Inspection·October 28, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transport a resident in the appropriate wheelchair to prevent an accident for 1 (R1) of 3 residents reviewed for accidents in a sample of 10. This failure resulted in R1 falling face first into the dining room floor resulting in a left nasal bone deformity and both ulnar and olecranon fracture of the left upper extremity. The findings include: R1's Face Sheet documented an admission date to the facility of 2/09/25 with diagnoses including cerebral palsy, weakness, anxiety, and type 2 diabetes mellitus with diabetic neuropathy.R1's MDS (Minimum Data Set) dated 9/23/25 documents in Section C that R1 has a BIMS (Brief Interview of Mental Status) score of 15 indicating R1 is cognitively intact. The same MDS section GG-Mobility documents that R1 needed substantial/maximal assistance (helper does more than half the effort-helper lifts or holds trunk or limbs and provides more than half the effort) and uses a manual wheelchair for mobility.R1's Care Plan documents that R1 is totally dependent on nursing for all aspects of care related to Cerebral Palsy with interventions including Ensure proper body alignment when in bed or chair with a start date of 10/10/25. R1's Care Plan also documented an update on 10/18/2025 with a category of pain: resident is at risk for pain related to: fracture resulting from fall on 10/18/25.On 10/22/2025 at 12:12 PM, R1 stated she did fall out of a wheelchair in the dining room on 10/18/2025. R1 stated she had been in a different wheelchair then her usual wheelchair. R1 stated the wheelchair she had been transferred to on 10/18/2025 was a high back wheelchair and she uses a standard wheelchair with no high back. R1 stated V11 (Certified Nurse Assistant/CNA) was moving her from the dining room table when she fell forward into the floor hitting her face and left arm.On 10/23/2025 at 11:00 AM, R1 further explained that she does use footrests with her normal wheelchair and stated her legs were too short to reach the footrests on the high back wheelchair that she was in when she fell on [DATE].On 10/22/2025 at 1:37 PM, V8 (CNA) stated that he did transfer R1 from her bed using a mechanical lift to a high back wheelchair on 10/18/2025. V8 stated at the time he thought it was her wheelchair, however he learned later that it was another resident's wheelchair.On 10/23/2025 at 6:20 AM, V4 (CNA) stated he had been in assisting R1 from the dining room table when she fell the evening of 10/18/2025. V4 stated he went to assist R1 by pulling her wheelchair back from the dining room table and he made it about a foot when R1 fell forward hitting her face on the floor. V4 stated R1 had been in a high back wheelchair with no footrest at the time of the incident, and this is not her regular wheelchair.On 10/24/2025 at 8:25 AM, V17 (Occupational Therapist/OT) stated with R1's decrease in core strength, maximum assistance with mobility and her body size, R1 would appropriately fit the standard mechanical wheelchair that comes up to the base of her neck with foot pedals. V17 stated with a high-back wheelchair, the high-back part of the chair would be pushing on the back of R1's head and forcing her forward out of the wheelchair. V17 stated R1 would not be able to support herself while leaning forward and unable to reposition on her own. On 10/24/2025 at 9:40 AM, V9 (Registered (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146045 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 10/28/2025 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)