Inspection·February 19, 2025

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 observation, interview, and record review the facility failed to ensure incontinence care was provided timely and failed to ensure they had enough supplies to provide care for 4 of 5 (R1, R3, R8, R11) residents reviewed for activities of daily living in the sample of 12. Residents Affected - Some Findings Include: 1. R1's Resident Face Sheet with a print date of 2/18/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, heart disease, hypertension, urinary incontinence, and history of falling. R1's MDS (Minimum Data Set) dated 1/8/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. This same MDS documents R1 requires partial/moderate assist with showers/bathing, dressing, personal hygiene, and transfers. This MDS documents R1 is frequently incontinent of bowel and bladder. R1's current Care Plan documents a Problem area with a start date of 11/21/23 of (R1) is frequently incontinent of bowel and bladder. The interventions for this Problem area include, Provide incontinent care as needed. On 2/18/25 at 5:43 AM, R1 was laying in his bed. His bed sheets appeared to have a brown stain on them and his pants appeared urine soaked. R1 stated they come in through the night and change him but he doesn't remember when they came in last. On 2/18/25 at 5:44 AM, V7 (CNA/Certified Nursing Assistant) stated R1 requires assist/supervision and is very incontinent at night. V7 stated she last provided incontinence care to R1 around 2:30 AM. When asked about the linens appearing brown stained, V7 stated they have to strip R1's bed every morning. V7 stated R1 typically wakes up saturated even with a bed check at 2 AM. V7 stated they don't have enough supplies to provide care. V7 stated she doesn't have any wash cloths, no towels and they split the linens they do have with A wing. V7 stated it seemed like they are always short staffed. On 2/18/25 at 5:49 AM, V7 (CNA) assisted R1 to transfer to his wheelchair. R1's pants were saturated from his waist to his knees. The top sheet was brown stained and appeared wet, the thin plastic bed pad appeared saturated, the thicker cloth bed pad appeared saturated, and the bottom sheet was wet. V7 confirmed the bed pads and sheets were wet. R1 self-propelled himself to the nurse's station, the unknown nurse asked if he was ready for coffee. R1 self propelled to the dining room and was given a cup of coffee to drink. On 2/18/25 at 5:52 AM, V3 (RN/Registered Nurse) stated bed checks should be done every two hours. On 2/18/25 at 6:18 AM, V8 (CNA) stated they didn't have enough supplies. V8 stated there were two showers that didn't get done because she didn't have linens to complete the showers. V8 stated R1 was one of the residents who didn't get a shower. V8 stated R1 is not independent with toileting and doesn't change his own clothes if they get wet. This surveyor walked with V8 to R1 who was still sitting in the dining room in the same clothes he was in when he was transferred out of the bed at 5:49 AM. V8 asked V7 (CNA) if she changed R1 and V7 stated R1 usually changes himself so she assumed he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 0677 had. Level of Harm - Minimal harm or potential for actual harm The untitled paper with R1's name and dated 2/17/25 document, R1 did not get a shower with no towels or washcloths handwritten at the bottom of the paper. Residents Affected - Some On 2/18/25 at 6:27 AM, R1 was taken to the bathroom by V7 and V8. R1 stood up and transferred to the toilet with assistance. R1's depend and pants were saturated with urine. V7 and V8 wet the corner of a full sized towel to wash R1's buttock and groin area and stated they were using the towel because they had no wash clothes. On 2/18/25 at 10:24 AM, V15 (CNA) stated incontinence care should be provided every two hours. V15 stated it wasn't acceptable for a resident to go four hours without being checked or provided incontinence care. On 2/18/25 at 9:44 AM, V13 (LPN/Licensed Practical Nurse) stated incontinence care should be provided every one to two hours. When asked if going from 2 AM to 6 AM was too long a time frame for incontinence care to be provided, V13 stated in her opinion, it is too long. 2. R3's Resident Face Sheet with a print date of 2/18/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease, neuromuscular dysfunction of bladder, hydronephrosis, diabetes, and a history of urinary tract infections. R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting, is incontinent of bowel and has an indwelling urinary catheter. R3's current Care Plan documents a Problem area with a start date of 6/24/22 of, (R3) needs extensive assist x (times) 2 for activities of daily living r/t (related to) weakness. This Problem area includes an intervention of, Assist x 2 as needed with ADL's . On 2/18/25 at 8:18 AM, R3 stated they don't always have enough staff and showers don't always get done. R3 stated he wears depends, and uses a bed pan. R3 stated sometimes he has to wait to get on/off the bed pan. When asked if any care wasn't provided due to staffing, R3 stated pericare isn't consistently provided. R3 stated it should be done daily and it isn't. 3. R8's Resident Face Sheet with a print date of 2/18/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic kidney disease, anxiety disorder, post traumatic stress disorder, insomnia, and diarrhea. R8's MDS dated [DATE] documents a BIMS score of 13, which indicates R8 is cognitively intact. This same MDS documents R8 is dependent on staff for toileting and is frequently incontinent of bowel and bladder. R8's current Care Plan documents a Problem area with a start date of 1/14/25 of, (R8) is incontinent of bowel and bladder and is not appropriate for a B&B (bowel and bladder) program due to impaired cognitive status. This Problem area includes an intervention of, Provide incontinence care as needed. On 2/18/25 at 7:50 AM, R8 stated they don't have enough staff to meet her needs timely. R8 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she is incontinent at night and they occasionally come in and change her but they have so many residents and not enough staff. 4. R11's Resident Face Sheet with a print date of 2/19/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include osteomyelitis, fatigue, pain, anxiety disorder, heart disease, and hypertension. R11's MDS dated [DATE] documents a BIMS score of 10, which indicates R11 has a moderate cognitive deficit This same MDS documents R11 requires substantial/maximal assistance with toileting. R11's current Care Plan does not document a Problem area for incontinence or activities of daily living. On 2/18/25 at 11:59 AM, R11 stated they don't have enough staff. R11 stated he uses the call light, they answer and say they will be right back, and he ends up pissing his pants because they don't come back timely. On 2/18/25 at 9:56 AM, V14 (CNA) stated linens are a big issue right now. V14 stated she had no linens to provide care. V14 stated she can't give showers or remake the beds she has stripped and is using her own personal wipes to provide incontinence care. V14 stated they don't have enough staff and they don't have the supplies they need to provide care. V14 stated when they are short staffed showers don't get done, and residents don't get turned and repositioned as often as they should. V14 stated she does her best but when she is providing care to 30 residents it is impossible to meet all of their needs timely. This surveyor walked with V14 to the linen carts and supply rooms. The C wing linen carts contained gloves, three gowns, depends, two bed pads, and a couple of sheets. There were no towels, wash cloths, or bed pads in the C wing linen closet. The main supply room on A wing had five towels, no sheets, bed pads, or wash cloths. V14 stated on Friday (2/14/25) she didn't have linens until 11 AM, then it was lunch time and she was able to get three of the eight showers done after lunch because she was working alone from 4 PM to 6 PM. On 2/18/25 at 5:33 AM, V6 (CNA) stated they don't have enough CNA's working. V6 stated there are five CNA's working tonight and there are 35 residents on A wing and around 30 on C wing. V6 stated she wasn't sure how many residents there were on the rehab hall. V6 stated incontinence care and turning and positioning isn't done like it should be when they don't have enough staff. On 2/18/25 at 6:01 AM, V5 (CNA) stated most of the time they have enough supplies. V5 stated when they run out of something she does the best she can with what she has and uses alternatives such as blankets instead of sheets. On 2/18/25 at 12:57 PM, V12 (CNA) stated the facility linens are washed off site and the truck doesn't deliver them until 9:00 AM. On 2/18/25 at 3:12 PM, V2 (DON/Director of Nurses) stated residents should be checked every couple of hours to see if incontinence care needs to be provided. This surveyor shared the observation and interviews related to R1's incontinence care and V2 stated she would expect R1 to be checked more often. V2 stated four to four and a half hours was too long to go without incontinence care. V2 stated if they are running low on linens they have a washer and dryer on site they can wash clothes with. V2 stated she told staff if there wasn't linens they should spray them out and get them to the laundry. V2 stated she couldn't fix what they didn't tell her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/18/25 at 3:43 PM, V16 (ADON/RN-Assistant Director of Nurses/Registered Nurse) stated she knew they had less staff than normal for day shift on 2/18/25 starting at 6:00 AM. V16 stated they had three CNA's scheduled from 6 to 8 AM and then three more coming in at 8 AM. V16 stated she asked night shift to stay over for two hours. V16 stated they would have had one CNA on each unit and then the CNA staying over would have floated. When asked if that was enough to meet the needs of the residents, V16 stated, it can meet the needs but we also need two on each hall. V16 stated they had enough staff to meet the needs of the residents timely. When asked why staff and residents were telling this surveyor they didn't have enough staff, V16 stated it was probably due to all of the call in's related to the flu. On 2/18/25 at 4:09 PM, V1 (Administrator) stated he hadn't had any complaints/concerns related to incontinence care and/or showers not being provided timely. V1 stated, we get to them when we can. The facility Bathing a Resident policy dated July 2014 documents, It is the policy of (name of facility) that residents will receive a shower/bath will be scheduled regularly and prn (as needed). The facility Perineal Care policy dated 7/2017 documents, Purpose: the purposes of this procedure are to provide cleanliness and comfort to the resident to prevent infections and skin irritation, and to observe the resident's skin condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 observation, interview, and record review the facility failed to ensure sufficient staff to provide care in a timely manner for 5 of 12 (R1, R3, R4, R8, and R11) residents reviewed for sufficient staff in the sample of 12. This failure has the potential to affect all 77 residents currently residing at the facility. Findings Include: The facility Midnight Census report dated 2/18/25 documents 77 residents currently reside at the facility. 1. R1's Resident Face Sheet with a print date of 2/18/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, heart disease, hypertension, urinary incontinence, and history of falling. R1's MDS (Minimum Data Set) dated 1/8/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. This same MDS documents R1 requires partial/moderate assist with showers/bathing, dressing, personal hygiene, and transfers. This MDS documents R1 is frequently incontinent of bowel and bladder. R1's current Care Plan documents a Problem area with a start date of 11/21/23 of (R1) is frequently incontinent of bowel and bladder. The interventions for this Problem area include, Provide incontinent care as needed. On 2/18/25 at 5:43 AM, R1 was laying in his bed. His bed sheets appeared to have a brown stain on them and his pants appeared urine soaked. R1 stated they come in through the night and change him but he doesn't remember when they came in last. On 2/18/25 at 5:44 AM, V7 (CNA/Certified Nursing Assistant) stated R1 requires assist/supervision and is very incontinent at night. V7 stated she last provided incontinence care to R1 around 2:30 AM. When asked about the linens appearing brown stained, V7 stated they have to strip R1's bed every morning. V7 stated R1 typically wakes up saturated even with a bed check at 2 AM. V7 stated they don't have enough supplies to provide care. V7 stated she doesn't have any wash cloths, no towels and they split the linens they did have with A wing. V7 stated it seemed like they are always short staffed. On 2/18/25 at 5:49 AM, V7 (CNA) assisted R1 to transfer to his wheelchair. R1's pants were saturated from his waist to his knees. The top sheet was brown stained and appeared wet, the thin plastic bed pad appeared saturated, the thicker cloth bed pad appeared saturated, and the bottom sheet was wet. V7 confirmed the bed pads and sheets were wet. R1 self-propelled himself to the nurse's station, the unknown nurse asked if he was ready for coffee. R1 self propelled to the dining room and was given a cup of coffee to drink. On 2/18/25 at 5:52 AM, V3 (RN-Registered Nurse) stated they don't always have enough staff. V3 stated care gets provided but no extra care gets done. V3 stated bed checks should be done every two hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 On 2/18/25 at 6:18 AM, V8 (CNA) stated they had enough staff on night shift tonight. V8 stated last night (2/17/25) she worked the wing by herself. V8 stated that happens more than it doesn't. V8 stated she had 23 residents and they are high incontinence care. V8 stated R1 is not independent with toileting and doesn't change his own clothes if they get wet. This surveyor walked with V8 to R1 who was still sitting in the dining room in the same clothes he was in when he was transferred out of the bed at 5:49 AM. V8 asked V7 (CNA) if she changed R1 and V7 stated R1 usually changes himself so she assumed he had. On 2/18/25 at 6:27 AM, R1 was taken to the bathroom by V7 and V8. R1 stood up and transferred to the toilet with assistance. R1's depend and pants were saturated with urine. V7 and V8 wet the corner of a full sized towel to wash R1's buttock and groin area and stated they were using the towel because they had no wash clothes. On 2/18/25 at 8:27 AM, V9 (CNA) stated she works from 8 AM to 5:45 PM and there were two CNA's working when she arrived at 8:00 AM today. On 2/18/25 at 10:24 AM, V15 (CNA) stated incontinence care should be provided every two hours. V15 stated it wasn't acceptable for a resident to go four hours without being checked or provided incontinence care. On 2/18/25 at 9:44 AM, V13 (LPN-Licensed Practical Nurse) stated incontinence care should be provided every one to two hours. When asked if going from 2 AM to 6 AM was too long a time frame for incontinence care to be provided, V13 stated in her opinion, it is too long. V13 stated staffing is hit or miss. 2. R3's Resident Face Sheet with a print date of 2/18/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease, neuromuscular dysfunction of bladder, hydronephrosis, diabetes, and a history of urinary tract infections. R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting, is incontinent of bowel and has an indwelling urinary catheter. R3's current Care Plan documents a Problem area with a start date of 6/24/22 of, (R3) needs extensive assist x (times) 2 for activities of daily living r/t (related to) weakness. This Problem area includes an intervention of, Assist x 2 as needed with ADL's (Activities of Daily Living) . On 2/18/25 at 8:18 AM, R3 stated they don't always have enough staff and showers don't always get done. R3 stated he wears depends, and uses a bed pan. R3 stated sometimes he has to wait to get on/off bed pan. When asked if any care wasn't provided due to staffing, R3 stated pericare isn't consistently provided. R3 stated it should be done daily and it isn't. 3. R4's Resident Face Sheet with a print date of 2/19/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include repeated falls, low back pain, arthritis, and pain. R4's MDS (Minimum Data Set) dated 1/7/25 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates R4 has a severe cognitive deficit. This same MDS documents R4 requires partial/moderate assist of staff for dressing and transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 R4's current Care Plan documents a Problem area with a start date of 12/27/24 of, resident has had a decline in ADL function and requires assistance with transfers and mobility. The interventions documented for the Problem area include, Have consistent approach amongst caregivers . On 2/18/25 at 6:09 AM, R4 stated nobody ever has enough staff anywhere. R4 was sitting at the dining room table drinking coffee and stated she didn't want to get up this early but they got her up anyway. On 2/18/25 at 6:18 AM, when asked why R4 was gotten up early if she didn't want to, V8 (CNA) stated they were told day shift was going to be short staffed and to get as many people up as they could. On 2/18/25 at 6:27 AM, V8 stated R4 sometimes gets up early but probably wouldn't have been up if they had not been told to get as many residents up as possible. On 2/18/25 at 3:43 PM, when asked to tell this surveyor about the conversation she had with the CNA's related to getting residents up early on 2/18/25, V16 (ADON-Assistant Director of Nurses/RN-Registered Nurse) stated she knew they had less staff than normal for day shift on 2/18/25 starting at 6:00 AM. On 2/18/25 at 3:12 PM, V2 (DON/Director of Nurses) stated they can't make a resident get up early if they don't want to. V2 stated staffing is good. V2 stated some days are better than others. 4. R8's Resident Face Sheet with a print date of 2/18/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic kidney disease, anxiety disorder, post traumatic stress disorder, insomnia, and diarrhea. R8's MDS dated [DATE] documents a BIMS score of 13, which indicates R8 is cognitively intact. This same MDS documents R8 is dependent on staff for toileting and is frequently incontinent of bowel and bladder. R8's current Care Plan documents a Problem area with a start date of 1/14/25 of, (R8) is incontinent of bowel and bladder and is not appropriate for a B&B (bowel and bladder) program due to impaired cognitive status. This Problem area includes an intervention of, Provide incontinence care as needed. On 2/18/25 at 7:50 AM, R8 stated they don't have enough staff to meet her needs timely. R8 stated she is incontinent at night and they occasionally come in and change her but they have so many residents and not enough staff. 5. R11's Resident Face Sheet with a print date of 2/19/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include osteomyelitis, fatigue, pain, anxiety disorder, heart disease, and hypertension. R11's MDS dated [DATE] documents a BIMS score of 10, which indicates R11 has a moderate cognitive deficit This same MDS documents R11 requires substantial/maximal assistance with toileting. R11's current Care Plan does not document a Problem area for incontinence or activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 On 2/18/25 at 11:59 AM, R11 stated they don't have enough staff. R11 stated he uses the call light, they answer and say they will be right back, and he ends up pissing his pants because they don't come back timely. On 2/18/25 at 9:56 AM, V14 (CNA) stated linens are a big issue right now. V14 stated she had no linens to provide care. V14 stated she can't give showers or remake the beds she has stripped and is using her own personal wipes to provide incontinence care. V14 stated they don't have enough staff and they don't have the supplies they need to provide care. V14 stated when they are short staffed showers don't get done, and residents don't get turned and repositioned as often as they should. V14 stated she does her best but when she is providing care to 30 residents it is impossible to meet all of their needs timely. V14 stated staffing was pretty good today (2/18/25) but they called her in around 5:30 AM for a bonus shift. This surveyor walked with V14 to the linen carts and supply rooms. The C wing linen carts contained gloves, three gowns, depends, two bed pads, and a couple of sheets. There were no towels, wash cloths, or bed pads in the C wing linen closet. The main supply room on A wing had five towels, no sheets, bed pads, or wash cloths. V14 stated on Friday (2/14/25) she didn't have linens until 11 AM, then it was lunch time and she was able to get three of the eight showers done after lunch because she was working alone from 4 PM to 6 PM. On 2/18/25 at 5:33 AM, V6 (CNA) stated they don't have enough CNA's working. V6 stated there are five CNA's working tonight and there are 35 residents on A wing and around 30 on C wing. V6 stated she wasn't sure how many residents there were on the rehab hall. V6 stated incontinence care and turning and positioning isn't done like it should be when they don't have enough staff. On 2/18/25 at 3:12 PM, V2 (DON-Director of Nurses) stated residents should be checked every couple of hours to see if incontinence care needs to be provided. This surveyor shared the observation and interviews related to R1's incontinence care and V2 stated she would expect R1 to be checked more often. V2 stated four to four and a half hours was too long to go without incontinence care. V2 stated she couldn't fix what they didn't tell her. V2 stated staffing is good. V2 stated some days are better than others. V2 stated they don't let the resident's suffer and department heads will work the floor if they need to. On 2/18/25 at 3:43 PM, when asked to tell this surveyor about the conversation she had with the CNA's related to getting residents up early on 2/18/25, V16 (ADON/RN) stated she knew they had less staff than normal for day shift on 2/18/25 starting at 6:00 AM. V16 stated they had three CNA's scheduled from 6 to 8 AM and then three more coming in at 8 AM. V16 stated she asked night shift to stay over for two hours. V16 stated they would have had one CNA on each unit and then the CNA staying over would have floated. When asked if that was enough to meet the needs of the residents, V16 stated, it can meet the needs but we also need two on each hall. V16 stated they had enough staff to meet the needs of the residents timely. When asked why staff and residents were telling this surveyor they didn't have enough staff, V16 stated it was probably due to all of the call in's related to the flu. On 2/18/25 at 4:09 PM, V1 (Administrator) stated he hadn't had any complaints/concerns related to incontinence care and/or showers not being provided timely. V1 stated, we get to them when we can. V1 stated staffing is as good as it can be. V1 stated they had enough staff to meet the needs of the residents timely. The facility Staffing Policy dated 11/2021 documents, Policy: The facility provides adequate staffing to meet needed care and services for our resident population and according to regulatory staffing requirements .Procedure: 1. Our facility maintains adequate staffing on each shift to ensure that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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 our resident's needs and services are met and schedules adequate staff to meet or exceed individual state requirements 3. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 10 of 10