Inspection·September 4, 2025

F 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interventions include: 1. Listen to R1 and validate feelings. 2. 1:1 given weekly with social services. 3. Let Psych Nurse Practitioner know of any issues. 4. Give Medications as ordered. 5. If R1 talks of suicide ideations will follow directions as given by Nurse Practitioner or Medical Doctor, created date of 4/25/2025. R1's Care Plan also documents a Problem area of R1 will punch self in face causing self-harm with a start date of 4/25/25 and edit date of 8/15/25. The Goal documented is R1 will not cause harm to self /others when becomes upset. Documented interventions for this Problem area include: 1) listen to resident and validate feelings 2) remind resident punching self doesn't solve anything 3) try to get resident to talk through her feelings 4) remind resident we are here to help 5) give medications as ordered 6) psych Nurse Practitioner made aware of situation ASAP for direction if needed with a start date of 4/25/25 and edit date of 5/1/25.R1's Progress Notes document the following:4/14/2025: R1 sent to ER for stating she had bad thoughts, were very strong, wanting to strangle herself and began punching self in her face. Resident returned on 4/14/2025 with a recommendation to refer R1 to (Name of Counseling Service) for counseling. 4/15/2025: R1 continued to have suicidal ideations and asked to be sent to hospital stating she was going to hurt herself when staff leaves room. Resident placed on 1:1. R1 called 911 herself for transfer to local hospital. R1 was transferred to local hospital and the local hospital transferred R1 to another hospital. R1 returned to facility on 4/21/2025 with medication changes. 4/21/2025: R1 was sent back out to the local hospital for suicidal behaviors/ideations, screaming, crying out, punching self in the face and bouncing head off of the headboard. R1 returned to facility on 4/22/2024 at 4:13AM. 4/24/2025: R1 sent to ER for suicidal behaviors/ideations, hyperventilating, screaming and crying out, punching self in face, and bouncing head off of headboard. R1 called 911 herself. Transferred out of facility via ambulance. R1 returned to the facility on 4/25/2025 at 10:07AM shows R1 returned to facility shortly after leaving facility.4/27/2025: R1 was sent to ER due to R1 stating she was thinking about harming herself and reported having suicidal thoughts. Call back was received from the local hospital and R1 was being placed in a psych facility to be determined.4/29/2025: At 12:30AM R1 returned to facility. R1 was placed on 1:1 with a CNA on 4/29/25 at 11:58PM.5/23/2025: At 5:47AM R1 called 911 twice verbalizing she does not feel safe and wants to strangle herself. R1 taken to local hospital. On 5/23/2025 at 7:12AM the note documents that R1 planned to return to the facility. 6/10/2025: At 10:09PM R1 was screaming and bouncing her head off the wall. R1 was sent to the local hospital for altered mental status/ suicidal ideations/aggressive behavior toward self. On 6/11/2025 at 1:53AM R1 returned to facility and stated she wanted to strangle herself. R1 called 911 herself. 6/11/2025: At 7:24PM R1 was transferred to a behavioral health facility. On 6/17/2025 at 3:29PM R1 returned to facility with an increase in antidepressant medication. 6/24/2025: At 9:40PM R1 was screaming, moaning, beating head off the doorway and punching herself in the face. R1 transferred to the local ER. There was no note of time or date of return. 6/27/2025: At 3:39AM R1 was in her room and staff heard R1 hitting herself. R1, stated she wanted to hurt herself, then R1 started banging her head on the door frame violently. R1 stated I would rather kill myself than go to the hospital, I'm going to hang myself. R1 was sent to the hospital and returned at 4:30AM and R1 had 1:1 with a CNA. On 6/27/2025 at 5:22PM R1 transferred to local hospital for suicidal thoughts. R1 returned at 11:12PM. 7/26/2025: At 1:54PM R1 screaming and cursing at other residents, screaming and banging her head off her walls saying she was going to kill herself. R1 sent to ER at 2:17PM and returned at 5:46PM. On 7/26/2025 at 9:55PM R1 called 911 due to suicidal thoughts, R1 transferred out to local hospital. 7/27/2025: At 8:22AM R1 returns from local hospital where she was seen by a counselor. Once R1 was in her room, R1 starts screaming I'm gonna kill myself, I'm gonna hurt myself, room completely stripped to include fitted sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 2 of 8 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 09/04/2025 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 7/27/2025 at 8:43AM R1 loud again and attempting to strangle herself with a fitted sheet and the use of her hands, refuses out of her room to be monitored and not enough staff for 1:1. On 7/27/2025 at 9:52AM R1was sent back out to ER. R1 returned at 7:42PM.7/28/2025: At 10:55AM R1 has 1:1 monitoring.8/6/2025: At 11:09AM R1 was aggressive, disruptive behaviors, screaming and cussing and making threats that she wants to strangle herself with a sheet. R1 stated she was going to barricade herself in her room and kill herself. R1 unable to be redirected or consoled, all items (sheets, cords, blankets, pillowcases, clothes ) removed from room. R1 began gently headbutting her door frame and stating that she wants to go to the hospital. (R1) was disturbing other residents on the hall and when they yelled from their room for her to be quiet, resident threatened 2 different female residents that she ‘will punch them in their faces' and called them ‘f****ing b******.' (R1) yelled out to staff ‘I am going to barricade myself in the room and kill myself.' Staff prevented (R1) moving furniture to barricade door. (R1) held a fist up and threatened a CNA when taking her vitals, staff rotated someone monitoring behaviors for 2 hours, resident realized that her (small, baby-sized) [NAME] blanket was removed from her room and began screaming at staff to give her things back. This writer explained to (R1) that it's protocol to remove all items when someone is threatening suicidal plans. (R1) began screaming at staff that she ‘will call the cops on us for stealing if we did not give the [NAME] blanket back.' (V20-RN) was able to console resident and resident stated ‘I won't try to kill myself if I can have [NAME] back. [NAME] blanket returned to (R1) and no more behaviors observed at this time. (V3-Assistant Director of Nursing/ADON) called and currently in room with resident.8/9/2025: At 8:50PM R1 was screaming and banging her head forcefully on the wall, choking self and strangling self with a blanket. R1 sent to ER and returned on 8/10/2025 at 5:32AM. 8/11/2025: At 9:03PM R1 was 1:1 at nurses' station and wanted to go to bed so R1 went to her room and started beating her head on the wall. R1 was sent to the ER for evaluation. R1 returned to facility on 8/15/2025 at 1:18AM.8/18/2025 (documented as a late entry on 8/25/25 at 9:46AM) Sweep made of (R1's) room. All Hazards removed and cords secured. Daily audit sheet completed to ensure no further hazards in room authored by V1 (Administrator).R1's Behavior Tracking Logs dated 6/20/2025 - 8/20/2025 were reviewed and document the following:6/27/25 at 2:18AM: R1 had disruptive sounds behavior with interventions, behaviors documented was disruptive sounds with interventions of redirecting, 1:1, offering food/fluids, toileting, and positioning and was ineffective. 6/30/2025 at 10:05P: R1 stated she was having bad thoughts and was biting her fingers. R1 was also punching herself in the face. Interventions of 1:1, offer food/fluids and calm environment was ineffective. No other behaviors were documented for June 2025. 7/1/2025 at 8:22AM: R1 had 1:1 that was effective for hearing or seeing things not there. 7/1/2025 at 9:05PM: R1 was yelling and crying in her room when staff checks on her, she is saying she is having racing thoughts, providing a calm environment was not effective.7/30/2025 at 9:04PM: R1 was hitting self and interventions to redirect and 1:1 was ineffective. No other behaviors were documented for July 2025.8/6/2026 at 11:37PM: R1 had behaviors of cursing at others, with redirection ineffective nor was 1:1 effective. No other behaviors documented for August 2025. R1's Physician Orders documents an order for 15-minute checks once a day and as needed for diagnosis of bipolar disorder with a start date of 4/3/25. There were no other orders documented in R1's Physician's Orders for increased monitoring.On 8/29/2025 at 4:00PM, V1 (Administrator) stated he was unsure of who took out the call light out of R1's room or when this occurred. V1 was unsure about the 15-minute checks as well.On 8/29/2025 at 4:30PM, V2 (Director of Nursing/DON) stated she didn't know about the 15-minute checks for R1 but may have a few somewhere. V2 stated she didn't know when 15-minute checks started or when they ended. V2 referred this surveyor to V3 for the 15-minute checks. V2 stated she doesn't think (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 3 of 8 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 09/04/2025 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she has any of the 15-minute check sheets.On 8/29/2025 at 5:35PM, V3 (Assistant Director of Nursing) stated when R1 returned to the facility on 6/27/2025 she instructed the staff to move R1 to another room and to remove all items that R1 could be used to harm herself. V3 stated they removed the call light at that time. V3 stated she did not direct them to remove the call light in the bathroom because R1 shared a bathroom with another resident. V3 stated she didn't think about the remote cord or other cords left in the room. V3 stated she did know that at one time R1 was on 15-minute checks but she didn't know when they started or how long they were for.On 8/29/2025 at 4:30PM, V9 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated R1 was in a private room prior to 6/27/2025. On 6/27/2025 R1 was returning from a hospital stay and the staff felt it would be safer for R1 to be in a room that was more visible so they moved her to another hall. V9 stated this is when they removed the call light, when R1 was placed in the different room. V9 didn't know of any other items removed but she does know they would not let R1 take any personal items that could be used to harm herself. V9 stated she did not have any 15-minute check sheets and she was not sure where they would be.On 8/29/2025 at 6:55PM, V20 (Licensed Practical Nurse/LPN) stated she doesn't recall R1 being on 15-minute checks.R1's Psychiatric Notes and Evaluations document the following:4/4/2025: R1 was seen by V21 (Master of Social Work/Licensed Clinical Social Worker) documents writer will meet with R1 on a weekly to biweekly basis for 6 months.4/7/2025: R1 was seen by V12 (Psychiatric Nurse Practitioner) and documents continue medication and treatment plan, staff to report any behavioral changes to provider. 4/21/25: Psych note documents R1 is to follow up with (Name of Counseling Service) for counseling and send to ER (Emergency Room) immediately if R1 expresses Suicidal Ideations and or exhibits self-harm behaviors/threats.6/23/3035: documents R1 was readmitted to the facility on [DATE] from a Psychiatric/Behavioral Health Facility for wanting to strangle herself and in-house Psych visits to increase to weekly.Visits by Psychiatric group for in-house visits shows no changes in plan of care for 6/28/2025, 6/30/2025, 7/7/2025 and 7/12/2025. On 7/14/2025 and 7/21/2025 medication changes were ordered by V12. 7/28/2025: V12 documents, the provider recommends facility to find proper placement for resident where needs can by appropriately met at appropriate level of care.8/4/25: R1 was seen by V12 and documents facility currently awaiting referral responses for placement Client to continue to meet with Social Worker.8/11/25: R1 was seen by V12 with no changes in plan of care. On 8/20/2025 at 9:30AM, R1 was observed in her room resting in her bed. Observation was made of the following items present in R1's room: R1 had a large blanket on her with a medium size thin blanket lying beside her, a cord attached to the bed remote occupied by R1 and the same cord on the unoccupied bed in the room. There were two Walmart bags present on bedside table. There were cords noted to the TV and air conditioner and hanging freely. R1's bathroom had an approximately 4-foot call light cord noted and a utility pipe coming out of the wall approximately 6 inches from the ceiling. There was a folded chair leaned up against the wall in R1's room. R1 was sleeping at this time. There were no staff observed with R1 or present outside of R1's room at this time.On 8/20/2025 at 10:15AM, V4 (Licensed Practical Nurse/LPN) stated she takes care of R1 on some of her shifts. V4 stated she caught R1 with a fitted sheet wrapped around her neck. V4 stated she got the sheet removed and stated she told R1 that she would pass out before she died doing that. V4 stated she could not remember exactly when this incident occurred. V4 stated R1 has good days and bad days. V4 stated R1 is suicidal at times.On 8/20/2025 at 10:18AM, V1 (Administrator) stated R1 was admitted from a behavioral facility up North that closed. R1 stated they do 1:1 off and on, according to R1's behaviors. V1 stated he told R1 that if she tried to strangulate herself then she would pass out before she died. This interview took place outside of R1's room. R1 was observed getting up from her bed and went into her bathroom and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 4 of 8 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 09/04/2025 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few closed the door. On 8/20/2025 at 11:25AM, R1 stated she wants to be in a place where people are more her age. R1 stated she frequently has bad thoughts. R1 was asked to explain what she meant by bad thoughts, R1 stated, I frequently have thoughts of suicide, and the thoughts are coming more frequently now. R1 was asked if she had a plan, R1 stated, I will strangle myself. R1 stated, They took my fitted sheet and call light. R1 then started laughing. R1 stated, They caught me with the sheet around my neck and they stopped me, I was trying to do it. R1 then stated, The thought of suicide is really frequently lately. R1 was asked if there were ever staff that stayed in her room with her, R1 stated No, they never stay. R1 stated, I have good days and bad days; the bad days are really bad. R1 stated, I usually eat in my room by myself. R1 was asked what she does when she needs help. R1 stated, I am independent so I don't ask for help.On 8/20/2025 at 11:40AM, V6 (Licensed Practical Nurse) stated she does take care of R1 when she works. V6 stated, I have seen behaviors out of R1 like banging her head against the wall. V6 stated, I have never seen her try suicide. V6 stated R1 can be verbally aggressive to other residents especially R3. V6 stated R3 is confused but she will argue back at R1. V6 stated she was not aware of ever having 1:1 monitoring for R1.On 8/20/2025 at 11:58AM, V7 (Physician) was asked if he was familiar with R1, V7 stated Oh my God, please help with her, she is violent. V7 then stated, Is she still at the facility? V7 was asked if he was unaware of her return from the hospital and V7 stated, She has been sent out so many times I can't keep track. V7 stated she needs to be placed somewhere more fitting for her. V7 stated he gave the facility several facilities to send referrals to but evidently nobody will take her. V7 was asked if he felt like R1 was a threat to herself and others. V7 stated, Yes she is a threat to herself and to others, she hurt a staff member there by giving the staff member a head concussion. V7 was asked if he felt like R1 could possibly harm or kill herself and V7 stated, Oh, yes and I believe she tried but they caught her. V7 was asked if he felt like a call light in the bathroom and cords like remotes to the bed could be hazards for a resident with suicidal ideation. V7 stated, Of course they can, and I know they took away the sheets and I don't know that they can take everything away, but something needs to be done to assure safety for (R1), but they mainly need to get her placed somewhere more fitting and a place where she can be monitored closely. V7 stated R1 beats her head against the wall too and she could get a serious injury from that.On 8/20/2025 at 12:54PM, V8 (Licensed Practical Nurse) stated R1 used to be on the hall that she works but has since moved to the other hall. V8 was asked why R1 moved and V8 stated, I am not sure. When I came back to work after a couple of days off, (R1) had been moved. V8 was asked if she has ever seen behaviors with R1 while R1 resided on her hall, V8 stated she had seen behaviors like R1 banging her head against the walls. V8 stated, One time I heard R1 state she was going to kill herself, so we sent her to the hospital. V8 stated she has never seen R1 have any behaviors with other residents.On 8/20/2025 at 1:00PM, V2 (DON) came into V1's office where this surveyor was discussing R1's statement that she had frequent thoughts of suicide and had a plan of strangulation. V2 spoke up and said, I have never heard her mention that. V2 then left the room and yelled back that she was going to have R1 go to her office and sit with her. V2 then shortly came back to V1's office and summoned this surveyor to R1's room and stated that R1 stated she didn't say that. At 1:05PM, this surveyor entered the room, R1 was observed to be crying and when this surveyor asked her again about what she had said about wanting to kill herself, R1 stated she did say that. V2 and this surveyor stepped out of R1's room and V2 was asked if she felt the room of R1 was safe for someone that plans on strangulation. V2 went back into the room and looked around and noted the cords and stated, No but we did take away her sheets and call light. V2 was asked if R1 was ambulatory and V2 stated yes. V2 was then asked if R1 took herself to the bathroom independently and V2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 5 of 8 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 09/04/2025 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few yes, she does. This surveyor asked V2 to go look at R1's bathroom and see if she sees any hazards there. V2 came out of the bathroom and stated she wasn't aware there was a call light pull cord in the bathroom. V2 stated, I will cut that down right now and V2 left to go get scissors. V2 then went in the bathroom and cut the call cord. V1 then came to the hallway outside of R1's room and V2 reported that there was a call cord in the bathroom, and she cut it down. V1 stated he was unaware there was a cord in there as well. V1 stated to V2, (R1) has to be on constant 1:1 until we get her placed somewhere else, we have to for her safety. V2 stated, We will have to have department heads to take turns with her until I can get staff assigned to sit with her at all times. V1 and V2 were shown the thick metal pipe in the bathroom wall at the top above the toilet. V2 stated, Oh my I hadn't noticed that either. V2 stated, Well that is the sprinkler, and I can't do anything about that so there is that. At this time, this surveyor requested documentation of staff education for Suicidal Plan and/or Behavioral Health Care and V2 stated she has never done that type of training since she has been the Director of Nursing. V2 stated she has never trained the staff on Suicidal Plan/Threat or Behavioral Health Care. V2 stated she did not have training materials or policies on these topics and will have to get that information from corporate.On 8/20/2025 at 1:30PM, V1 requested this surveyor come to R1's room and stated, We have secured down all the cords and have taken off the remotes with cords on R1's bed and we have secured all the cords on the other bed in R1's room. All cords observed in R1's room were secured to the walls with plastic and screws. The folding chair was also removed. A staff member was observed sitting outside R1's door for 1:1 monitoring.On 8/27/2025 at 2:00PM, V1 presented an untitled document with V1's signature, a list of items and date of 8/20/2025, documenting items removed from R1's room. These items included, cords secured to wall, call cords removed from bathroom, folding chair removed, sharp objects removed, Walmart bags removed, and other hazardous items removed.On 8/20/2025 at 1:37PM, V9 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated she is involved with R1's care. V9 stated, She is something else. V9 stated, (R1) can be really good and then gets a trigger. V9 was asked what she meant by that, V9 stated, Anytime she doesn't get her way or what she wants. V9 stated the behaviors that she had mostly heard of was R1 banging her head hard against the wall. V9 stated that they took her sheets away because she said she was going to put the sheet around her neck and kill herself and V9 could not recall the date that this occurred. V9 stated she does work on care plans and some of R1's interventions were put in the wrong place on R1's Care Plan for the suicide interventions, but the interventions are 1. Listen to resident to validate comments. 2. Weekly 1:1 session with Social Services. 3. Let Psych know of issues. 4. Administer medications as ordered. 5. If resident talks of suicide, notify psych NP or MD for directions. V9 stated there was a period after a hospital return (unsure of which hospital return) when we had her on 1:1 but that was lifted by the Nurse Practitioner. V9 stated R1 has harmed a staff member and from what she heard the staff member turned around to leave R1's room and R1 slammed the door hitting the staff member in the back of their head causing a concussion. V9 stated some other behaviors are yelling, cursing, and disruptive to other residents. V9 states sometimes R1 states she has bad thoughts and R1 is encouraged to call the crisis hotline for psych but R1 refuses to call.On 8/20/2025 at 3:30PM, V3 (Assistant Director of Nursing) stated R1 has quite a bit of behaviors and must be sent to the emergency room as directed by V12 (Psychiatric Mental Health Nurse Practitioner). V3 was asked to describe such behaviors and V3 explained behaviors as yelling, screaming, temper tantrum for lack of words, and banging her head against the wall. V3 stated R1's triggers are when R1's sister or dad do not come to the facility when she wants them to. V3 stated she has heard R1 say she has bad thoughts, and some days are bad days. V3 stated that staff reported to her that R1 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 6 of 8 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 09/04/2025 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was going to strangle herself, so she reported this to V1 and V2. V3 stated we usually send R1 to the Emergency Room, but they send R1 right back. V3 was asked if a resident had suicidal thoughts and specifically strangulation, what are some items that should not be in the room, V3 stated any kind of cords, sheets and things of that nature. V3 stated she was not aware that R1's bathroom had a call light cord present and was unaware of the television cords. V3 stated she was unsure about the air conditioner cord or if it could be detached. V3 stated R1 has a blanket that she likes, and it is thin, but it does bring R1 comfort, so we left it with her. V3 was asked about plastic bags and V3 stated, those must have been brought in yesterday and they shouldn't be in there as she could harm herself with those. V3 stated R1 had gone shopping with her sister yesterday and that must be where those came from. V3 stated, I take suicide thoughts and attempts very seriously because you never know when they are going to do it. V3 stated R1 can go from being fine to behaviors escalating quickly but we usually know when she is escalating by the yelling and screaming. V3 stated she doesn't schedule extra staff for 1:1 but if the need arises, she calls people in to try to cover the 1:1. V3 was asked if she has had behavior training, V3 stated she has in the past but has not received training since she has been employed at this facility. V3 stated she is unaware of any behavior training in the facility.On 8/20/2025 at 3:50PM, V1 approached surveyor and said, Well we sent R1 out because of what she reported to you, and they are sending her right back. V1 was asked what his plans were for R1 when she arrives back to the facility. V1 stated, Nothing really, I am not going to do the 1:1 thing because that is what she wants and that is rewarding her behavior to me. V1 stated he must find a way to get her placed. V1 stated, I don't think (R1) is strong enough to hang herself. V1 was asked to explain what he meant by R1 not being strong enough, V1 stated I mean physically strong enough to do that. On 8/21/2025 at 9:00AM, R1 was observed resting in bed with a blanket. A staff member was observed sitting outside R1's door monitoring R1.On 8/21/2025 at 9:15AM, V10 (Social Service Director/SSD) stated she does frequent 1:1 session with R1. V10 stated I talk to her every day. V10 was asked what prompted the weekly 1:1 session with R1 and V10 stated, Mainly her diagnoses. V10 stated R1 has told her before she is having strong thoughts/bad feelings several times but always denies hearing voices. V10 said that she asked R1 what bad thoughts meant and R1 did not explain what the thoughts were. V10 stated she has tried very hard to get R1 into a better suited facility for her but continues to get denials. V10 stated she had gotten accepted into a facility and then R1 was sent to the hospital and then that facility denied her. V10 stated she was going to keep trying as R1 needs to be at a behavioral facility and with other residents her age. V10 stated she has sent out several referrals and has followed up with many, but nobody will accept R1. V10 stated she is still trying to place R1 in another facility.On 8/21/2025 at 9:33AM, V2 stated the plan for R1 was to continue to see the Psych Nurse Practitioner and send to the emergency room when behaviors arise and continue Suicide Watch. V2 stated she understood that some of the items that were in R1's room are considered a risk but V2 stated this is her home and we must follow Long Term Care Regulations. V2 stated we try to keep it like home. V2 stated we had R1 in a nice Suite but due to behaviors starting in June we had to move her to a different room for better visual checks on R1. V2 stated, We are not a behavioral facility. V2 stated I will keep R1 with 1:1 at all times until R1 is placed in a facility that is more equipped to handle a behavior resident. V2 was asked if she has done any type of training to the nursing department related to Behaviors, or Suicidal Residents and how to handle the situation if behaviors arise. V2 stated, I had training years ago, but I have never done any type of training to the staff here at the facility. I will get with Corporate and see what types of training they want me to do. V2 stated (R1) has been on 1:1 since yesterday. V2 stated she feels like R1 is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 7 of 8 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 09/04/2025 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete manipulating the staff with her behaviors but said we still must deal with that type of behaviors as well.On 9/2/2025 at 11:52AM, V1 was asked if he knew if the referral was ever made for R1 with (Name of Counseling Center) that was recommended in the Progress Note on 4/14/25 by the hospital, V1 stated the facility does not do that and those types of referrals have to go through the hospital. V1 was asked if (Name of Counseling Center) ever comes to the facility to make visits with R1 and V1 stated no but she does have the hotline to call if ever she needs to call. V1 was asked if he knew why R1 sometimes would call 911 on her own when she is having behaviors, V1 stated she does that on her own before the nurse gets to call for help. V1 stated R1 has a phone and has the right to call the hotline as well as 911 when she wants to.On 8/22/2025 at 12:50PM, V12 (Psychiatric Mental Health Nurse Practitioner) stated she visits R1 on a weekly basis and visits are held in R1's room. V12 stated, This facility is not the right placement for this type of resident with her mental health issues. V12 stated the services that R1 needs are not available here, R1 needs to be in a Psychiatric facility with clients more her age. V12 stated she was unaware of a call light cord present in R1's bathroom. V12 also stated she didn't notice all the cords present in R1's room such as cords to bed remotes, television cords, or a chair present in the room. V12 was asked if she felt those types of objects could be used to cause harm or have a successful attempt at suicide. V12 stated, Yes, they really could, and they do not need to be present in her room at all. V12 stated, Anytime someone makes the statement that they want to commit suicide and especially with a plan, should be taken very serious. V12 stated R1 has an excessive manipulatory behavior. V12 stated, I have always told the facility if (R1) ever makes the statement that she wants to die or wants to kill herself, they are to send (R1) straight to the Emergency Room. V12 stated, The facility should have never accepted this resident as she requires more services than the facility can accommodate. V12 stated R1 has behaviors if she doesn't get her way. V12 stated she is unsure what the facility will do as they have tried to place her several places, but everyone denies her. V12 stated she was not sure what the plan is for R1 at this point, but she does feel R1 has to have 1:1 at all times due to her being ambulatory and could retrieve harmful items from another resident's room. V12 stated there is a risk that R1 would harm herself if given the opportunity especially when her behaviors escalate.The facility policy titled Suicidal Threats dated [NAME][TRUNCATED] Event ID: Facility ID: 146045 If continuation sheet Page 8 of 8