Inspection·July 24, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documents on 07/01/25 at 6:24PM and 6:25 PM oxycodone every 4 hours 1 tablet administered by V6 (RN), on 07/04/25 at 6:11PM oxycodone every 4 hours corrected by V7 (RN) for 2 tablets comment documents correction at shift change with V6 (RN), at 6:36PM 1 tablet administered by V6 (RN), on 07/07/25 oxycodone 1 tablet administered at 6:19PM by V6 (RN) and at 6:20PM by V7 (RN), on 07/08/25 oxycodone every 4 hours 1 tablet administered at 6:04PM and 6:05PM by V6 (RN), at 5:02AM V7 administered 1 tablet and at 5:16AM V7(RN) has 1 tablet documented as correction resident dropped. On 07/12/25 at 6:21PM oxycodone every 4 hours 2 tablets administered by V6 (RN) and at 6:21PM by V6 (RN) another 1 tablet administer and then V7 (RN) administered another 1 tablet at 6:51PM, at 10:38 PM V7 (RN) signed out 2 tablets and comment documents tab wasted resident dropped. On 07/13/25 at 6:24PM oxycodone every 4 hours 1 tablet administered by V6 (RN) and then again at 6:26PM another 1 tablet administered by V6 (RN).On 07/21/25 at 3:06PM, R3 said that he gets his medication as ordered as far as he knows. R3 didn't have a problem with his medication administration. R3 said that he has never dropped any of his pain pills and that he always takes his medication with no problem.3. R5's Face Sheet dated 07/17/25 documents an admission date of 05/28/25 with diagnoses in part of pressure ulcer of buttock, pain nondisplaced fracture of anterior wall of right acetabulum, and pain in unspecified joint.R5's MDS dated [DATE] documents in Section C a BIMS score of 04 which indicates R5 is cognitively impaired.R5's Physician Order Report dated 06/17/25 to 07/17/25 documents a prescription with a start date of 05/28/25 with an end date of open ended for oxycodone 5mg 1 tablet every 4 hours PRN for dx (diagnosis) of pain.R5's Medication Administration History dated 07/01/25 to 07/17/25 documents oxycodone 5mg 1 tablet every 4 hours PRN was administered on 07/08/25 at 6:06Pm by V6 (RN), again at 6:06PM by V6 (RN) and then at 6:25PM by V7 (RN), and on 07/12/25 administered at 6:23PM by V6 (RN) and again at 6:24PM by V6 (RN).R5's Controlled Substance Report from 07/01/25 to 07/20/25 documents on 07/08/25 oxycodone every 4 hours 1 tablet was administered at 6:06pm by V6 (RN) and another 1 tablet administered at 6:06Pm by V6 (RN), and then at 6:25PM 1 tablet administered by V7 (RN), and on 07/12/25 oxycodone every 4 hours 1 tablet was administered at 6:23PM by V6 (RN) and at 6:24PM by V6 (RN).On 07/16/25 at 7:30PM, V9 (Licensed Practical Nurse/LPN) stated that she has heard residents complain that when V7 (RN) works that they don't get the correct pill, that their pain pill will look different such as shape and color. V9 said that she has also heard that V7 (RN) is logging under other nurses' names and signing out controlled substances. V9 said that she has had residents ask why they didn't get their pain medication when V7(RN) was working. V9 said that she has reported this to V1 (Administrator) and to V2 (Director of Nursing).On 07/16/25 at 2:20PM, V13 (Licensed Practical Nurse/LPN) stated that she worked on 07/12/25 on the evening shift. V13 stated that R2 had come up and ask if he could have a pain pill and she noticed that V6 (RN) had signed out R2's Oxycodone 5mg tablets 2 times, both at 6:23PM. V13 said that she contacted V6 (RN) and asked him if he gave R2 his oxycodone 5mg tablet 2 times at 6:23PM. V13 said that V6 (RN) told her that he did not give R2 any oxycodone that day and that he did not sign either of those administrations out. V13 said that she got to looking and noticed that R5 also had two tablets of her oxycodone signed out one after the other at 6:23PM and again at 6:24PM by V6. V13 said that she contacted V6 (RN) and asked him if he gave R5 the oxycodone at 6:23PM and at 6:24PM she said that V6 said that he did not administer those pills at that time and he did not sign out those pills on the controlled substance report or medication administration report. V13 said that on 7/12/25 she tried to contact V1 (Administrator/ADM) but he wasn't in town, and he told her to call V2 (Director of Nursing/DON). V13 said that she thought that V7 (RN) was signing out medication under V6's name and maybe taking the drugs. V13 said that she didn't think that V6 was even in the building when the medications were being signed out. V13 said that she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 2 of 14 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 07/24/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not able to give R2 his oxycodone because it had already been signed out and it wasn't in the time frame for him to get another pill. V13 said that she was told not to say anything to V7 (RN) or anyone that V1 and V2 would take care of it and they had policies in place to take care of these things.On 07/16/25 at 11:45AM, V1 (Administrator/ADM) stated that now he is looking at some of the narcotic sign off sheets of R2, R3, and R5's that he does see that there is a problem and that they need to make sure to monitor the narcotics more carefully. V1 said that he did see several narcotics were signed off one right after the other when there should have been several hours in between some of those medications. V1 said that he just can't accuse someone of taking medications that they need proof and now it's brought to his attention he will monitor it closely. V1 said that on 07/12/25 that V13 (LPN) did contact him, and he told her to contact V2 (DON) he said that V13 was saying something about she thought that V7 (RN) was signing out narcotics under V6's (RN) name. V1 said they did do disciplinary action on V7(RN) along with in servicing all the nurses about not signing out medications under another nurse's name and an in-service on making sure that you have 2 nurses to witness when you destroy narcotic medications. V1 said that V7 (RN) had been destroying medications by herself sometimes. V1 said that he had the computers looked at to make sure that none of the nurses' passwords were saved and he did find out that V6's (RN) password was saved on one of the computers.On 07/16/25 at 1:15PM, V2 (Director of Nursing/DON) stated that she was made aware of a possible problem with V7 (RN) signing off controlled medications by V13 (LPN) on 07/12/25. V2 said that she doesn't know how V7 (RN) would have been able to sign out medication under V6's (RN) name. V2 said that V1 told her that V6's (RN) password was saved under google on a computer and they did remove the password. V2 said that she thinks V13 (LPN) called her around 9:00PM and said that V7 (RN) signed off controlled medications under V6 (RN) name at 6:23PM and that V6 (RN) wasn't in the building when the medication was signed out. V2 said they pulled V6's (RN) punch sheet, and he punched out of the building at 6:30PM. V2 said that when she came in on 07/13/25, she looked at the controlled substance reports. V2 said that they did give V7 (RN) a disciplinary action for disposing of controlled substance without another nurse to witness the destruction along with signing out medications under another nurse's name. V2 said that V7 (RN) stated that she did not sign out medication under another nurse's name. V2 said that she did see on several controlled substance report sheets that V7 (RN) marks other she said that when she looked at the controlled substance sheets that there wasn't a lot of the sheets that are marked other. V2 said that she doesn't know why there are a couple of times that V7 (RN) signed out medications right after another nurse has given the controlled medications already. V2 said that it does bear watching the narcotics more closely. V2 said that she did in-service all nurses about making sure they don't sign out medication under another nurse's name and to make sure that there are always 2 nurses present when destroying medication. V2 said that they are going to investigate the narcotics more. V2 said that V7 (RN) told her that when she does destroy medications that she has another nurse witness it.On 07/16/25 at 5:34PM, V7 (RN) stated that she did receive education from V2 about making sure that she always has two nurses present when destroying medication along with making sure that she is not signed into another nurse's name when administering medications. V7 said that she was also educated on how to amend the controlled substance sheet and medication administration history, so it doesn't look like we administered medications close together when we forget to sign out medications. V7 said that sometimes the internet will go out and then they can't chart, and it will look like they signed out medication closely. V7 said that if she was logged into V6's (RN) account when charting she did not know she was logged in as V6 (RN). V7 said that it looks like she gives R3 a lot on the controlled substance report because R3 will drop the pill sometimes or when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 3 of 14 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 07/24/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is punching out the oxycodone it's a half tablet and it will break apart and disintegrates when she pops it out. V7 said that she crushes R2's medications because he has swallowing problems, and she doesn't want him to choke. V7 said that she always makes sure to chart in the comment section on the controlled substance reports when she has to take an extra pill or if her or the resident drops a pill.On 07/21/25 at 1:33PM, V6 (RN) stated that he did not sign off on the controlled substance reports or on the Medication Administration Report for R2's oxycodone on 07/08/25 at 6:05PM for 2 administrations. V6 said that he didn't sign off on 07/12/25 at 6:23PM for 2 administrations. V6 said that at 6:23PM on 7/12/25 he had already given the keys to V7 (RN) and that he was on the way out the door and he stopped in to help another resident who was having breathing problems then went out the door. V6 said that there is no way he could have signed off those medications for sure on 07/12/25. V6 said that he did not sign out oxycodone for R3 on 07/01/25 at 6:24PM and at 6:25PM. V6 said that he did not witness V7's (RN) correction on 07/04/25 and he doesn't know how he signed off that he gave R3's medication at 6:36PM. V6 stated he wasn't even working on that side on 07/04/25. V6 said that he did not give R3 oxycodone on 07/08/25 at 6:04PM or at 6:05PM. V6 said that he did not give R3 on 07/21/25 any medications at 6:21PM two times. V6 stated that on 7/21/25 he did not give R3 any oxycodone at 6:24PM or at 6:26PM. V6 said that it is pi**ing him off that these are signed off under his name and he did not administer those medications at those times and dates. V6 said that he doesn't know what is going on but it's making him mad. V6 said that he follows the doctors' orders and that he doesn't give any oxycodone or pain medication at the end of his shift. V6 said that at 6PM he gives his keys to the next shift coming on and gives report and does the narcotic count.On 07/22/25 at 2:04PM, V1 stated they don't have a policy on drug diversion.The facility policy titled Abuse Prevention Program with a revision date of 7/2015 documents under #4. Establishing a Resident Sensitive Environment documents this facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. Event ID: Facility ID: 146045 If continuation sheet Page 4 of 14 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 07/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to report allegations of abuse and misappropriation of property within the required time frames for 3 (R2, R3, and R5) of 6 residents reviewed for abuse in a sample of 13The Findings Include: 1.R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus.R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact.R2's Physician Order Report dated 06/17/25 to 07/17/25 documents a prescription with a start date of 12/27/24 with an end date of open ended of oxycodone 5mg (Milligrams) 1 tablet every 4 hours for pain.R2's Medication Administration History dated 07/01/25 to 07/17/25 documents oxycodone 5mg administer 1 tablet every 4 hours PRN (as needed) for pain which documents on 07/08/25 an administration at 6:05PM by V6 (Registered Nurse/RN), 6:06PM by V6 (RN) and 6:22PM by V7 (RN). R2's Medication Administration History also documents oxycodone was administered 2 times by V6 on 07/12/25 both given at 6:23PM.R2's Controlled Substance Report dated 07/01/25 to 07/20/25 documents on 07/08/25 at 6:05PM oxycodone every 4 hours PRN 1 tablet was administered by V6, on 07/08/25 at 6:05PM oxycodone every 4 hours PRN 1 tablet was administered by V6, on 07/08/25 at 6:22PM oxycodone every 4 hours 1 tablet was administered by V7 (RN). R2's Controlled Substance Report also documents on 07/12/25 V6 administered oxycodone 2 times, both at 6:23PM. 2. R3's Face Sheet dated 07/17/25 documents an admission date of 06/04/25 with diagnoses in part of unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, Phantom limb syndrome pain, pain unspecified, pain in left shoulder, and chronic lymphocytic leukemia.R3's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates moderately impaired cognition.R3's Physician Order Report for 06/17/25 to 07/17/25 documents a prescription with a start date of 06/04/25 and an end date of open ended for oxycodone 15mg give 1/2 tablet (7.5) every 4 hours PRN (as needed) dx (diagnosis) displaced fracture of anterior wall of left acetabulum.R3's Medication Administration History for 07/01/25 to 07/17/25 documents on 7/1/25 oxycodone 15mg administer 1/2 tablet was administered at 6:24PM and at 6:25PM both by V6 (RN), on 07/07/25 administered at 6:19PM by and at 6:20PM both by V7 (RN), on 07/08/25 administered at 6:04PM and at 6:05PM both by V6 (RN), on 07/12/25 administered 2 times at 6:21PM both by V6 (RN), and at 6:51PM by V7 (RN), on 07/13/25 administered at 6:24PM and at 6:26Pm both by V6 (RN).R3's Controlled Substance Report from 07/01/25 to 07/20/25 documents on 07/01/25 at 6:24PM and 6:25 PM oxycodone every 4 hours 1 tablet administered by V6 (RN), on 07/04/25 at 6:11PM oxycodone every 4 hours corrected by V7 (RN) for 2 tablets comment documents correction at shift change with V6 (RN), at 6:36PM 1 tablet administered by V6 (RN), on 07/07/25 oxycodone 1 tablet administered at 6:19PM by V6 (RN) and at 6:20PM by V7 (RN), on 07/08/25 oxycodone every 4 hours 1 tablet administered at 6:04PM and 6:05PM by V6 (RN), at 5:02AM V7 administered 1 tablet and at 5:16AM V7(RN) has 1 tablet documented as correction resident dropped. On 07/12/25 at 6:21PM oxycodone every 4 hours 2 tablets administered by V6 (RN) and at 6:21PM by V6 (RN) another 1 tablet administer and then V7 (RN) administered another 1 tablet at 6:51PM, at 10:38 PM V7 (RN) signed out 2 tablets and comment documents tab wasted resident dropped. On 07/13/25 at 6:24PM oxycodone every 4 hours 1 tablet administered by V6 (RN) and then again at 6:26PM another 1 tablet administered by V6 (RN). 3. R5's Face Sheet dated 07/17/25 documents an admission date of 05/28/25 with diagnoses in part of pressure ulcer of buttock, pain nondisplaced fracture of anterior wall of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 5 of 14 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 07/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right acetabulum, and pain in unspecified joint.R5's MDS dated [DATE] documents in Section C a BIMS score of 04 which indicates R5 is cognitively impaired.R5's Physician Order Report dated 06/17/25 to 07/17/25 documents a prescription with a start date of 05/28/25 with an end date of open ended for oxycodone 5mg 1 tablet every 4 hours PRN for dx (diagnosis) of pain.R5's Medication Administration History dated 07/01/25 to 07/17/25 documents oxycodone 5mg 1 tablet every 4 hours PRN was administered on 07/08/25 at 6:06Pm by V6 (RN), again at 6:06PM by V6 (RN) and then at 6:25PM by V7 (RN), and on 07/12/25 administered at 6:23PM by V6 (RN) and again at 6:24PM by V6 (RN).R5's Controlled Substance Report from 07/01/25 to 07/20/25 documents on 07/08/25 oxycodone every 4 hours 1 tablet was administered at 6:06pm by V6 (RN) and another 1 tablet administered at 6:06Pm by V6 (RN), and then at 6:25PM 1 tablet administered by V7 (RN), and on 07/12/25 oxycodone every 4 hours 1 tablet was administered at 6:23PM by V6 (RN) and at 6:24PM by V6 (RN).On 07/16/25 at 7:30PM V9 (Licensed Practical Nurse/LPN) stated that she has heard resident complain that when V7 (RN) works that they don't get the correct pill and that their pain pill will look different such as shape and color. V9 said that she has also heard that V7 (RN) is logging under other nurses' names and signing out controlled substances. V9 said that she has had resident ask why they didn't get their pain medication when V7(RN) was working. V9 said that she has reported this to V1 (Administrator) and to V2 (Director of Nursing).On 07/16/25 at 2:20PM, V13 (Licensed Practical Nurse/LPN) stated that she worked on 07/12/25 on the evening shift. V13 stated that R2 had come up and ask if he could have a pain pill and she noticed that V6 (RN) had signed out R2's Oxycodone 5mg tablets 2 times, both at 6:23PM. V13 said that she contacted V6 (RN) and asked him if he gave R2 his oxycodone 5mg tablet 2 times at 6:23PM. V13 said that V6 (RN) told her that he did not give R2 any oxycodone that day and that he did not sign either of those administrations out. V13 said that she got to looking and noticed that R5 also had two tablets of her oxycodone signed out one after the other at 6:23PM and again at 6:24PM by V6. V13 said that she contacted V6 (RN) and asked him if he gave R5 the oxycodone at 6:23PM and at 6:24PM she said that V6 said that he did not administer those pills at that time and he did not sign out those pills on the controlled substance report or medication administration report. V13 said that on 7/12/25 she tried to contact V1 (Administrator/ADM) but he wasn't in town, and he told her to call V2 (Director of Nursing/DON). V13 said that she thought that V7 (RN) was signing out medication under V6's name and maybe taking the drugs. V13 said that she didn't think that V6 was even in the building when the medications were being signed out. V13 said that she was not able to give R2 his oxycodone because it had already been signed out and it wasn't in the time frame for him to get another pill. V13 said that she was told not to say anything to V7 (RN) or anyone that V1 and V2 would take care of it and they had policies in place to take care of these things. On 07/16/25 at 11:45AM, V1 (Administrator/ADM) stated that now he is looking at some of the narcotic sign off sheets for R2, R3, and R5's that he does see that there is a problem and that they need to make sure to monitor the narcotics more carefully. V1 said that he did see several narcotics were signed off one right after the other when there should have been several hours in between some of those medications. V1 said that he just can't accuse someone of taking medications that they need proof and now it's brought to his attention he will monitor it closely. V1 said that on 07/12/25 that V13 (LPN) did contact him, and he told her to contact V2 (DON). V1 said that V13 was saying something about she thought that V7 (RN) was signing out Narcotics under V6's (RN) name. V1 said they did do disciplinary action on V7(RN) along with in servicing all the nurses about not signing out medications under another nurse's name and an in-service on making sure that you have 2 nurses to witness when you destroy narcotic medications. V1 said that V7 (RN) had been destroying controlled medications by herself sometimes. V1 said that he had the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 6 of 14 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 07/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few computers looked at to make sure that none of the nurse's passwords were saved and he did find out that V6's (RN) password was saved on one of the computers. On 07/16/25 at 1:15PM, V2 (Director of Nursing/DON) stated that she was made aware of a possible problem with V7 (RN) signing off controlled medications by V13 (LPN) on 07/12/25. V2 said that she doesn't know how V7 (RN) would have been able to sign out medication under V6's (RN) name. V2 said that V1 told her that V6's (RN) password was saved under google on a computer and they did remove the password. V2 said that she thinks V13 (LPN) called her around 9:00PM and said that V7 (RN) signed off controlled medications under V6's (RN) name at 6:23PM and that V6 (RN) wasn't in the building when the medication was signed out. V2 said they pulled V6 (RN) punch sheet, and he punch out of the building at 6:30PM. V2 said that when she came in on 07/13/25 that she looked at the controlled substance reports. V2 said that they did give V7 (RN) a disciplinary action for disposing of controlled substance without another nurse to witness the destruction along with signing out medications under another nurse's name. V2 said that V7 (RN) stated that she did not sign out medication under another nurse's name. V2 said that she did see on several controlled substance report sheets that V7 (RN) marks other and said that when she looked at the controlled substance sheets that there wasn't a lot of the sheets that are marked other. V2 said that she doesn't know why there are a couple of times that V7 (RN) signed out medications right after another nurse has given the controlled medications already. V2 said that it does bear watching the narcotics more closely. V2 said that she did in-service all nurses about making sure they don't sign out medication under another nurse name and to make sure that there are always 2 nurses present when destroying medication. V2 said that they are going to investigate the narcotics more. V2 said that V7 (RN) told her that when she does destroy medications that she has another nurse witness it. On 07/16/25 at 5:34PM V7 (RN) stated that she did receive education from V2 about making sure that she always has two nurse present when destroying medication along with making sure that I'm not signed into another nurse's name when administering medications. V2 said that she was also educated on how to amend the controlled substance sheet and medication administration history, so it doesn't look like we administered medication close together when we forget to sign out medications. V7 said that sometimes the internet will go out and then they can't chart, and it will look like they signed out medication closely. V7 said that if she was logged into V6 (RN) account when charting she did not know she was logged in as V6 (RN). V7 said that it looks like she gives R3 a lot on the controlled substance report because R3 will drop the pill sometimes or when she is punching out the oxycodone it's a half tablet and it will break apart and disintegrates when she pops it out. V7 said that she crushes R2's medications because he has swallowing problems, and she doesn't want him to choke. V7 said that she always makes sure to chart in the comment section on the controlled substance reports when she has to take an extra pill or if her or the resident drops a pill. On 07/21/25 at 1:33PM V6 (RN) stated that he did not sign off on the controlled substance report or on the Medication Administration report for R2's oxycodone on 07/08/25 at 6:05PM for 2 administrations. V6 said that he didn't sign off on 07/12/25 at 6:23PM for 2 administrations. V6 said that at 6:23PM on 7/12/25 he had already given the keys to V7 (RN) and that he was on the way out the door and he stopped in to help another resident who was having breathing problems then went out the door. V6 said that there is no way he could have signed off those medications for sure on 07/12/25. V6 said that he did not sign out oxycodone for R3 on 07/01/25 at 6:24PM and at 6:25PM. V6 said that he did not witness V7 (RN) correction on 07/04/25 and he doesn't know how he signed off that he gave R3 6:36PM. V6 stated he wasn't even working on that side on 07/04/25. V6 said that he did not give R3 oxycodone on 07/08/25 at 6:04PM or at 6:05PM. V6 said that he did not give R3 on 07/21/25 any medications at 6:21PM two times. V6 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 7 of 14 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 07/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that he did not give R3 on 07/13/25 any oxycodone at 6:24PM or at 6:26PM. V6 said that it is pi**ing him off that these are signed off under his name and he did not administer those medications at those times and dates. V6 said that he doesn't know what is going on but it's making him mad. V6 said that he follows the doctors' orders and that he doesn't give any oxycodone or pain medication at the end of his shift. V6 said that at 6PM he gives his keys to the next shift coming on and gives report and does count. On 7/21/25 at 2:00PM, V1 (ADM) said the day on 07/12/25 that V13 reported it was hard to prove that V7 signed off those medications under V6 because the cameras were down on one hall and he couldn't see if anyone was over on that hall passing medication to the residents. V1 said that he has never dealt with drug diversion before and this is his first time. V1 said that he looks at the behavior of the employees working to see if they look like they are taking anything. V1 said that he hasn't seen anyone that looked like they are under the influence of drugs. V1 said this is his very first experience with it as a few weeks ago. V1 said that he doesn't know at what point to contact the police and he would have to talk with his supervisor. V1 said that he doesn't know when it would come to the point of contacting the local authorities. V1 said there are several discrepancies in the narcotic count sheets. V1 said that he does see where V6 signed off the narcotics on the 12th at the same time and a minute apart on R2 and R5. V1 said that he doesn't know where the medication went to. V1 said that they always encourage staff to speak up regarding any kind of abuse and they don't get in trouble for it. V1 said they encourage staff to let them know what is going on.On 07/22/25 at 11:49AM, V1 (ADM) stated that he did not submit an initial report into Illinois Department of Public Health regarding the narcotics being signed off one right after the other, because they were signed out and he didn't think anything was missing. V1 stated that he was notified by the surveyor about the medications on R2, R3, and R5 that were signed out one after the other on several dates. V1 stated that it did seem weird, and he didn't know why those medications would have been signed off like that and he didn't know where the medications were. The facility policy titled Abuse Prevention Program with a revision date of 7/2015 documents under 8. External Reporting of Potential Abuse a. Initial reporting of allegations. If mistreatment has occurred, the resident's representative and the Department of Public Health shall be informed as soon as possible, but no later than within 24 hours of the allegation. The allegation shall either be called or faxed in to the regional Public Health Office. Public health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. and The facility shall immediately contact local law enforcement authorities (i.e. telephoning 911 where available) in the following situations:.4. When a crime has been committed in a facility by a person other than a resident. Event ID: Facility ID: 146045 If continuation sheet Page 8 of 14 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 07/24/2025 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 0610 Respond appropriately to all alleged violations. 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 initiate and complete investigations of abuse allegations in accordance with required time frames for 3 (R2, R3, and R5) of 6 residents reviewed for abuse in a sample of 13The Findings Include:1.R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus.R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact.R2's Physician Order Report dated 06/17/25 to 07/17/25 documents a prescription with a start date of 12/27/24 with an end date of open ended of oxycodone 5mg (Milligrams) 1 tablet every 4 hours for pain.R2's Medication Administration History dated 07/01/25 to 07/17/25 documents oxycodone 5mg administer 1 tablet every 4 hours PRN (as needed) for pain which documents on 07/08/25 an administration at 6:05PM by V6 (Registered Nurse/RN), 6:06PM by V6 (RN) and 6:22PM by V7 (RN). R2's Medication Administration History also documents oxycodone was administered 2 times by V6 on 07/12/25 both given at 6:23PM.R2's Controlled Substance Report dated 07/01/25 to 07/20/25 documents on 07/08/25 at 6:05PM oxycodone every 4 hours PRN 1 tablet was administered by V6, on 07/08/25 at 6:05PM oxycodone every 4 hours PRN 1 tablet was administered by V6, on 07/08/25 at 6:22PM oxycodone every 4 hours 1 tablet was administered by V7 (RN). R2's Controlled Substance Report also documents on 07/12/25 V6 administered oxycodone 2 times, both at 6:23PM. 2. R3's Face Sheet dated 07/17/25 documents an admission date of 06/04/25 with diagnoses in part of unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, Phantom limb syndrome pain, pain unspecified, pain in left shoulder, and chronic lymphocytic leukemia.R3's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates moderately impaired cognition.R3's Physician Order Report for 06/17/25 to 07/17/25 documents a prescription with a start date of 06/04/25 and an end date of open ended for oxycodone 15mg give 1/2 tablet (7.5) every 4 hours PRN (as needed) dx (diagnosis) displaced fracture of anterior wall of left acetabulum.R3's Medication Administration History for 07/01/25 to 07/17/25 documents on 7/1/25 oxycodone 15mg administer 1/2 tablet was administered at 6:24PM and at 6:25PM both by V6 (RN), on 07/07/25 administered at 6:19PM by and at 6:20PM both by V7 (RN), on 07/08/25 administered at 6:04PM and at 6:05PM both by V6 (RN), on 07/12/25 administered 2 times at 6:21PM both by V6 (RN), and at 6:51PM by V7 (RN), on 07/13/25 administered at 6:24PM and at 6:26Pm both by V6 (RN).R3's Controlled Substance Report from 07/01/25 to 07/20/25 documents on 07/01/25 at 6:24PM and 6:25 PM oxycodone every 4 hours 1 tablet administered by V6 (RN), on 07/04/25 at 6:11PM oxycodone every 4 hours corrected by V7 (RN) for 2 tablets comment documents correction at shift change with V6 (RN), at 6:36PM 1 tablet administered by V6 (RN), on 07/07/25 oxycodone 1 tablet administered at 6:19PM by V6 (RN) and at 6:20PM by V7 (RN), on 07/08/25 oxycodone every 4 hours 1 tablet administered at 6:04PM and 6:05PM by V6 (RN), at 5:02AM V7 administered 1 tablet and at 5:16AM V7(RN) has 1 tablet documented as correction resident dropped. On 07/12/25 at 6:21PM oxycodone every 4 hours 2 tablets administered by V6 (RN) and at 6:21PM by V6 (RN) another 1 tablet administer and then V7 (RN) administered another 1 tablet at 6:51PM, at 10:38 PM V7 (RN) signed out 2 tablets and comment documents tab wasted resident dropped. On 07/13/25 at 6:24PM oxycodone every 4 hours 1 tablet administered by V6 (RN) and then again at 6:26PM another 1 tablet administered by V6 (RN). 3. R5's Face Sheet dated 07/17/25 documents an admission date of 05/28/25 with diagnoses in part of pressure ulcer of buttock, pain nondisplaced fracture of anterior wall of right acetabulum, and pain in unspecified joint.R5's MDS dated Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 9 of 14 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 07/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] documents in Section C a BIMS score of 04 which indicates R5 is cognitively impaired.R5's Physician Order Report dated 06/17/25 to 07/17/25 documents a prescription with a start date of 05/28/25 with an end date of open ended for oxycodone 5mg 1 tablet every 4 hours PRN for dx (diagnosis) of pain.R5's Medication Administration History dated 07/01/25 to 07/17/25 documents oxycodone 5mg 1 tablet every 4 hours PRN was administered on 07/08/25 at 6:06Pm by V6 (RN), again at 6:06PM by V6 (RN) and then at 6:25PM by V7 (RN), and on 07/12/25 administered at 6:23PM by V6 (RN) and again at 6:24PM by V6 (RN).R5's Controlled Substance Report from 07/01/25 to 07/20/25 documents on 07/08/25 oxycodone every 4 hours 1 tablet was administered at 6:06pm by V6 (RN) and another 1 tablet administered at 6:06Pm by V6 (RN), and then at 6:25PM 1 tablet administered by V7 (RN), and on 07/12/25 oxycodone every 4 hours 1 tablet was administered at 6:23PM by V6 (RN) and at 6:24PM by V6 (RN).On 07/16/25 at 7:30PM V9 (Licensed Practical Nurse/LPN) stated that she has heard resident complain that when V7 (RN) works that they don't get the correct pill and that their pain pill will look different such as shape and color. V9 said that she has also heard that V7 (RN) is logging under other nurses' names and signing out controlled substances. V9 said that she has had resident ask why they didn't get their pain medication when V7(RN) was working. V9 said that she has reported this to V1 (Administrator) and to V2 (Director of Nursing). On 07/16/25 at 2:20PM, V13 (Licensed Practical Nurse/LPN) stated that she worked on 07/12/25 on the evening shift. V13 stated that R2 had come up and ask if he could have a pain pill and she noticed that V6 (RN) had signed out R2's Oxycodone 5mg tablets 2 times, both at 6:23PM. V13 said that she contacted V6 (RN) and asked him if he gave R2 his oxycodone 5mg tablet 2 times at 6:23PM. V13 said that V6 (RN) told her that he did not give R2 any oxycodone that day and that he did not sign either of those administrations out. V13 said that she got to looking and noticed that R5 also had two tablets of her oxycodone signed out one after the other at 6:23PM and again at 6:24PM by V6. V13 said that she contacted V6 (RN) and asked him if he gave R5 the oxycodone at 6:23PM and at 6:24PM she said that V6 said that he did not administer those pills at that time and he did not sign out those pills on the controlled substance report or medication administration report. V13 said that on 7/12/25 she tried to contact V1 (Administrator/ADM) but he wasn't in town, and he told her to call V2 (Director of Nursing/DON). V13 said that she thought that V7 (RN) was signing out medication under V6's name and maybe taking the drugs. V13 said that she didn't think that V6 was even in the building when the medications were being signed out. V13 said that she was not able to give R2 his oxycodone because it had already been signed out and it wasn't in the time frame for him to get another pill. V13 said that she was told not to say anything to V7 (RN) or anyone that V1 and V2 would take care of it and they had policies in place to take care of these things.On 07/16/25 at 11:45AM, V1 (Administrator/ADM) stated that now he is looking at some of the narcotic sign off sheets for R2, R3, and R5's that he does see that there is a problem and that they need to make sure to monitor the narcotics more carefully. V1 said that he did see several narcotics were signed off one right after the other when there should have been several hours in between some of those medications. V1 said that he just can't accuse someone of taking medications that they need proof and now it's brought to his attention he will monitor it closely. V1 said that on 07/12/25 that V13 (LPN) did contact him, and he told her to contact V2 (DON). V1 said that V13 was saying something about she thought that V7 (RN) was signing out Narcotics under V6's (RN) name. V1 said they did do disciplinary action on V7(RN) along with in servicing all the nurses about not signing out medications under another nurse's name and an in-service on making sure that you have 2 nurses to witness when you destroy narcotic medications. V1 said that V7 (RN) had been destroying controlled medications by herself sometimes. V1 said that he had the computers looked at to make sure that none of the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 10 of 14 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 07/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few passwords were saved and he did find out that V6's (RN) password was saved on one of the computers. On 07/16/25 at 1:15PM, V2 (Director of Nursing/DON) stated that she was made aware of a possible problem with V7 (RN) signing off controlled medications by V13 (LPN) on 07/12/25. V2 said that she doesn't know how V7 (RN) would have been able to sign out medication under V6's (RN) name. V2 said that V1 told her that V6's (RN) password was saved under google on a computer and they did remove the password. V2 said that she thinks V13 (LPN) called her around 9:00PM and said that V7 (RN) signed off controlled medications under V6's (RN) name at 6:23PM and that V6 (RN) wasn't in the building when the medication was signed out. V2 said they pulled V6 (RN) punch sheet, and he punch out of the building at 6:30PM. V2 said that when she came in on 07/13/25 that she looked at the controlled substance reports. V2 said that they did give V7 (RN) a disciplinary action for disposing of controlled substance without another nurse to witness the destruction along with signing out medications under another nurse's name. V2 said that V7 (RN) stated that she did not sign out medication under another nurse's name. V2 said that she did see on several controlled substance report sheets that V7 (RN) marks other and said that when she looked at the controlled substance sheets that there wasn't a lot of the sheets that are marked other. V2 said that she doesn't know why there are a couple of times that V7 (RN) signed out medications right after another nurse has given the controlled medications already. V2 said that it does bear watching the narcotics more closely. V2 said that she did in-service all nurses about making sure they don't sign out medication under another nurse name and to make sure that there are always 2 nurses present when destroying medication. V2 said that they are going to investigate the narcotics more. V2 said that V7 (RN) told her that when she does destroy medications that she has another nurse witness it. On 07/16/25 at 5:34PM V7 (RN) stated that she did receive education from V2 about making sure that she always has two nurse present when destroying medication along with making sure that I'm not signed into another nurse's name when administering medications. V2 said that she was also educated on how to amend the controlled substance sheet and medication administration history, so it doesn't look like we administered medication close together when we forget to sign out medications. V7 said that sometimes the internet will go out and then they can't chart, and it will look like they signed out medication closely. V7 said that if she was logged into V6 (RN) account when charting she did not know she was logged in as V6 (RN). V7 said that it looks like she gives R3 a lot on the controlled substance report because R3 will drop the pill sometimes or when she is punching out the oxycodone it's a half tablet and it will break apart and disintegrates when she pops it out. V7 said that she crushes R2's medications because he has swallowing problems, and she doesn't want him to choke. V7 said that she always makes sure to chart in the comment section on the controlled substance reports when she has to take an extra pill or if her or the resident drops a pill. On 07/21/25 at 1:33PM V6 (RN) stated that he did not sign off on the controlled substance report or on the Medication Administration report for R2's oxycodone on 07/08/25 at 6:05PM for 2 administrations. V6 said that he didn't sign off on 07/12/25 at 6:23PM for 2 administrations. V6 said that at 6:23PM on 7/12/25 he had already given the keys to V7 (RN) and that he was on the way out the door and he stopped in to help another resident who was having breathing problems then went out the door. V6 said that there is no way he could have signed off those medications for sure on 07/12/25. V6 said that he did not sign out oxycodone for R3 on 07/01/25 at 6:24PM and at 6:25PM. V6 said that he did not witness V7 (RN) correction on 07/04/25 and he doesn't know how he signed off that he gave R3 6:36PM. V6 stated he wasn't even working on that side on 07/04/25. V6 said that he did not give R3 oxycodone on 07/08/25 at 6:04PM or at 6:05PM. V6 said that he did not give R3 on 07/21/25 any medications at 6:21PM two times. V6 stated that he did not give R3 on 07/13/25 any oxycodone at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 11 of 14 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 07/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 6:24PM or at 6:26PM. V6 said that it is pi**ing him off that these are signed off under his name and he did not administer those medications at those times and dates. V6 said that he doesn't know what is going on but it's making him mad. V6 said that he follows the doctors' orders and that he doesn't give any oxycodone or pain medication at the end of his shift. V6 said that at 6PM he gives his keys to the next shift coming on and gives report and does count.On 07/22/25 at 11:49AM, V1 (ADM) stated that he did not submit an initial report into Illinois Department of Public Health regarding the narcotics being signed off one right after the other, because they were signed out and he didn't think anything was missing. V1 stated that he was notified by the surveyor about the medications on R2, R3, and R5 that were signed out one after the other on several dates. V1 said that he was going to start the initial report and send it in to the Department of Public Health.On 07/22/25 at 12:14PM, an initial report was submitted to the Illinois Department of Public Health incident web portal which document residents' names as R2 and R5, Incident Category as drug diversion, police notification documents Yes, and the Date of Occurrence documents 07/21/25.On 07/23/25 at 3:14PM, V1 was notified that R3 was not listed in the initial incident report to Illinois Department of Public Health along with the date of occurrence was listed as 07/21/25 instead of 07/12/25.On 07/23/25 at 3:28PM, V1 sent in a new initial incident report into the Illinois Department of Public Health web portal that included R2, R3, and R5 with incident Category as Drug Diversion and the date of occurrence as 07/12/25.The facility policy titled Abuse Prevention Program with a revision date of 7/2015 documents #5. Internal reporting requirements and identification of allegations. Upon learning of the report, the administrator shall initiate an incident investigation.#7. Internal Investigation of Abuse, neglect, or misappropriation allegations and response A. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. B. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. F. Final Abuse investigation report the investigator will report the conclusion of the investigation in writing to the administrator or designee within five working days of the reported incident. Event ID: Facility ID: 146045 If continuation sheet Page 12 of 14 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 07/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to properly dispose of controlled substance medication for 2 (R2 and R3) of 6 residents reviewed for pharmacy services in a sample of 13. The Findings Include:1. R2's Face Sheet dated 07/17/25 documents an admission date of 12/19/24 with diagnoses in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, pain in left knee, malignant neoplasm of oropharynx, squamous cell carcinoma of skin of scalp and neck, malignant neoplasm of esophagus.R2's Minimum Data Set (MDS) dated [DATE] documents in Section C a BIMS (Brief Interview for Mental Status) score of 13, which indicates that R2 is cognitively intact.R2's Physician Order Report dated 06/17/25 to 07/17/25 documents a prescription with a start date of 12/27/24 with an end date of open ended of oxycodone 5mg (Milligrams) 1 tablet every 4 hours for pain. R2's Controlled Substance Report dated 07/01/25 to 07/20/25 for oxycodone every 4 hours PRN (as needed) documents on 07/01/25 at 7:12PM, 07/03/25 at 4:02AM, and 07/10/25 at 12:38AM by V7 (Registered Nurse/RN) an amount of 1 tablet documents an action of correction with a reason of other and documents correction under comments. 2. R3's Face Sheet dated 07/17/25 documents an admission date of 06/04/25 with diagnoses in part of unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, Phantom limb syndrome pain, pain unspecified, pain in left shoulder, and chronic R3's Face Sheet dated 07/17/25 documents an admission date of 06/04/25 with diagnoses in part of unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, Phantom limb syndrome pain, pain unspecified, pain in left shoulder, and chronic lymphocytic leukemia.R3's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates moderately impaired cognition.R3's Physician Order Report for 06/17/25 to 07/17/25 documents a prescription with a start date of 06/04/25 and an end date of open ended for oxycodone 15mg give 1/2 tablet (7.5) every 4 hours PRN (as needed) dx (diagnosis) displaced fracture of anterior wall of left acetabulum. R3's Controlled Substance Report for 07/01/25 to 07/20/25 for Oxycodone every 4 hours PRN on 07/03/25 at 5:07AM by V7 (RN) 1 tablet given, action as correction, comments resident dropped. On 07/04/25 at 6:11PM by V7 (RN) documents 2 tablets, action correction, comments correction at shift change with V6 (RN). On 07/06/25 at 6:30PM by V7 (RN) 1 tablet given, action as correction, comments correction. On 07/07/25 at 5:13AM by V7 (RN) 1 tablet given, action as correction, comments correction. On 07/08/25 at 5:16Am by V7 (RN) 1 tablet given, action as correction, comments res (resident) dropped. On 07/12/25 at 10:38PM by V7 (RN) 1 tablet given, action as correction, comments tab wasted, resident dropped.On 07/16/25 at 11:45AM, V1 (Administrator/ADM) state that he was notified by V13 (Licensed Practical Nurse/LPN) on 07/12/25 that V7(RN) was not disposing of controlled substance with a witness. V1 stated that they did do a disciplinary action with V7 (RN) regarding making sure that when disposing of controlled substances that she has another nurse to witness the dispose of the controlled substance.On 07/16/25 at 1:15PM, V2 (Director of Nursing/DON) stated that on R3 that V7 (RN) stated that she signed out so many and had correction and others marked was because R3 would drop the medication a lot and V7 (RN) would have to get a new pill. V2 said that she did give V7 (RN) a disciplinary action with V7 (RN) regarding making sure when she is disposing of controlled substance, she has another nurse present to witness the disposal. V2 said that V7 told her that she did have a witness when she disposed of controlled substance, she just forgot to have them sign that they witnessed.On 07/16/25 at 5:34PM, V7 (RN) stated that she was given a disciplinary action from V2 (DON) regarding not disposing of controlled substance properly by not having a witness to observe the disposal of the controlled substance. V7 said that when she marks other or correction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 13 of 14 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 07/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete on the controlled substance reports that she usually always put something under the comment section. V7 said if there is nothing under the comment section of the controlled substance report for she doesn't know why. V7 said that she does have another witness when she must dispose of a controlled substance, she just forgets to have them sign the controlled substance report form. V7 said that will never happen again. V7 said that R3 will drop his controlled substance often and she will have to get another one out or the pill has disintegrated because it is only a half of tab and it falls apart easy when you pop it out.On 07/22/25 at 12:03PM, V6 (Registered Nurse) stated that he did not do a correction with V7 (RN) on 07/04/25 and that he doesn't know why his name is in the comments on R3's-controlled substance report. V6 stated that he has never witnessed or disposed of any controlled substance with V7 (RN).A documents titled Employee Disciplinary Action with a date of 07/13/25 documents employee name of V7 (RN). A description of infraction documents was noted that (V7) was not disposing of controlled substance correctly. Also she charted under another nurses name. All shifts must complete a narc (Narcotic) count to ensure accuracy. All Narcs must be destroyed per regulations including a 2nd nurse as a witness. In the future if not correction, further disciplines will follow. Supervisor's Signature is V2 (DON).The Facility policy titled Controlled Substance Disposal with no effective date documents under policy- Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures B. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substance wasted for any reason. Event ID: Facility ID: 146045 If continuation sheet Page 14 of 14