition level. R15's same MDS Section J documents that R15 has had falls since admission/reentry. On 9/10/24 at 10:30 AM, R15 was observed to be in her recliner and no call light within reach. On 9/11/24 at 9:30 AM, 11:30 AM, 1:30 PM and 2:32 PM, R15 was observed sitting in her recliner with the call light sitting on top of her personal refrigerator in her room not within reach. On 9/11/23 at 2:35 PM, V5 (Certified Nurse Assistant) stated that the family does not want R15 to have a call light due to the possibility that she could strangle herself with it. V5 stated that they do not have an alternate source of a call light right now, they just check on her every two hours for sure and then when they are going up and down the hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 5 of 10 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 09/13/2024 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 32 residents living at the facility. Findings include: 1. R7's Face Sheet documented an admission Date of 1/31/20 and listed diagnoses including History of Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. R7's Minimum Data Set, dated [DATE] indicated R7 has moderate deficits in cognition and is totally dependent on staff for toileting, showering, and dressing. R7's Care Plan dated 8/27/24 documented a problem area, Resident's ability to perform activities of daily living requires assistance of staff. On 09/10/24 at 02:11PM, R7 was in his room sitting in his wheelchair watching TV. R7 was alert to person and place but not time. R7 stated he needed to use the bathroom and pushed his call light. After 15 minutes and 46 seconds, V8, Certified Nursing Assistant (CNA), responded and assisted R7 with toileting. 2. R15's Face Sheet documented an admission date of 2/9/21 and listed diagnoses including polyneuropathy, Hypertension, and Dementia. R15's Minimum Data Set, dated [DATE] documented that R15 has severe deficits in cognition and requires substantial assistance from staff for toileting, showering, and dressing. R15's Care Plan dated 8/20/24 documented a problem area, Due to cognitive deficits, (R15) is dependent on staff for meeting his/her emotional, intellectual, physical and social needs. On 09/11/24 at 11:04 AM, V6, family member of R15, stated when she was visiting on 9/7/24 on day shift, it took an hour to get staff to take V6 to the bathroom. V6 stated on 9/8/24 on day shift, there was one CNA and one nurse to care for the whole building. On 09/11/24 at 1:13 PM, V7, Licensed Practical Nurse, stated there have been times where it has just been her and one CNA for the whole building on day shift on weekends. She stated there is also an issue at times with there being only one CNA and one nurse on night shift. On 09/12/24 at 1:16 PM, V9, CNA, stated there are times when there is only one CNA and one nurse for the whole building, and that it can happen on any shift both through the week and on the weekend. On 09/13/24 at 8:13am, V1, Administrator, stated she is the staff member responsible for scheduling nursing and CNA staff. V1 stated nurses work 12 hour shifts from 6am to 6pm and 6pm to 6am, and CNAs work 8 hour shifts. V1 stated one nurse and 2 CNAs are scheduled each shift. V1 stated there are times when CNA's call in, especially on the 2pm to 10pm shift and 10pm to 6am shift, but coverage can usually be obtained. V1 stated corporate staff have told her one CNA on the 10pm to 6am shift is enough for the current census, and that when the census gets up to 36 she can schedule a total of 3 CNAs either on day shift or evening shift, but not both. On 9/13/24 at 12:10 PM, V2, Interim Director of Nurses, stated it is her expectation that call lights should be answered within five minutes. Nursing and CNA Schedules for July, August, and September 2024 documented the following dates with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 6 of 10 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 09/13/2024 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)

F 0725 one CNA and one nurse providing care for the entire facility: Level of Harm - Minimal harm or potential for actual harm 7/1/24, 10pm to 6am shift. 7/4/24, 10pm to 6am shift. Residents Affected - Many 7/12/24, 10pm to 6am shift. 7/13/24, 10pm to 6am shift. 7/18/24, 2pm to 10pm shift. 8/2/24, 2pm to 10pm shift. 8/10/24, 6am to 2pm and 2pm to 10pm shifts. 8/18/24, 6am to 2pm shift. 9/8/24, 6am to 2pm shift. 9/9/24, 2pm to 10pm shift. 9/10/24, 2pm to 10pm shift. The Long - Term Care Facility Application for Medicare and Medicaid provided by the facility with a date of 09/11/2024 documents that 32 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 7 of 10 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 09/13/2024 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)

F 0727 Level of Harm - Minimal harm or potential for actual harm 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 provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 32 residents residing in the facility. Residents Affected - Many Findings include: Review of June 2024 Nursing Schedule documents no RN coverage was provided at the facility on 06/19/2024 and 06/29/2024. Review of July 2024 Nursing Schedule documents no RN coverage was provided at the facility on 07/13/2024, 07/14/2024, 07/17/2024, 07/27/2024 and 07/28/2024. Review of August 2024 Nursing Schedule documents no RN coverage was provided at the facility on 08/03/2024, 08/04/2024, 08/17/2024 and 08/18/2024. On 09/10/24 at 02:01 PM, V1 (Administrator) stated that she is aware there are shifts that have no RN (Registered Nurse) coverage. V1 stated the facility utilizes agency nurses to fill in gaps. V1 stated that she has recently hired RN's and the September schedule has more RN coverage on it. On 09/13/2024 at 10:47 A.M., V1 stated the facility tries to have RN coverage for all days but it is hard to get RN's to apply. V1 stated that she recently hired more RN's so this should not be an issue moving forward. V1 verified the accuracy of the June 2024, July 2024, and August 2024 nursing schedules. The Long - Term Care Facility Application for Medicare and Medicaid provided by the facility with a date of 09/11/2024 documents that 32 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 8 of 10 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 09/13/2024 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)

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. Based on record review and interview the facility failed to ensure residents were free from unnecessary medications for 1 of 5 (R2) residents reviewed for unnecessary medications in a sample of 41. The Findings Include: R2's Face sheet documents an admit date of 9/6/23 and includes the following diagnosis: vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's current Physician Order Sheet documents an order for 1 mg (milligram) Risperadol with diagnosis: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 9/6/2023. A psychotropic and sedative/hypnotic utilization by resident report provided by V1 (Administrator) dated 9/6/24 documents that R2 started Risperidone 1 mg pm (as needed) on 9/6/23 and is due for a Gradual Dose Reduction (GDR) evaluation on 12/2024. The column labeled Last GDR is blank. On 9/13/24 at 1:30PM, V1 stated at this time there are no other pharmacy reports that show communication to recommend any medication reductions in the medical record. On 9/13/24 at 11:00 AM, V11 (Pharmacist) stated that he would check to see if there were any previous GDR attempts/recommendations for R2, but his routine is review the GDR's every 5 months to ensure that he catches all the medications to ensure they are reviewed per the Medicare guidelines. Review of R2's behavior tracking from 8/13/24-9/12/24 provided by V1 has no behaviors occurring. On 9/11/24 at 2:30 PM, V1 stated that all residents are tracked for the same behaviors because the new system does not allow them to individualize them. According to the tracking sheet R12 is tracked for verbal expression of distress, sleep cycle issues, apathetic/anxious/sad appearance, loss of interest, did the resident have any of the following problems or behaviors (PHQ-9-OV) (with no further explanation). On 9/13/24 at 12:30 PM, V9 (Certified Nurse Assistant) stated that R2 has not had any behaviors that he is aware of. On 9/13/24 at 1:00 PM, V2 (Minimum Data Set Coordinator) stated that R2 used to have behaviors of not having anxiety and eating and drinking all his snack and drinks that family brings in, but they have worked with him and this has all improved. V2 stated that since then he has not really had any behaviors. V2 stated that this is not tracked as a behavior nor is it on his care plan. V2 stated that she cannot find any further documentation regarding any recommendations or attempts at reduction of psychotropic medications. On 9/13/24 at 1:30 PM, V1 provided a document titled Gradual Dose Reduction Schedule that documented, Antipsychotics and Anxiolytics: During the first year of the use of these drugs in the facility, there should be one attempt to reduce the medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 9 of 10 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 09/13/2024 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)

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 observation, record review, and interview, the facility failed to store food and maintain the kitchen in safe and sanitary manner to prevent potential contamination. This has the potential to all 32 residents residing in the facility. Findings Include: On 9/10/24 at 9:45 AM, the initial kitchen tour was completed and the following concerns were noted: the top of the dish machine had a layer of flaky dried matter on top covering the entire surface, a scoop with a handle was found inside the bulk thickener touching the food item, bottom shelves of stainless steel tables were dusty and had old/dried food debris on them, bulk food containers were found to be sticky to touch and dried spills going down the side and food debris on top, a container on the cooks table holding various utensils/seasonings was found to have crumbs and food debris in the bottom, the steam table had dried/black food substance burnt to the bottom of all inserts, the side of the stove was found to have old/dried food spills down the side, the floor under the stove and cooks stainless steel table had spilled food/food debris/paper products underneath them, the floor in the kitchen was upswept with food and paper products scattered everywhere, the stove top is full of old dried spilled food on the burners and under the burners near the flame. A sample cleaning schedule provided by V4 documents that the following items are to be cleaned after each use: can opener, coffee machine, counters, cutting boards, dining room chairs/tables, dishes, floors, food carts, food preparation appliances, kitchen/dining room floors, mixers, pots/pans, Range/Stove Top, and toaster. Items to be cleaned weekly are: dish machine, oven, garbage containers, garbage disposal, interior of dishwasher, refrigerator, sanitize dining room chairs, storeroom floor and windows. Monthly cleaning schedule includes; clean behind/under major appliances, freezer condenser boils/pans, shelves, stove hood/filters, and vacuum and dust back of appliances. Daily cleaning schedule lists: exterior of dishwasher and appliances, floors, kitchen sinks/faucets, kitchen towels/cloths, microwave and waster disposal. On 9/10/24 at 11:30 AM, V10 (Cook) was observed to be pureeing the lunch meal. V10 reached into the bulk food thickener and used the scoop without washing his hands or gloves. V10 then set the measuring cup on the table with no clean barrier and then placed the scoop back in the container when he was finished with the pureed pork. At this same time an observation of V10 stirring cherries on the stove with a spatula that he picked up off the stove top burner with no clean barrier between to stir the cherries. On 9/10/24 at 2:00 PM, V4 (Dietary Manager) stated that they have a cleaning list that is supposed to be completed weekly. V4 stated that for some reason it was not completed this week and she cannot say for sure how long it has been since the stove was cleaned. V4's expectation is that it is cleaned at least once a week. V4 stated that the she will remove the scoops out of the bulk containers and clean them. V4 stated that she will speak with her staff regarding placing food utensils on a clean barrier instead of on a table top and then used to cook the food. The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/11/24, documents 32 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145807 If continuation sheet Page 10 of 10