Health inspection·December 23, 2025

F 0550 other applicable provisions of this part. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 2 of 53 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 12/23/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 supply linens (washcloths) and ensure the call lights were within reach for 6 of 6 residents (R1, R3, R4, R7, R22, R35) reviewed for accommodation of needs in a sample of 44. Findings include:1. On 11/26/25 at 2:34 PM, V7 (Certified Nursing Assistant/CNA) stated he ran out of washcloths about 2 weeks ago and had to use a pillowcase as a washcloth. On 11/26/25 at 3:03 PM, V5 (CNA) stated they ran out of washcloths the prior week and she had to cut up a towel to use as a washcloth. On 11/26/25 at 3:24PM observed on C hall cart there was only 1 washcloth noted along with no towels. The cart on long A hall had only 1 washcloth.On 11/26/25 at 3:27PM there were no washcloths noted in the linen cart on the short A hall linen cart.On 11/26/25 at 3:33PM the shower room on A hall did not have any washcloths.On 11/26/25 at 3:41 PM, V9 (CNA) stated he has run out washcloths before and when they don't have washcloths, he will use a towel, or he will buy wipes with his own money and use those. On 12/1/25 at 11:34 AM, V6 (CNA) stated they sometimes run short on washcloths so he buys wipes himself and will use them to clean residents. On 12/02/25 at 10:44AM, V5 (CNA) stated that they are out of washcloths and towels and R35 was wanting a washcloth to be able to shave. V5 went outside to the laundry room to look for towels and washcloths. V5 said that she also went to the other halls to look for wash cloths and towels and couldn't find any washcloths at either place.On 12/02/25 at 10:50AM, R35 stated that he was just wanting a washcloth so he could shave. R35 stated that they weren't able to find a washcloth or a towel for him to be able to shave. R35 stated that he just wouldn't be able to shave now. R35's Face Sheet documents an admission date of 7/17/2025 with diagnoses including in part encounter for other orthopedic aftercare, wedge compression fracture of first lumbar vertebra, heart failure, chronic kidney disease, unspecified fall, difficulty in walking, displaced fracture of medial malleolus of left tibia, and pain. R35's MDS dated [DATE] document a BIMS of 15, indicating R35's cognition is intact. On 12/2/25 at 12:23 PM, V1 (Administrator) stated he has heard about supply issues but as soon as he hears about it, he will go to the store and buy what is needed. V1 stated linens are washed at an off-site facility and they are delivered every morning. V1 stated linens are delivered to the laundry house behind the facility and there is no formal process to get the linens to the floor for staff to use and it isn't any one person's responsibility to restock linen carts or the linen room after delivery. V1 stated he agrees there should be a process on who brings the laundry in, but anyone can get them as they need them. V1 stated he has extra towels and washcloths locked up that anyone can get from him at any time. V1 stated he has to lock up the extra towels and washcloths because if he doesn't the staff will hide them. V1 stated if a resident needs a washcloth, then it should be available. On 12/2/25 at 3:18 PM, V19 (CNA) stated she doesn't have any issues with supplies but sometimes will run out of washcloths. V19 stated that V1 just told her today that he had extra washcloths locked up and if she ran out again, she needed to let him know and he would get her some. 2. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue. R1's Minimum Data Set, dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R1's Care Plan documents R1 is at risk for falling. On 11/26/25 at 9:02 AM, R1 was lying in bed, and her call light was not in reach. One call light was on the wheelchair across the room, and the other call light was lying on the floor. R1 stated her call light is often out of reach. R1 was orientated to person, place, time, and situation during the interview. 3. R3's Face Sheet documents an admission date of 8/22/2018 with diagnose including in part Parkinson's disease, type 2 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 3 of 53 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 12/23/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis. R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact. R3's Care Plan documents R3 is at risk for falls. On 11/25/25 at 2:41 PM, R3 was laying in his bed and stated he uses his call light when he can reach it. The call light was observed lying on the floor out of reach. R3 stated sometimes different workers move his call light away from him where he can't reach it when he needs it. On 11/25/25 at 4:14 PM, observed R3 lying in bed and his call light was on the floor out of reach. 4. R4's Face Sheet documents an admission date of 4/30/2024 with diagnoses including in part hypertension, type 2 diabetes, chronic kidney disease, morbid obesity, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, acquired absence of left leg below knee, history of falling, pain in left shoulder, and other chronic pain. R4's MDS dated [DATE] documents a BIMS of 15, indicating R4's cognition is intact. R4's Care Plan documents R4 is at risk for falls. On 11/26/25 at 9:45 AM, observed one of R4's call lights clipped up high on the room divider curtain and the other was clipped to the call light wall box, both call lights were out of reach for R4. R4 stated sometimes they clip it up high on the curtain and he has to stand up and reach it and he is afraid he is going to fall trying to get to it. 5. R7's Face Sheet documents an admission date of 4/29/2021 with diagnoses including in part dementia, primary generalized arthritis, malignant neoplasm of unspecified site of left female breast, anxiety disorder, primary insomnia, neuromuscular dysfunction of bladder, overactive bladder, history of falling, and pain. R7's MDS dated [DATE] documents a BIMS of 8, indicating R7's cognition is moderately impaired. On 11/25/25 at 10:44 AM, R7 was lying in bed and the two call lights in her room were clipped to the upper part of the room divider curtain out of reach for the resident. This surveyor asked R7 if she uses her call light and she stated, the girls make me so mad because they always hang the call light up high on the curtain where I can't reach it so when I need it I can't use it. On 12/1/25 at 8:22 AM, R7 was in bed and her call light was out of reach. One call light was clipped up high on the room divider curtain and the other was laying on the empty bed on the other side of the room, both call lights were out of reach. 6. R22's Face Sheet documents an admission date of 11/17/25 with diagnoses including in part wedge compression fracture of second lumbar vertebra, chronic kidney disease stage 3, chronic and pain. On 11/25/25 at 4:23 PM, R22 was sitting in his wheelchair in his room and one call light was wrapped around the light fixture on the wall and the other was clipped to the wall box where the call light inserts into the wall. Both call lights were out of reach. R22 who was alert and oriented stated he can't reach the call light because they are too high.On 12/18/25 at 9:10 AM, V2 (Director of Nursing) stated call lights should be within reach for residents when they are in their room. On 11/25/25 at 4:17 PM, V1 (Administrator) stated call lights should always be in reach for the resident when they are in the room. V1 stated staff should be doing checks on residents every 2 hours to make sure they have the call light in reach and don't need anything. A facility policy titled Answering the Call Light dated July 2014 documents under General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Event ID: Facility ID: 146045 If continuation sheet Page 4 of 53 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 12/23/2025 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 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to prevent the verbal and physical abuse of a resident from staff for 1 of 7 residents (R7) reviewed for abuse in the sample of 44. This failure resulted in psycho/social harm to R7 having feelings of irritation, anger, and continued complaints of pain to her right shoulder.The findings include:R7's face sheet, dated 12/22/25 documents an admission date of 04/29/2021 with diagnoses in part of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, primary arthritis, spondylosis with myelopathy or radiculopathy, malignant neoplasm of unspecified site of left breast, history of falling, and Vitamin D deficiency.R7's MDS (Minimum Data Set) dated 10/23/2025 documents in Section C a BIMS (Brief Interview for Mental Status) of 8 which indicates moderately impaired cognition. Section GG documents chair/bed to chair transfer as partial/moderate assistance.R7's Care Plan, edited 09/30/25 documents a problem of R7 is grieving due to recent loss of her son approaches for this problem include: Approach R7 in a calm manner and provide emotional support as needed. Another problem of Falls R7 is high risk for falls. R7 at risk for falling r/t (related to) history of falls visual acuity impairments, decreased safety awareness, impulsiveness with attempts to stand or self-transfers without assistance from staff leaning forward in chair with attempts to pick up objects. On 09/17/24 I slid out of my wheelchair in the hallway. I did not hit my head, and I do not have any obvious injury. On 1/22/25 I was observed sitting on the floor beside my bed. I have no apparent injury. On 03/27/25 I rolled out of bed when sleeping. I had shoulder pain, but it went away. On 07/29/25 I slid off of a pillow that was in the seat of my w/c (wheelchair). No injury. On 11/02/25 I was attempting to move from my w/c to the bed and slid to the floor. Approaches for this problem include: Keep assistive devices at bedside. Another problem area of R7 is considered at risk for abuse/neglect (per assessment) due to dx (diagnosis) of dementia/chronic pain/resistance of care/exit seeking approaches for this problem area include: address all complaints/concerns promptly with grievances policy and procedure, intervene if observing any peer-on peer conflict to avoid potential abusive situation. A facility document titled Long-Term Care Facility and IID-Serious Injury Incident report documents under general information: Incident Date 01/05/2025 with a time of incident of 0630 and a report date of 01/05/25. Resident #1 involved in Incident: R7 listed as victim. Staff #1 involved in the incident: V13 position CNA (Certified Nursing Assistant) , retained no, suspended yes, terminated no. Witness Name V16 (former Assistant Director of Nursing) and V49 (CNA). Detailed Incident Summary (Who, What, When, Where, Why) Resident #1 (R7) is a 95 y.o (year old) Fw/PMH (Female with a Past Medical History): dementia, CAD (Coronary Artery Disease), HTN (Hypertension), anxiety, insomnia, depression. Per the facility protocol, an investigation was conducted in response to an allegation of abuse involving resident #1 (R7). Per interview conducted with witness #2 (R49), resident approached witness #2 and staff during a conversation. Witness #1 (V16) stated that resident #1 stated she needed to be careful with that man staff asked resident not to interrupt and took resident #1 (R7) to room. Per staff member resident #1 (R7) referred to him as a druggie, loser, and a fool He did ask her to stop and took her to her room. While in the room staff member states that resident slapped him and scratched his face. Resident #1 then through a water pitcher at staff member striking him in the back of the head. Staff member left the room with no further incident. Staff member stated that he went outside to take a break following the incident. Staff member states that he did rush his care with resident #1, but he was never aggressive with the resident #1. Staff member states that he was frustrated with the resident's behavior. Multiple staff members did hear about the incident second hand. The PCP (Primary Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 5 of 53 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 12/23/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few Physician, Administrator, ADON (Assistant Director of Nursing) and family were notified of the incident. An interview was conducted with the resident with ADON present. A skin assessment was completed with no findings by the ADON. Law enforcement notified of incident and investigation is ongoing with no current concerns. Facility investigation unsubstantiated with no findings of abuse. Resident #1 had no recollection of event on follow up interview. Dated 02/28/25 by V1 (Administrator) at 12:00PM. On 11/25/25 at 2:34 PM, R7 who was alert to person and place stated one day V1's (Administrator) son V13 (CNA) took her into her room and shut the door then grabbed her around her arms and chest from behind and squeezed her until it hurt then took her wheelchair away. R7 stated she told V1 and V1 took care of it. R7 stated she mentioned a couple times I ought to call the police but never did. R7 stated V13 never came back, she thinks he left town. On 12/17/25 at 3:45 PM, R7 who was alert to person and place stated she did have a man hurt her one time a while back and she doesn't know why he did it. R7 stated the man was V1's son V13. R7 stated V1's son took her into the room in her wheelchair and got behind her and wrapped his arms around her and squeezed really hard until it hurt. R7 stated she felt like he broke her arms. R7 stated she doesn't remember what he said to her or why he did it, but she remembers he hurt her and to this day her right shoulder hurts. R7 stated after V13 let go of her arms he took her wheelchair away. R7 stated she doesn't remember how she got her wheelchair back. R7 stated that it scared her, and she didn't know what to do. At that time observed R7 trying to show she couldn't reach across her body with her right arm and when she moved her right arm across her body to her left, she grabbed her right shoulder and said ouch, it hurts when I do that. On 12/2/25 at 2:26 PM, V20 (CNA) stated R7 says V1's son V13 tells her all the time that V1's son V13 hurt her arms. V20 stated that R7 will roll to V1's office door at times and tell him his son hurt her. On 12/11/25 at 1:08 PM, V13 (former CNA) stated R7 called him a drug addict and multiple other things and he got tired of being called that. V13 stated, I didn't do anything to hurt that woman, I shut the door and I apologized. V13 stated he took R7 back to her room because it was late and maybe she was acting up because she was tired. V13 stated he took her into her room to get her ready for bed then R7 came out again so he took her back into her room and then she threw water at me and smacked me in the face and chest, you know like what old ladies do. V13 stated he walked out of the room when R7 started hitting him but he doesn't remember if she was in her bed, in her wheelchair, or if he was in the middle of transferring her into her bed. V13 stated at one point he got down to eye level with R7 and was trying to talk to her. V13 stated he might have raised his voice at her in frustration during this but then he left the room in frustration and took the wheelchair. V13 stated he doesn't remember who gave R7 the wheelchair back. V13 stated, I never harmed that woman, I was just over exaggerated on the story in the morning. V13 stated at the end of the day that woman was down on the other hallway upset most of the night. V13 said that some people know how to handle her better than he does. V13 stated he tried to help R7 go to bed, and she got up immediately and she was very frustrated with him and it was unclear to him why. V13 stated he is one person to 20 residents, so he didn't want his clothes wet to take care of all the other residents. V13 stated, the other staff were appeasing her and giving her crap that I can't give her. V13 stated he already told her she couldn't have a soda, and the others gave it to her on the other hall. V13 stated R7 will go to the other parts of the building and find someone that will give her soda to make her happy. V13 stated he doesn't have the money to buy residents soda, and the residents can't expect the same treatment from every CNA. V13 stated he didn't have any conversation with R7 after the incident. V13 stated there were call ins and they were short 2 CNA's (Certified Nurse Assistants) so he was very busy and doesn't remember if she came back to her room that night. V13 stated he doesn't remember who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 6 of 53 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 12/23/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few called him and asked him what happened. V13 stated he resigned from his position after all of this happened. On 12/13/25 at 3:19PM, V14 (Licensed Practical Nurse/LPN) stated he was on A wing passing meds the night of the incident with V13 and R7 and he was (in hall) because he had just come out from there passing meds. V14 stated while he was going in and out of rooms, he noticed one-time R7's door was closed then next time she was out of the room then the next time her door was closed again then he saw R7's wheelchair in the hallway and her door was closed. V14 stated R7 doesn't usually have her door closed so it worried him. V14 stated he went to R7's room to check on her and she was visibly upset and saying V13 put her in her bed and took her wheelchair away from her and she wanted to get up. V14 told R7 he would be right back and get her taken care of, he was taking his med cart back up to where it belongs and while he was taking his cart he started thinking that taking a wheelchair away was considered a restraint and he got worried so he went and got V31 (Registered Nurse) to ask for help with the situation. V14 stated he asked V31 if taking R7's wheelchair away was a restraint and V31 stated yes, that last time someone took her wheelchair away she fell and had to get staples. V14 stated he and V31 ran back to R7's room and when they walked in R7 was still visibly upset and was reaching for V31 to console her. V14 stated then R7 refused her medications with him because she was so upset but she ended up taking them for V31. V14 stated R7 is independent with getting herself from the wheelchair to the bed and back to her wheelchair. V14 stated V13 told him that R7 called him a druggy saying he will never make anything of himself and V14 told him it doesn't matter what a resident says to you, you cannot take away their wheelchair and shut them in their room. V14 stated he didn't report the incident because he didn't know he was supposed to. V14 stated V1 (Administrator) called him and asked what happened. V14 stated no one else from the facility contacted him regarding this incident. V14 stated the police never contacted him regarding this incident. V14 stated he doesn't remember talking to anyone from Illinois Department of Public Health prior to right now. V14 stated this incident bothered him for a long time because he just felt like it wasn't right and wondered what could have happened to R7 if no one was there. On 12/4/25 at 2:29 PM, V49 (CNA) stated she recalls the incident with R7 and V13 but she doesn't remember the exact day and doesn't remember what time of the shift it was, but it was during a midnight shift. V49 stated she and V13 were having a conversation at the nurse's station and R7 interrupted them and V13 told R7 to mind her own business, they were trying to have a conversation. V49 said that R7 then told her that V13 is a no good use of a man and then called him a drug addict. V49 said that V13 got angry and grabbed R7's wheelchair and pushed her to her room and shut the door. V49 said she was at the nurses station and could hear R7 and V13 yelling at each other but doesn't remember what was said. V49 said she heard R7 yelling give me my wheelchair back, please get me out of bed, and help. V49 said then V13 took R7's wheelchair out of the room and left it in the hall and slammed her door closed all while R7 was still yelling. V49 said that V13 came back to the nurses station and told her that he threw R7 into bed and that R7 threw a water bottle at him and he threw it back at R7 then left the room. V49 stated she told V13 to not mess with R7 anymore or touch her that she was going to take care of her. V49 said that R7 was taken to the Suites unit (but she couldn't remember who took her) and R7 was put in a bed in an empty room to sleep the rest of the night. V49 said another CNA was working the suites and took care of R7 the rest of the night. V49 did not report it because she thought someone else did because V1 (Administrator) called her the next day to ask her what happened. V49 stated she told V1 the same thing she told this surveyor. On 12/4/25 at 2:57 PM, V22 (CNA) stated she took report from V13 on Saturday 2/22/25 in the morning and V13 told her that he and R7 weren't getting along during the night, and he said he tried to put R7 in bed and she would not let go of her wheelchair, so he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 7 of 53 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 12/23/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few dumped her into bed. V22 stated that during report on 2/23/25 V13 told her that he and R7 weren't getting along again so he took her wheelchair away from her and he told V22 that if she called him a druggie again, he would throw water in her face and make R7 eat a bar of soap. V22 stated that R7 mentions often that V13 grabbed her arms and was rough with her and hurt her. V22 stated when there are reports of abuse to administration, actions are never taken, and they treat the reporter different after that. On 12/8/25 at 12:28 PM, V12 (LPN) stated she left the facility in late August of 2025 due to feeling like administration would sweep things under the rug and that V2 (Director of Nursing) was verbally abusive to residents and staff. V12 stated she arrived to work at 6am the morning after the alleged abuse of R7 by V13 (CNA). V12 stated she was getting report from V14 (LPN) and V14 told her that V13 took R7's wheelchair and put it in the hallway and V12 stated yes, it was a restraint, you can't take away R7's only means of transportation. V12 stated while she was getting report from V14 in the hallway on A wing, V13 walked by, and she told V13 she heard he took away R7's wheelchair during the night and she told V13 that he can't do that because that is considered a restraint. V12 said that then V13 said to V14 if she calls me a druggie again one more time I'm going to shove a bar of soap down her throat and throw water in her face. V12 told V13 that he can't do that because that is abuse and V12 stated she asked V13 why is he bullying a [AGE] year old that has dementia and she probably doesn't even know what she is saying then V13 stated he doesn't care. V12 stated after V13 walked away V22 (CNA) came up to her and told her that V13 told her he was trying to put R7 in bed last night because she was having behaviors and she wouldn't let go of her wheelchair so he dumped her out of the wheelchair into her bed. V12 stated she immediately called V1 (Administrator) to report potential abuse and she was afraid he wouldn't do anything about it because it was his son so she told him if he didn't do anything about it she was going to call the police. V12 stated after a couple of hours V1 still hadn't shown up so she went to V16 (Former Assistant Director of Nursing/ADON) and told her what happened and that V1 still hadn't come in to handle it so V16 stated she would get a hold of V1. V12 stated V1 didn't show up to the facility until he arrived with the police around 3:30 PM that day. V12 stated V16 was on shift that day during day shift and she was the ADON at the time. V12 stated she doesn't know who called the police. V12 stated she left because she spoke up about things that weren't right multiple times and she felt like the administration swept it under the rug. V12 stated when she arrived to work that morning at 6:00 AM R7 was still on the rehab unit and would not come back to her unit because she was so upset. V12 stated she was finally able to get her to come back around 2PM or 3PM that day. V12 stated she did a body assessment after the police and V1 arrived at the facility. V12 said that the police officer and V1 were present as they looked at R7's arms and under her arms where R7 said she was hurting. V12 stated she did not see any markings. V12 stated anytime Illinois Department of Public Health came into the facility V2 (DON) would tell staff to keep their mouths shut about the alleged abuse of R7 by V13. On 12/8/25 at 3:51 PM, V16 (Former ADON) stated she no longer works for the facility but she was the ADON at the time of the incident between R7 and V13. V16 stated she came in like normal for her shift around 8 or 8:30 AM and when she arrived the nurse on duty V12 came up to her and told her about an incident that occurred during the night shift. V16 said that V12 stated it was reported to her that V13 took R7's wheelchair away from her and V13 also told her that if R7 called him names again he was going to shove a bar of soap down R7's throat. V16 stated she took a written statement from V12 and V22 about the incident. V16 stated V12 notified V1 (Administrator) of the incident. V16 stated V1 didn't get to the facility until late that day and she stated she kept calling V1 and texting him about what to do with the incident. V16 stated when V1 came to the facility he took over the investigation from her, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 8 of 53 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 12/23/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few she is not aware of what happened after that. V16 doesn't remember if she did the body assessment to R7 or not. V16 stated she wasn't there when V1 talked to R7 about the situation. V16 stated R7 told her a boy grabbed hold of her and hurt her. On 12/03/25 at 2:49PM, V31 (RN) said that he was working the night that the incident occurred with V13 and R7. V31 said that he was working a different hall and that V14 (LPN) came and got him. V31 said that V13 had taken R7 out of her wheelchair and put her in her bed and had the door shut and the wheelchair on the outside of R7's room. V31 said that R7 was in her room yelling and that he and V14 went in and got R7 back up out of bed and moved her to a different hall because V13 was still working on her hall. V31 said that R7 will usually transfer herself if she has her wheelchair next to her, but V13 moved her wheelchair away from her. On 12/08/25 at 11:28AM, V1 (Administrator) said that he doesn't think that V16 (Former ADON) was working the night that V13 and R7 had the alleged altercation. V1 said that he was not told about the incident between V13 and R7 until the next morning. V1 said that he talked to the officer and that he really doesn't know a lot about the abuse allegation that the police were doing their investigation into it. V1 said that he investigated the allegation of abuse between V13 and R7 and it was not substantiated. V1 said he had to investigate this with an unbiased mind because it was his son. V1 said that date of 1/5/25 was wrong on the reportable/incident report that he forgot to change the date to 02/23/25. On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if a resident wanted their wheelchair to get out of bed and they were in bed and the wheelchair was taken away from them she would consider it abuse or seclusion and she stated that isn't right. Statements provided from the facility regarding the investigation present as follows:V22's (CNA) statement with no date documents, Saturday during report V13 mentioned him and R7 weren't getting along and attempted to put R7 in bed. R7 wouldn't let go of wheelchair so V13 stated he dumped her out of the wheelchair into bed. On Sunday 02/23/25 during report V13 mentioned that R7 and him weren't getting along again and he took her wheelchair and said to me and the nurse next time R7 is mean to him or calls him a Druggie he will throw water in her face or make her eat a bar of soap. A statement dated 02/23/25 with no staff name documents, Today when I arrived to work at 6AM got report. V14 asked me if taking a wheelchair is restraints, right? then told me V13 was being hateful to R7 and put her in bed and took her wheelchair from her. V22 then told me that she forgot to let me know but V13 said in report that he picked R7 up in the wheelchair and dumped her in the bed. R7 is stating that he kept pinching her on her arms and twisting the skin. I told V13 he cannot treat residents like that nor take the wheelchair from them. V13 told me I apologized for taking her wheelchair but next time she calls me a druggie I'm gonna throw water in her face or shove a bar of soap down her throat. V14, V22 and V31 were there for this happening. A statement that says interview with V31 (RN) heard about incident 2nd hand, V31 gave ger medication and took her to C-wing. R7 was upset at that time. Not an eyewitness to any proceeding events prior to taking R7 to C-wing. A statement that says interview with R7 dated 02/25/25 no clear recollection of events at time of interview. A statement that says interview with R7 no date documents. Beat the tar out of me. Stated individual beat her all over. States she screamed and hollered but no one came. Put arms around her and squeezed her. Stated he pinched her under right arm specifically. He hit her on shins as well. A typed statement by V13 dated 02/26/25 which documents R7 has a history of wandering the building. Normally there are no restrictions. (The facility) is currently under precautions due to respiratory illnesses. I try to encourage R7 to stay on her hallway due to infection risks. R7 does suffer from Alzheimer's dementia and does become agitated with restrictions despite repeated attempts to redirect her. R7 is a risk for falls and has poor safety awareness. At the time of this incident, I was talking with the other CNA on the hall. R7 came up to us and started (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 9 of 53 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 12/23/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete calling me a druggy, loser, and fool. I asked R7 to stop and took her to her room. I asked R7 at that time to please stop calling me names. R7 proceeded to slap and scratch my face. I transferred R7 to her bed. As I was leaving the room, R7 threw a water pitcher at me that hit the back of my head. I quickly left the room with the wheelchair. I placed the wheelchair right outside the room. I told V49 (CNA) that I was going outside to have a cigarette. I was told after returning that the wheelchair was returned to R7 and that she went to another hallway where she remained for the rest of the night. I was frustrated when I gave the report the next morning, but I never was aggressive with R7 in any manner. My care may have been rushed but it was never aggressive. As I gave report, I did not use proper words. It was obvious that I was frustrated with the resident's behavior. A statement by V14 dated 02/24/25 documents, V13 put R7 in room and closed door x 3, returned with w/c after 3rd time, went into room with meds and R7 stated that CNA took w/c away. You talked to V31 and decided that w/c needed to be returned. V31 took resident to c-wing, did not see any interaction between V13 and R7, per V14 V31 was not on the hall at the time of the incident. V14 returned wheelchair immediately, R7 spent rest of night on the suites. An incident report from the local police department documents: Incident Assault, reported 02/23/25 at 4:16PM. Officer arrived at 02/23/25 at 3:34PM. Report of incident Assault: On 02/23/25 I (local officer) responded to (the facility) for a complaint of possible Elderly Abuse. Upon arrival I was met by two nurses that were witnesses to the complaint. I first spoke to V12. V12 stated that she is one of the head nurses at the business and was made aware of an incident that possibly took place the evening of 02/22/25 involving a male CNA and a resident. V12 stated when she arrived at work that a CNA V13 had taken a wheelchair from R7 which her means of getting around the facility. V12 then said that V22 (CNA) another nurse and complainant to this incident, advised her that V13 was telling her during report this morning that he picked R7 up in her wheelchair the night prior and dumped her into her bed. V12 said she confronted V13 about his behavior towards R7 to which he replied I apologized for taking her wheelchair, but next time she calls me a druggie I'm gonna throw water in her face and shove a bar of soap down her throat. V12 advised that R7 is stating that V13 was pinching her arms and twisting her skin during these events as well. V12 stated her and V22 then both went to their Administrator V1 and filed statements and formal complaints against V13 for his conduct. I did not speak to V22 specifically regarding the events due to her working with patient, but she provided her written statement about her involvement with V13. V12 and V22 both provided their written statements and are attached to (Local Police Department) complaint forms in file. I would like to note at this time that V13 is the son of V1, the administrator for the facility. I would also like to note that I was advised that R7 has serve dementia. I spoke with V1, V1 advised that he was made aware of the situation involving his son and resident the morning of 02/23/25 and soon came into work to start his investigation. V1 stated that his son V13 has been suspended from work pending the investigation into the allegations. He advised that he and nurses at the facility have observed R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with R7 while at the facility due to her medical state. V1 stated that a full investigation would be completed on the facilities behalf and reports would be available to investigation as requested. V1 stated that he would be in contact with R7's POA to advise them of the allegations. V1 also provided his bosses information if investigators were to need to contact her. The facility policy titled Abuse Prevention with a revision date of 07/2015 documents in part, 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 10 of 53 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 12/23/2025 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 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from involuntary seclusion for 1 of 7 residents (R7) reviewed for abuse and neglect in the sample of 44. This failure resulted in R7 experiencing feelings of emotional distress and acts of crying out in fear from being placed into her bed without her wheelchair nearby leaving her with no means of transferring out of bed or mobility safely. The findings include: R7's face sheet, dated 12/22/25 documents an admission date of 04/29/2021 with diagnoses in part of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, primary arthritis, spondylosis with myelopathy or radiculopathy, malignant neoplasm of unspecified site of left breast, history of falling, and Vitamin D deficiency.R7's MDS (Minimum Data Set) dated 10/23/2025 documents in Section C a BIMS (Brief Interview for Mental Status) of 8 which indicates moderately impaired cognition. Section GG documents chair/bed to chair transfer as partial/moderate assistance.R7's Care Plan, edited 09/30/25 documents a problem of R7 is grieving due to recent loss of her son approaches for this problem include: Approach R7 in a calm manner and provide emotional support as needed. Another problem of Falls R7 is high risk for falls. R7 at risk for falling r/t (related to) history of falls visual acuity impairments, decreased safety awareness, impulsiveness with attempts to stand or self-transfers without assistance from staff leaning forward in chair with attempts to pick up objects. On 09/17/24 I slid out of my wheelchair in the hallway. I did not hit my head, and I do not have any obvious injury. On 1/22/25 I was observed sitting on the floor beside my bed. I have no apparent injury. On 03/27/25 I rolled out of bed when sleeping. I had shoulder pain, but it went away. On 07/29/25 I slid off of a pillow that was in the seat of my w/c (wheelchair). No injury. On 11/02/25 I was attempting to move from my w/c to the bed and slid to the floor. Approaches for this problem include: Keep assistive devices at bedside. Another problem area of R7 is considered at risk for abuse/neglect (per assessment) due to dx (diagnosis) of dementia/chronic pain/resistance of care/exit seeking approaches for this problem area include: address all complaints/concerns promptly with grievances policy and procedure, intervene if observing any peer-on peer conflict to avoid potential abusive situation. A facility document titled Long-Term Care Facility and IID-Serious Injury Incident report documents under general information: Incident Date 01/05/2025 with a time of incident of 0630 and a report date of 01/05/25. Resident #1 involved in Incident: R7 listed as victim. Staff #1 involved in the incident: V13 position CNA (Certified Nursing Assistant) , retained no, suspended yes, terminated no. Witness Name V16 (former Assistant Director of Nursing) and V49 (CNA). Detailed Incident Summary (Who, What, When, Where, Why) Resident #1 (R7) is a 95 y.o (year old) Fw/PMH (Female with a Past Medical History): dementia, CAD (Coronary Artery Disease), HTN (Hypertension), anxiety, insomnia, depression. Per the facility protocol, an investigation was conducted in response to an allegation of abuse involving resident #1 (R7). Per interview conducted with witness #2 (R49), resident approached witness #2 and staff during a conversation. Witness #1 (V16) stated that resident #1 stated she needed to be careful with that man staff asked resident not to interrupt and took resident #1 (R7) to room. Per staff member resident #1 (R7) referred to him as a druggie, loser, and a fool He did ask her to stop and took her to her room. While in the room staff member states that resident slapped him and scratched his face. Resident #1 then through a water pitcher at staff member striking him in the back of the head. Staff member left the room with no further incident. Staff member stated that he went outside to take a break following the incident. Staff member states that he did rush his care with resident #1, but he was never aggressive with the resident #1. Staff member states that he was frustrated with the resident's behavior. Multiple staff members did Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 11 of 53 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 12/23/2025 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 0603 Level of Harm - Actual harm Residents Affected - Few hear about the incident second hand. The PCP (Primary Care Physician, Administrator, ADON (Assistant Director of Nursing) and family were notified of the incident. An interview was conducted with the resident with ADON present. A skin assessment was completed with no findings by the ADON. Law enforcement notified of incident and investigation is ongoing with no current concerns. Facility investigation unsubstantiated with no findings of abuse. Resident #1 had no recollection of event on follow up interview. Dated 02/28/25 by V1 (Administrator) at 12:00PM. On 11/25/25 at 2:34 PM, R7 who was alert to person and place stated one day V1's (Administrator) son V13 (CNA) took her into her room and shut the door then grabbed her around her arms and chest from behind and squeezed her until it hurt then took her wheelchair away. R7 stated she told V1 and V1 took care of it. R7 stated she mentioned a couple times I ought to call the police but never did. R7 stated V13 never came back, she thinks he left town. On 12/17/25 at 3:45 PM, R7 who was alert to person and place stated she did have a man hurt her one time a while back and she doesn't know why he did it. R7 stated the man was V1's son V13. R7 stated V1's son took her into the room in her wheelchair and got behind her and wrapped his arms around her and squeezed really hard until it hurt. R7 stated she felt like he broke her arms. R7 stated she doesn't remember what he said to her or why he did it, but she remembers he hurt her and to this day her right shoulder hurts. R7 stated after V13 let go of her arms he took her wheelchair away. R7 stated she doesn't remember how she got her wheelchair back. R7 stated that it scared her, and she didn't know what to do. At that time observed R7 trying to show she couldn't reach across her body with her right arm and when she moved her right arm across her body to her left, she grabbed her right shoulder and said ouch, it hurts when I do that. On 12/11/25 at 1:08 PM, V13 (former CNA) stated R7 called him a drug addict and multiple other things and he got tired of being called that. V13 stated, I didn't do anything to hurt that woman, I shut the door and I apologized. V13 stated he took R7 back to her room because it was late and maybe she was acting up because she was tired. V13 stated he took her into her room to get her ready for bed then R7 came out again so he took her back into her room and then she threw water at me and smacked me in the face and chest, you know like what old ladies do. V13 stated he walked out of the room when R7 started hitting him but he doesn't remember if she was in her bed, in her wheelchair, or if he was in the middle of transferring her into her bed. V13 stated at one point he got down to eye level with R7 and was trying to talk to her. V13 stated he might have raised his voice at her in frustration during this but then he left the room in frustration and took the wheelchair. V13 stated he doesn't remember who gave R7 the wheelchair back. V13 stated, I never harmed that woman, I was just over exaggerated on the story in the morning. V13 stated at the end of the day that woman was down on the other hallway upset most of the night. V13 said that some people know how to handle her better than he does. V13 stated he tried to help R7 go to bed, and she got up immediately and she was very frustrated with him and it was unclear to him why. V13 stated he is one person to 20 residents, so he didn't want his clothes wet to take care of all the other residents. V13 stated, the other staff were appeasing her and giving her crap that I can't give her. V13 stated he already told her she couldn't have a soda, and the others gave it to her on the other hall. V13 stated R7 will go to the other parts of the building and find someone that will give her soda to make her happy. V13 stated he doesn't have the money to buy residents soda, and the residents can't expect the same treatment from every CNA. V13 stated he didn't have any conversation with R7 after the incident. V13 stated there were call ins and they were short 2 CNA's (Certified Nurse Assistants) so he was very busy and doesn't remember if she came back to her room that night. V13 stated he doesn't remember who called him and asked him what happened. On 12/13/25 at 3:19PM, V14 (Licensed Practical Nurse/LPN) stated he was on A wing passing meds the night of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 12 of 53 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 12/23/2025 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 0603 Level of Harm - Actual harm Residents Affected - Few incident with V13 and R7 and he was by (in hallway) because he had just come out from there passing meds. V14 stated while he was going in and out of rooms, he noticed one-time R7's door was closed then next time she was out of the room then the next time her door was closed again then he saw R7's wheelchair in the hallway and her door was closed. V14 stated R7 doesn't usually have her door closed so it worried him. V14 stated he went to R7's room to check on her and she was visibly upset and saying V13 put her in her bed and took her wheelchair away from her and she wanted to get up. V14 told R7 he would be right back and get her taken care of, he was taking his med cart back up to where it belongs and while he was taking his cart he started thinking that taking a wheelchair away was considered a restraint and he got worried so he went and got V31 (Registered Nurse) to ask for help with the situation. V14 stated he asked V31 if taking R7's wheelchair away was a restraint and V31 stated yes, that last time someone took her wheelchair away she fell and had to get staples. V14 stated he and V31 ran back to R7's room and when they walked in R7 was still visibly upset and was reaching for V31 to console her. V14 stated the R7 refused her medications with him because she was so upset but she ended up taking them for V31. V14 stated R7 is independent with getting herself from the wheelchair to the bed and back to her wheelchair. V14 stated V13 told him that R7 called him a druggy saying he will never make anything of himself and V14 told him it doesn't matter what a resident says to you, you cannot take away their wheelchair and shut them in their room. V14 stated he didn't report the incident because he didn't know he was supposed to. V14 stated V1 (Administrator) called him and asked what happened. V14 stated no one else from the facility contacted him regarding this incident. V14 stated the police never contacted him regarding this incident. V14 stated he doesn't remember talking to anyone from Illinois Department of Public Health prior to right now. V14 stated this incident bothered him for a long time because he just felt like it wasn't right and wondered what could have happened to R7 if no one was there. On 12/4/25 at 2:29 PM, V49 (CNA) stated she recalls the incident with R7 and V13 but she doesn't remember the exact day and doesn't remember what time of the shift it was, but it was during a midnight shift. V49 stated she and V13 were having a conversation at the nurse's station and R7 interrupted them and V13 told R7 to mind her own business, they were trying to have a conversation. V49 said that R7 then told her that V13 is a no good use of a man and then called him a drug addict. V49 said that V13 got angry and grabbed R7's wheelchair and pushed her to her room and shut the door. V49 said she was at the nurses station and could hear R7 and V13 yelling at each other but doesn't remember what was said. V49 said she heard R7 yelling give me my wheelchair back, please get me out of bed, and help. V49 said then V13 took R7's wheelchair out of the room and left it in the hall and slammed her door closed all while R7 was still yelling. On 12/4/25 at 2:57 PM, V22 (CNA) stated she took report from V13 on Saturday 2/22/25 in the morning and V13 told her that he and R7 weren't getting along during the night and he said he tried to put R7 in bed and she would not let go of her wheelchair, so he dumped her into bed. V22 stated that during report on 2/23/25 V13 told her that he and R7 weren't getting along again so he took her wheelchair away from her and he told V22 that if she called him a druggie again, he would throw water in her face and make R7 eat a bar of soap. On 12/8/25 at 12:28 PM, V12 (LPN) stated she left the facility in late August of 2025 due to feeling like administration would sweep things under the rug and that V2 (Director of Nursing) was verbally abusive to residents and staff. V12 stated she arrived to work at 6am the morning after the alleged abuse of R7 by V13 (CNA). V12 stated she was getting report from V14 (LPN) and V14 told her that V13 took R7's wheelchair and put it in the hallway and V12 stated yes, it was a restraint, you can't take away R7's only means of transportation. V12 stated while she was getting report from V14 in the hallway on A wing, V13 walked by, and she told V13 she heard he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 13 of 53 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 12/23/2025 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 0603 Level of Harm - Actual harm Residents Affected - Few took away R7's wheelchair during the night and she told V13 that he can't do that because that is considered a restraint. V12 said that then V13 said to V14 if she calls me a druggie again one more time I'm going to shove a bar of soap down her throat and throw water in her face. V12 told V13 that he can't do that because that is abuse and V12 stated she asked V13 why is he bullying a [AGE] year old that has dementia and she probably doesn't even know what she is saying then V13 stated he doesn't care. V12 stated after V13 walked away V22 (CNA) came up to her and told her that V13 told her he was trying to put R7 in bed last night because she was having behaviors and she wouldn't let go of her wheelchair so he dumped her out of the wheelchair into her bed. V12 stated she immediately called V1 (Administrator) to report potential abuse and she was afraid he wouldn't do anything about it because it was his son so she told him if he didn't do anything about it she was going to call the police. V12 stated after a couple of hours V1 still hadn't shown up so she went to V16 (Former Assistant Director of Nursing/ADON) and told her what happened and that V1 still hadn't come in to handle it so V16 stated she would get a hold of V1. V12 stated V1 didn't show up to the facility until he arrived with the police around 3:30 PM that day. V12 stated V16 was on shift that day during day shift and she was the ADON at the time. V12 stated she doesn't know who called the police. V12 stated she left because she spoke up about things that weren't right multiple times and she felt like the administration swept it under the rug. V12 stated when she arrived to work that morning at 6:00 AM R7 was still on the rehab unit and would not come back to her unit because she was so upset. V12 stated she was finally able to get her to come back around 2PM or 3PM that day. V12 stated she did a body assessment after the police and V1 arrived at the facility. V12 said that the police officer and V1 were present as they looked at R7's arms and under her arms where R7 said she was hurting. V12 stated she did not see any markings. V12 stated anytime Illinois Department of Public Health came into the facility V2 (DON) would tell staff to keep their mouths shut about the alleged abuse of R7 by V13. On 12/8/25 at 3:51 PM, V16 (Former ADON) stated she no longer works for the facility but she was the ADON at the time of the incident between R7 and V13. V16 stated she came in like normal for her shift around 8 or 8:30 AM and when she arrived the nurse on duty V12 came up to her and told her about an incident that occurred during the night shift. V16 said that V12 stated it was reported to her that V13 took R7's wheelchair away from her and V13 also told her that if R7 called him names again he was going to shove a bar of soap down R7's throat. V16 stated she took a written statement from V12 and V22 about the incident. V16 stated V12 notified V1 (Administrator) of the incident. V16 stated V1 didn't get to the facility until late that day and she stated she kept calling V1 and texting him about what to do with the incident. V16 stated when V1 came to the facility he took over the investigation from her and she is not aware of what happened after that. V16 doesn't remember if she did the body assessment to R7 or not. V16 stated she wasn't there when V1 talked to R7 about the situation. V16 stated R7 told her a boy grabbed hold of her and hurt her. On 12/03/25 at 2:49PM, V31 (RN) said that he was working the night that the incident occurred with V13 and R7. V31 said that he was working a different hall and that V14 (LPN) came and got him. V31 said that V13 had taken R7's out of her wheelchair and put her in her bed and had the door shut and the wheelchair on the outside of R7' room. V31 said that R7 was in her room yelling and that he and V14 went in and got R7 back up out of bed and moved her to a different hall because V13 was still working on her hall. V31 said that R7 will usually transfer herself if she has her wheelchair next to her, but V13 moved her wheelchair away from her. On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if a resident wanted their wheelchair to get out of bed and they were in bed and the wheelchair was taken away from them she would consider it abuse or seclusion and she stated that isn't right. On 12/08/25 at 11:28AM, V1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 14 of 53 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 12/23/2025 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 0603 Level of Harm - Actual harm Residents Affected - Few (Administrator) said that date of 1/5/25 was wrong on the reportable/incident report that he forgot to change the date to 02/23/25. Statements provided from the facility regarding the investigation present as follows:V22's (CNA) statement with no date documents, Saturday during report V13 mentioned him and R7 weren't getting along and attempted to put R7 in bed. R7 wouldn't let go of wheelchair so V13 stated he dumped her out of the wheelchair into bed. On Sunday 02/23/25 during report V13 mentioned that R7 and him weren't getting along again and he took her wheelchair and said to me and the nurse next time R7 is mean to him or calls him a Druggie he will throw water in her face or make her eat a bar of soap. A statement dated 02/23/25 with no staff name documents, Today when I arrived to work at 6AM got report. V14 asked me if taking a wheelchair is restraints, right? then told me V13 was being hateful to R7 and put her in bed and took her wheelchair from her. V22 then told me that she forgot to let me know but V13 said in report that he picked R7 up in the wheelchair and dumped her in the bed. R7 is stating that he kept pinching her on her arms and twisting the skin. I told V13 he cannot treat residents like that nor take the wheelchair from them. V13 told me I apologized for taking her wheelchair but next time she calls me a druggie I'm gonna throw water in her face or shove a bar of soap down her throat. V14, V22 and V31 were there for this happening. A typed statement by V13 dated 02/26/25 which documents R7 has a history of wandering the building. Normally there are no restrictions. (The facility) is currently under precautions due to respiratory illnesses. I try to encourage R7 to stay on her hallway due to infection risks. R7 does suffer from Alzheimer's dementia and does become agitated with restrictions despite repeated attempts to redirect her. R7 is a risk for falls, and has poor safety awareness. At the time of this incident, I was talking with the other CNA on the hall. R7 came up to us and started calling me a druggy, loser, and fool. I asked R7 to stop and took her to her room. I asked R7 at that time to please stop calling me names. R7 proceeded to slap and scratch my face. I transferred R7 to her bed. As I was leaving the room, R7 threw a water pitcher at me that hit the back of my head. I quickly left the room with the wheelchair. I placed the wheelchair right outside the room. I told V49 (CNA) that I was going outside to have a cigarette. I was told after returning that the wheelchair was returned to R7 and that she went to another hallway where she remained for the rest of the night. I was frustrated when I gave the report the next morning, but I never was aggressive with R7 in any manner. My care may have been rushed but it was never aggressive. As I gave report, I did not use proper words. It was obvious that I was frustrated with the resident's behavior. A statement by V14 dated 02/24/25 documents, V13 put R7 in room and closed door x 3, returned with w/c after 3rd time, went into room with meds and R7 stated that CNA took w/c away. Talked to V31 and decided that w/c needed to be returned. V31 took resident to c-wing, did not see any interaction between V13 and R7, per V14 V31 was not on the hall at the time of the incident. V14 returned wheelchair immediately, R7 spent rest of night on the suites. An incident report from the local police department documents: Incident Assault, reported 02/23/25 at 4:16PM. Officer arrived at 02/23/25 at 3:34PM. Report of incident Assault: On 02/23/25 I (local officer) responded to (the facility) for a complaint of possible Elderly Abuse. Upon arrival I was met by two nurses that were witnesses to the complaint. I first spoke to V12. V12 stated that she is one of the head nurses at the business and was made aware of an incident that possibly took place the evening of 02/22/25 involving a male CNA and a resident. V12 stated when she arrived at work that a CNA V13 had taken a wheelchair from R7 which her means of getting around the facility. V12 then said that V22 (CNA) another nurse and complainant to this incident, advised her that V13 was telling her during report this morning that he picked R7 up in her wheelchair the night proper and dumped her into her bed. V12 said she confronted V13 about his behavior towards R7 to which he replied I apologized for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 15 of 53 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 12/23/2025 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 0603 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete taking her wheelchair, but next time she calls me a druggie I'm gonna throw water in her face and shove a bar of soap down her throat. V12 advised that R7 is stating that V13 was pinching her arms and twisting her skin during these events as well. V12 stated her and V22 then both went to their Administrator V1 and filed statements and formal complaints against V13 for his conduct. I did not speak to V22 specifically regarding the events due to her working with patient, but she provided her written statement about her involvement with V13. V12 and V22 both provided their written statements and are attached to (Local Police Department) complaint forms in file. I would like to note at this time that V13 is the son of V1, the administrator for the facility. I would also like to note that I was advised that R7 has serve dementia. I spoke with V1, V1 advised that he was made aware of the situation involving his son and resident the morning of 02/23/25 and soon came into work to start his investigation. V1 stated that his son V13 has been suspended from work pending the investigation into the allegations. He advised that he and nurses at the facility have observed R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with R7 while at the facility due to her medical state. V1 stated that a full investigation would be completed on the facilities behalf and reports would be available to investigation as requested. V1 stated that he would be in contact with R7's POA to advise them of the allegations. V1 also provided his bosses information if investigators were to need to contact her. The facility policy titled Abuse Prevention with a revision date of 07/2015 documents in part, 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 16 of 53 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 12/23/2025 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 interview and record review the facility failed to immediately report an allegation of staff to resident abuse to the administrator and failed to identify an incident of possible misappropriation of a resident's property and report the incident to the Illinois Department of Public Health for 2 of 7 residents (R2 and R7) reviewed for abuse and neglect in the sample of 44.Findings include:1. R7's face sheet, dated 12/22/25 documents an admission date of 04/29/2021 with diagnoses in part of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, primary arthritis, spondylosis with myelopathy or radiculopathy, malignant neoplasm of unspecified site of left breast, history of falling, and Vitamin D deficiency.R7's MDS (Minimum Data Set) dated 10/23/2025 documents in Section C a BIMS (Brief Interview for Mental Status) of 8 which indicates moderately impaired cognition. Section GG documents chair/bed to chair transfer as partial/moderate assistance.R7's Care Plan, edited 09/30/25 documents a problem of R7 is grieving due to recent loss of her son approaches for this problem include: Approach R7 in a calm manner and provide emotional support as needed. Another problem area of R7 is considered at risk for abuse/neglect (per assessment) due to dx (diagnosis) of dementia/chronic pain/resistance of care/exit seeking approaches for this problem area include: address all complaints/concerns promptly with grievances policy and procedure, intervene if observing any peer-on peer conflict to avoid potential abusive situation. On 11/25/25 at 2:34 PM, R7 who was alert to person and place stated V1's (Administrator) son V13 (Certified Nurse Assistant) took her into her room and shut the door then grabbed her around her arms and chest from behind and squeezed her until it hurt then took her wheelchair away. R7 stated she told V1 and V1 took care of it. R7 stated she mentioned a couple times I ought to call the police but never did. R7 stated V13 never came back, she thinks he left town. On 12/17/25 at 3:45 PM, R7 who was alert to person and place stated she did have a man hurt her one time a while back and she doesn't know why he did it. R7 stated the man was V1's son V13. R7 stated V1's son took her into the room in her wheelchair and got behind her and wrapped his arms around her and squeezed really hard until it hurt. R7 stated she felt like he broke her arms. R7 stated she doesn't remember what he said to her or why he did it, but she remembers he hurt her and to this day her right shoulder hurts. R7 stated after V13 let go of her arms he took her wheelchair away. R7 stated she doesn't remember how she got her wheelchair back. R7 stated that it scared her, and she didn't know what to do. On 12/11/25 at 1:08 PM, V13 (former CNA) stated R7 called him a drug addict and multiple other things and he got tired of being called that. V13 stated, I didn't do anything to hurt that woman, I shut the door and I apologized. V13 stated he took R7 back to her room because it was late and maybe she was acting up because she was tired. V13 stated he took her into her room to get her ready for bed then R7 came out again so he took her back into her room and then she threw water at me and smacked me in the face and chest, you know like what old ladies do. V13 stated he walked out of the room when R7 started hitting him but he doesn't remember if she was in her bed, in her wheelchair, or if he was in the middle of transferring her into her bed. V13 stated at one point he got down to eye level with R7 and was trying to talk to her. V13 stated he might have raised his voice at her in frustration during this but then he left the room in frustration and took the wheelchair. V13 stated he doesn't remember who gave R7 the wheelchair back. V13 stated, I never harmed that woman, I was just over exaggerated on the story in the morning. V13 stated at the end of the day that woman was down on the other hallway upset most of the night. V13 said that some people know how to handle her better than he does. V13 stated he tried to help R7 go to bed, and she got up immediately and she was very frustrated with him and it was unclear to him why. V13 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 17 of 53 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 12/23/2025 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 he is one person to 20 residents, so he didn't want his clothes wet to take care of all the other residents. V13 stated, the other staff were appeasing her and giving her crap that I can't give her. V13 stated he already told her she couldn't have a soda, and the others gave it to her on the other hall. V13 stated R7 will go to the other parts of the building and find someone that will give her soda to make her happy. V13 stated he doesn't have the money to buy residents soda, and the residents can't expect the same treatment from every CNA. V13 stated he didn't have any conversation with R7 after the incident. V13 stated there were call ins and they were short 2 CNA's (Certified Nurse Assistants) so he was very busy and doesn't remember if she came back to her room that night. V13 stated he doesn't remember who called him and asked him what happened. On 12/13/25 at 3:19PM, V14 (Licensed Practical Nurse/LPN) stated he was on A wing passing meds the night of the incident with V13 and R7 and he was by room [ROOM NUMBER] because he had just come out from there passing meds. V14 stated while he was going in and out of rooms, he noticed one-time R7's door was closed then next time she was out of the room then the next time her door was closed again then he saw R7's wheelchair in the hallway and her door was closed. V14 stated R7 doesn't usually have her door closed so it worried him. V14 stated he went to R7's room to check on her and she was visibly upset and saying V13 put her in her bed and took her wheelchair away from her and she wanted to get up. V14 stated he didn't report the incident because he didn't know he was supposed to. On 12/4/25 at 2:29 PM, V49 (CNA) stated she recalls the incident with R7 and V13 but she doesn't remember the exact day and doesn't remember what time of the shift it was, but it was during a midnight shift. V49 stated she and V13 were having a conversation at the nurse's station and R7 interrupted them and V13 told R7 to mind her own business, they were trying to have a conversation. V49 said that R7 then told her that V13 is a no good use of a man and then called him a drug addict. V49 said that V13 got angry and grabbed R7's wheelchair and pushed her to her room and shut the door. V49 said she was at the nurses station and could hear R7 and V13 yelling at each other but doesn't remember what was said. V49 said she heard R7 yelling give me my wheelchair back, please get me out of bed, and help. V49 said then V13 took R7's wheelchair out of the room and left it in the hall and slammed her door closed all while R7 was still yelling. V49 stated she did not report it because she thought someone else did because V1 (Administrator) called her the next day to ask her what happened. V49 stated she told V1 the same thing she told this surveyor. On 12/08/25 at 11:59AM, V31 (Registered Nurse/RN) said that he did not report the incident between V13 (CNA) and R7 to V1. V31 said that V12 (Licensed Practical Nurse/LPN) notified V1 the next morning and she called and reported it to V1 because she was asked by V14 (LPN) if taking away a wheelchair is considered a restraint. V31 said that V13 worked the rest of the night as far as he knew. On 12/8/25 at 12:28 PM, V12 (LPN) stated she left the facility in late August of 2025 due to feeling like administration would sweep things under the rug and that V2 (Director of Nursing) was verbally abusive to residents and staff. V12 stated she arrived to work at 6am the morning after the alleged abuse of R7 by V13 (CNA). V12 stated she was getting report from V14 (LPN) and V14 told her that V13 took R7's wheelchair and put it in the hallway and V12 stated yes, it was a restraint, you can't take away R7's only means of transportation. V12 stated while she was getting report from V14 in the hallway on A wing, V13 walked by, and she told V13 she heard he took away R7's wheelchair during the night and she told V13 that he can't do that because that is considered a restraint. V12 said that then V13 said to V14 if she calls me a druggie again one more time I'm going to shove a bar of soap down her throat and throw water in her face. V12 told V13 that he can't do that because that is abuse and V12 stated she asked V13 why is he bullying a [AGE] year old that has dementia and she probably doesn't even know what she is saying then V13 stated he doesn't care. V12 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 18 of 53 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 12/23/2025 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 after V13 walked away V22 (CNA) came up to her and told her that V13 told her he was trying to put R7 in bed last night because she was having behaviors and she wouldn't let go of her wheelchair so he dumped her out of the wheelchair into her bed. V12 stated she immediately called V1 (Administrator) to report potential abuse and she was afraid he wouldn't do anything about it because it was his son so she told him if he didn't do anything about it she was going to call the police. V12 stated after a couple of hours V1 still hadn't shown up so she went to V16 (Former Assistant Director of Nursing/ADON) and told her what happened and that V1 still hadn't come in to handle it so V16 stated she would get a hold of V1. V12 stated V1 didn't show up to the facility until he arrived with the police around 3:30 PM that day. V12 stated V16 was on shift that day during day shift and she was the ADON at the time. V12 stated she doesn't know who called the police. V12 stated she left because she spoke up about things that weren't right multiple times and she felt like the administration swept it under the rug. On 12/8/25 at 3:51 PM, V16 (Former ADON) stated she no longer works for the facility but she was the ADON at the time of the incident between R7 and V13. V16 stated she came in like normal for her shift around 8 or 8:30 AM and when she arrived the nurse on duty V12 came up to her and told her about an incident that occurred during the night shift. V16 said that V12 stated it was reported to her that V13 took R7's wheelchair away from her and V13 also told her that if R7 called him names again he was going to shove a bar of soap down R7's throat. V16 stated she took a written statement from V12 and V22 about the incident. V16 stated V12 notified V1 (Administrator) of the incident. V16 stated V1 didn't get to the facility until late that day and she stated she kept calling V1 and texting him about what to do with the incident. V16 stated when V1 came to the facility he took over the investigation from her and she is not aware of what happened after that. V16 doesn't remember if she did the body assessment to R7 or not. V16 stated she wasn't there when V1 talked to R7 about the situation. V16 stated R7 told her a boy grabbed hold of her and hurt her. On 12/08/25 at 11:28AM, V1 (Administrator) said that he doesn't think that V16 (Former ADON) was working the night that V13 and R7 had the alleged altercation. V1 said that he was not told about the incident between V13 and R7 until the next morning. V1 said that he talked to the officer and that he really doesn't know a lot about the abuse allegation that the police were doing their investigation into it. V1 said that he investigated the allegation of abuse between V13 and R7 and it was not substantiated. V1 said he had to investigate this with an unbiased mind because it was his son. V1 said that date of 1/5/25 was wrong on the reportable/incident report that he forgot to change the date to 02/23/25. 2.R2's Face Sheet documents an admission date of 12/23/2024 with diagnoses including in spina bifida, acute kidney failure, crossing vessel and stricture of ureter without hydronephrosis, hypertension, and pressure ulcer of sacral region.R2's MDS dated [DATE] documents a BIMS of 15, which indicates cognitively intact. Section G documents dependent for transfers.R2's Care plan with a created date of 10/22/25 documents that R2 is dependent with transfers and that R2 has ineffective role performance r/t (related to) making false statements.On 11/26/25 at 9:39AM, R2 stated that he hasn't had any staff ask to borrow money, but he did have 200.00 dollars stolen from a cup in his room around 6 months ago. R2 said that he put the money in a green cup he has that had a lid on it which he keeps it on his bedside table. R2 said that he doesn't know who took the money, but it was his fault for having that much money in the building on him. R2 said that he reported it to V1 (Administrator).On 12/03/25 at 2:01PM, V19 (Certified Nurse Assistant/CNA) stated that she was aware of R2 missing money. V19 said that was when he was on another hall. V19 stated that she never saw the money.On 12/03/25 at 2:49PM, V31 (Registered Nurse) stated that he was aware of R2 saying he was missing some money. V31 said that he never observed the money.On 12/02/25 at 12:23PM, V1 (Administrator) stated that he is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 19 of 53 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 12/23/2025 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 aware of any residents missing money. V1 stated R2 reported missing money but doesn't know how much money R2 was missing. V1 stated that he didn't do a formal investigation, he just asked people about it, and he didn't report it to Illinois Department of Public Health. V1 stated the grievance is all he has about the missing money and there isn't any paper trail of who he talked to about it. V1 said that he talked to the business office manager about the missing money, and she told him that R2 didn't have any money to be missing.A facility document titled Grievance/Concern/Complaint Form with a date received of 03/24/25 documents Name of Individual as R2. Reported to: V18 (Activities Director/Assistant Administrator). Describe actual event: stated while R2 was in the hosp. (Hospital) has money missing. Individual designated to take action: V1. Summary/Findings: was found R2 had no money we had to pay for his lunch. All ordering had to be completed with a card.The facility policy titled Abuse Prevention with a revision date of 07/2015 documents 5. Internal reporting requirements and identification of allegations- Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. All residents, visitors, volunteers, family members, or others are encouraged to report their concerns, suspected incidents of potential abuse, neglect, or mistreatment to the administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse, neglect, or misappropriation of property. 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 into the regional Public Health Office. Event ID: Facility ID: 146045 If continuation sheet Page 20 of 53 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 12/23/2025 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 interview and record review the facility failed to thoroughly and immediately investigate allegations of abuse and potential theft, failed to prevent further potential abuse/neglect from occurring while allowing staff to continue to have direct care with residents after allegations were made, and failed to conclude willful intent occurred involving a staff to resident altercation for 2 of 7 (R2 and R7) residents reviewed for abuse in a sample of 44. Findings include:1. R7's face sheet, dated 12/22/25 documents a admission date of 04/29/2021 with diagnoses in part of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, primary arthritis, spondylosis with myelopathy or radiculopathy, malignant neoplasm of unspecified site of left breast, history of falling, and Vitamin D deficiency.R7's MDS (Minimum Data Set) dated 10/23/2025 documents in Section C a BIMS (Brief Interview for Mental Status) of 8 which indicates moderately impaired cognition. Section GG documents chair/bed to chair transfer as partial/moderate assistance.R7's Care Plan, edited 09/30/25 documents a problem of R7 is grieving due to recent loss of her son approaches for this problem include: Approach R7 in a calm manner and provide emotional support as needed. Another problem area of R7 is considered at risk for abuse/neglect (per assessment) due to dx (diagnosis) of dementia/chronic pain/resistance of care/exit seeking approaches for this problem area include: address all complaints/concerns promptly with grievances policy and procedure, intervene if observing any peer-on peer conflict to avoid potential abusive situation.A facility document titled Long-Term Care Facility and IID-Serious Injury Incident report documents under general information: Incident Date 01/05/2025 with a time of incident of 0630 and a report date of 01/05/25. Resident #1 involved in Incident: R7 listed as victim. Staff #1 involved in the incident: V13 position CNA (Certified Nursing Assistant) , retained no, suspended yes, terminated no. Witness Name V16 (former Assistant Director of Nursing) and V49 (CNA). Detailed Incident Summary (Who, What, When, Where, Why) Resident #1 (R7) is a 95 y.o (year old) Fw/PMH (Female with a Past Medical History): dementia, CAD (Coronary Artery Disease), HTN (Hypertension), anxiety, insomnia, depression. Per the facility protocol, an investigation was conducted in response to an allegation of abuse involving resident #1 (R7). Per interview conducted with witness #2 (R49), resident approached witness #2 and staff during a conversation. Witness #1 (V16) stated that resident #1 stated she needed to be careful with that man staff asked resident not to interrupt and took resident #1 (R7) to room. Per staff member resident #1 (R7) referred to him as a druggie, loser, and a fool He did ask her to stop and took her to her room. While in the room staff member states that resident slapped him and scratched his face. Resident #1 then through a water pitcher at staff member striking him in the back of the head. Staff member left the room with no further incident. Staff member stated that he went outside to take a break following the incident. Staff member states that he did rush his care with resident #1, but he was never aggressive with the resident #1. Staff member states that he was frustrated with the resident's behavior. Multiple staff members did hear about the incident second hand. The PCP (Primary Care Physician, Administrator, ADON (Assistant Director of Nursing) and family were notified of the incident. An interview was conducted with the resident with ADON present. A skin assessment was completed with no findings by the ADON. Law enforcement notified of incident and investigation is ongoing with no current concerns. Facility investigation unsubstantiated with no findings of abuse. Resident #1 had no recollection of event on follow up interview. Dated 02/28/25 by V1 (Administrator) at 12:00PM. On 11/25/25 at 2:34 PM, R7 who was alert to person and place stated one day V1's (Administrator) son V13 (CNA) took her into her room and shut the door then grabbed her around her arms and chest from behind and squeezed her until it hurt then took her wheelchair away. R7 stated she told V1 and V1 took care of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 21 of 53 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 12/23/2025 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 it. R7 stated she mentioned a couple times I ought to call the police but never did. R7 stated V13 never came back, she thinks he left town. On 12/17/25 at 3:45 PM, R7 who was alert to person and place stated she did have a man hurt her one time a while back and she doesn't know why he did it. R7 stated the man was V1's son V13. R7 stated V1's son took her into the room in her wheelchair and got behind her and wrapped his arms around her and squeezed really hard until it hurt. R7 stated she felt like he broke her arms. R7 stated she doesn't remember what he said to her or why he did it, but she remembers he hurt her and to this day her right shoulder hurts. R7 stated after V13 let go of her arms he took her wheelchair away. R7 stated she doesn't remember how she got her wheelchair back. R7 stated that it scared her, and she didn't know what to do. At that time observed R7 trying to show she couldn't reach across her body with her right arm and when she moved her right arm across her body to her left, she grabbed her right shoulder and said ouch, it hurts when I do that. On 12/11/25 at 1:08 PM, V13 (former CNA) stated R7 called him a drug addict and multiple other things and he got tired of being called that. V13 stated, I didn't do anything to hurt that woman, I shut the door and I apologized. V13 stated he took R7 back to her room because it was late and maybe she was acting up because she was tired. V13 stated he took her into her room to get her ready for bed then R7 came out again so he took her back into her room and then she threw water at me and smacked me in the face and chest, you know like what old ladies do. V13 stated he walked out of the room when R7 started hitting him but he doesn't remember if she was in her bed, in her wheelchair, or if he was in the middle of transferring her into her bed. V13 stated at one point he got down to eye level with R7 and was trying to talk to her. V13 stated he might have raised his voice at her in frustration during this but then he left the room in frustration and took the wheelchair. V13 stated he doesn't remember who gave R7 the wheelchair back. V13 stated, I never harmed that woman, I was just over exaggerated on the story in the morning. V13 stated at the end of the day that woman was down on the other hallway upset most of the night. V13 said that some people know how to handle her better than he does. V13 stated he tried to help R7 go to bed, and she got up immediately and she was very frustrated with him and it was unclear to him why. V13 stated he is one person to 20 residents, so he didn't want his clothes wet to take care of all the other residents. V13 stated, the other staff were appeasing her and giving her crap that I can't give her. V13 stated he already told her she couldn't have a soda, and the others gave it to her on the other hall. V13 stated R7 will go to the other parts of the building and find someone that will give her soda to make her happy. V13 stated he doesn't have the money to buy residents soda, and the residents can't expect the same treatment from every CNA. V13 stated he didn't have any conversation with R7 after the incident. V13 stated there were call ins and they were short 2 CNA's (Certified Nurse Assistants) so he was very busy and doesn't remember if she came back to her room that night. V13 stated he doesn't remember who called him and asked him what happened. On 12/13/25 at 3:19PM, V14 (Licensed Practical Nurse/LPN) stated he was on A wing passing meds the night of the incident with V13 and R7 and he was in (hallway) because he had just come out from room passing meds. V14 stated while he was going in and out of rooms, he noticed one-time R7's door was closed then next time she was out of the room then the next time her door was closed again then he saw R7's wheelchair in the hallway and her door was closed. V14 stated R7 doesn't usually have her door closed so it worried him. V14 stated he went to R7's room to check on her and she was visibly upset and saying V13 put her in her bed and took her wheelchair away from her and she wanted to get up. V14 told R7 he would be right back and get her taken care of, he was taking his med cart back up to where it belongs and while he was taking his cart he started thinking that taking a wheelchair away was considered a restraint and he got worried so he went and got V31 (Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 22 of 53 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 12/23/2025 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 Nurse) to ask for help with the situation. V14 stated he asked V31 if taking R7's wheelchair away was a restraint and V31 stated yes, that last time someone took her wheelchair away she fell and had to get staples. V14 stated he and V31 ran back to R7's room and when they walked in R7 was still visibly upset and was reaching for V31 to console her. V14 stated the R7 refused her medications with him because she was so upset but she ended up taking them for V31. V14 stated R7 is independent with getting herself from the wheelchair to the bed and back to her wheelchair. V14 stated V13 told him that R7 called him a druggy saying he will never make anything of himself and V14 told him it doesn't matter what a resident says to you, you cannot take away their wheelchair and shut them in their room. V14 stated he didn't report the incident because he didn't know he was supposed to. V14 stated V1 (Administrator) called him and asked what happened. V14 stated no one else from the facility contacted him regarding this incident. V14 stated the police never contacted him regarding this incident. V14 stated he doesn't remember talking to anyone from Illinois Department of Public Health prior to right now. V14 stated this incident bothered him for a long time because he just felt like it wasn't right and wondered what could have happened to R7 if no one was there. On 12/4/25 at 2:29 PM, V49 (CNA) stated she recalls the incident with R7 and V13 but she doesn't remember the exact day and doesn't remember what time of the shift it was, but it was during a midnight shift. V49 stated she and V13 were having a conversation at the nurse's station and R7 interrupted them and V13 told R7 to mind her own business, they were trying to have a conversation. V49 said that R7 then told her that V13 is a no good use of a man and then called him a drug addict. V49 said that V13 got angry and grabbed R7's wheelchair and pushed her to her room and shut the door. V49 said she was at the nurses station and could hear R7 and V13 yelling at each other but doesn't remember what was said. V49 said she heard R7 yelling give me my wheelchair back, please get me out of bed, and help. V49 said then V13 took R7's wheelchair out of the room and left it in the hall and slammed her door closed all while R7 was still yelling. V49 said that V13 came back to the nurses station and told her that he threw R7 into bed and that R7 threw a water bottle at him and he threw it back at R7 then left the room. V49 stated she told V13 to not mess with R7 anymore or touch her that she was going to take care of her. V49 said that R7 was taken to the Suites unit (but she couldn't remember who took her) and R7 was put in a bed in an empty room to sleep the rest of the night. V49 said another CNA was working the suites and took care of R7 the rest of the night. V49 did not report it because she thought someone else did because V1 (Administrator) called her the next day to ask her what happened. V49 stated she told V1 the same thing she told this surveyor. On 12/4/25 at 2:57 PM, V22 (CNA) stated she took report from V13 on Saturday 2/22/25 in the morning and V13 told her that he and R7 weren't getting along during the night and he said he tried to put R7 in bed and she would not let go of her wheelchair, so he dumped her into bed. V22 stated that during report on 2/23/25 V13 told her that he and R7 weren't getting along again so he took her wheelchair away from her and he told V22 that if she called him a druggie again, he would throw water in her face and make R7 eat a bar of soap. V22 stated that R7 mentions often that V13 grabbed her arms and was rough with her and hurt her. V22 stated when there are reports of abuse to administration, actions are never taken, and they treat the reporter different after that. On 12/8/25 at 12:28 PM, V12 (LPN) stated she left the facility in late August of 2025 due to feeling like administration would sweep things under the rug and that V2 (Director of Nursing) was verbally abusive to residents and staff. V12 stated she arrived to work at 6am the morning after the alleged abuse of R7 by V13 (CNA). V12 stated she was getting report from V14 (LPN) and V14 told her that V13 took R7's wheelchair and put it in the hallway and V12 stated yes, it was a restraint, you can't take away R7's only means of transportation. V12 stated while she was getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 23 of 53 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 12/23/2025 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 report from V14 in the hallway on A wing, V13 walked by, and she told V13 she heard he took away R7's wheelchair during the night and she told V13 that he can't do that because that is considered a restraint. V12 said that then V13 said to V14 if she calls me a druggie again one more time I'm going to shove a bar of soap down her throat and throw water in her face. V12 told V13 that he can't do that because that is abuse and V12 stated she asked V13 why is he bullying a [AGE] year old that has dementia and she probably doesn't even know what she is saying then V13 stated he doesn't care. V12 stated after V13 walked away V22 (CNA) came up to her and told her that V13 told her he was trying to put R7 in bed last night because she was having behaviors and she wouldn't let go of her wheelchair so he dumped her out of the wheelchair into her bed. V12 stated she immediately called V1 (Administrator) to report potential abuse and she was afraid he wouldn't do anything about it because it was his son so she told him if he didn't do anything about it she was going to call the police. V12 stated after a couple of hours V1 still hadn't shown up so she went to V16 (Former Assistant Director of Nursing/ADON) and told her what happened and that V1 still hadn't come in to handle it so V16 stated she would get a hold of V1. V12 stated V1 didn't show up to the facility until he arrived with the police around 3:30 PM that day. V12 stated V16 was on shift that day during day shift and she was the ADON at the time. V12 stated she doesn't know who called the police. V12 stated she left because she spoke up about things that weren't right multiple times and she felt like the administration swept it under the rug. V12 stated when she arrived to work that morning at 6:00 AM R7 was still on the rehab unit and would not come back to her unit because she was so upset. V12 stated she was finally able to get her to come back around 2PM or 3PM that day. V12 stated she did a body assessment after the police and V1 arrived at the facility. V12 said that the police officer and V1 were present as they looked at R7's arms and under her arms where R7 said she was hurting. V12 stated she did not see any markings. V12 stated anytime Illinois Department of Public Health came into the facility V2 (DON) would tell staff to keep their mouths shut about the alleged abuse of R7 by V13. On 12/8/25 at 3:51 PM, V16 (Former ADON) stated she no longer works for the facility but she was the ADON at the time of the incident between R7 and V13. V16 stated she came in like normal for her shift around 8 or 8:30 AM and when she arrived the nurse on duty V12 came up to her and told her about an incident that occurred during the night shift. V16 said that V12 stated it was reported to her that V13 took R7's wheelchair away from her and V13 also told her that if R7 called him names again he was going to shove a bar of soap down R7's throat. V16 stated she took a written statement from V12 and V22 about the incident. V16 stated V12 notified V1 (Administrator) of the incident. V16 stated V1 didn't get to the facility until late that day and she stated she kept calling V1 and texting him about what to do with the incident. V16 stated when V1 came to the facility he took over the investigation from her and she is not aware of what happened after that. V16 doesn't remember if she did the body assessment to R7 or not. V16 stated she wasn't there when V1 talked to R7 about the situation. V16 stated R7 told her a boy grabbed hold of her and hurt her. On 12/03/25 at 2:49PM, V31 (RN) said that he was working the night that the incident occurred with V13 and R7. V31 said that he was working a different hall and that V14 (LPN) came and got him. V31 said that V13 had taken R7's out of her wheelchair and put her in her bed and had the door shut and the wheelchair on the outside of R7' room. V31 said that R7 was in her room yelling and that he and V14 went in and got R7 back up out of bed and moved her to a different hall because V13 was still working on her hall. V31 said that R7 will usually transfer herself if she has her wheelchair next to her, but V13 moved her wheelchair away from her. On 12/08/25 at 11:28AM, V1 (Administrator) said that he doesn't think that V16 (Former ADON) was working the night that V13 and R7 had the alleged altercation. V1 said that he was not told about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 24 of 53 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 12/23/2025 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 the incident between V13 and R7 until the next morning. V1 said that he talked to the officer and that he really doesn't know a lot about the abuse allegation that the police were doing their investigation into it. V1 said that he investigated the allegation of abuse between V13 and R7 and it was not substantiated. V1 said he had to investigate this with an unbiased mind because it was his son. V1 said that date of 1/5/25 was wrong on the reportable/incident report that he forgot to change the date to 02/23/25. On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if a resident wanted their wheelchair to get out of bed and they were in bed and the wheelchair was taken away from them she would consider it abuse or seclusion and she stated that isn't right. Statements provided from the facility regarding the investigation present as follows:V22's (CNA) statement with no date documents, Saturday during report V13 mentioned him and R7 weren't getting along and attempted to put R7 in bed. R7 wouldn't let go of wheelchair so V13 stated he dumped her out of the wheelchair into bed. On Sunday 02/23/25 during report V13 mentioned that R7 and him weren't getting along again and he took her wheelchair and said to me and the nurse next time R7 is mean to him or calls him a Druggie he will throw water in her face or make her eat a bar of soap. A statement dated 02/23/25 with no staff name documents, Today when I arrived to work at 6AM got report. V14 asked me if taking a wheelchair is restraints, right? then told me V13 was being hateful to R7 and put her in bed and took her wheelchair from her. V22 then told me that she forgot to let me know but V13 said in report that he picked R7 up in the wheelchair and dumped her in the bed. R7 is stating that he kept pinching her on her arms and twisting the skin. I told V13 he cannot treat residents like that nor take the wheelchair from them. V13 told me I apologized for taking her wheelchair but next time she calls me a druggie I'm gonna throw water in her face or shove a bar of soap down her throat. V14, V22 and V31 were there for this happening. A statement that says interview with V31 (RN) heard about incident 2nd hand, V31 gave ger medication and took her to C-wing. R7 was upset at that time. Not an eyewitness to any proceeding events prior to taking R7 to C-wing. A statement that says interview with R7 dated 02/25/25 no clear recollection of events at time of interview. A statement that says interview with R7 no date documents. Beat the tar out of me. Stated individual beat her all over. States she screamed and hollered but no one came. Put arms around her and squeezed her. Stated he pinched her under right arm specifically. He hit her on shins as well. A typed statement by V13 dated 02/26/25 which documents R7 has a history of wandering the building. Normally there are no restrictions. (The facility) is currently under precautions due to respiratory illnesses. I try to encourage R7 to stay on her hallway due to infection risks. R7 does suffer from Alzheimer's dementia and does become agitated with restrictions despite repeated attempts to redirect her. R7 is a risk for falls, and has poor safety awareness. At the time of this incident, I was talking with the other CNA on the hall. R7 came up to us and started calling me a druggy, loser, and fool. I asked R7 to stop and took her to her room. I asked R7 at that time to please stop calling me names. R7 proceeded to slap and scratch my face. I transferred R7 to her bed. As I was leaving the room, R7 threw a water pitcher at me that hit the back of my head. I quickly left the room with the wheelchair. I placed the wheelchair right outside the room. I told V49 (CNA) that I was going outside to have a cigarette. I was told after returning that the wheelchair was returned to R7 and that she went to another hallway where she remained for the rest of the night. I was frustrated when I gave the report the next morning, but I never was aggressive with R7 in any manner. My care may have been rushed but it was never aggressive. As I gave report, I did not use proper words. It was obvious that I was frustrated with the resident's behavior. A statement by V14 dated 02/24/25 documents, V13 put R7 in room and closed door x 3, returned with w/c after 3rd time, went into room with meds and R7 stated that CNA took w/c away. You talked to V31 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 25 of 53 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 12/23/2025 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 decided that w/c needed to be returned. V31 took resident to c-wing, did not see any interaction between V13 and R7, per V14 V31 was not on the hall at the time of the incident. V14 returned wheelchair immediately, R7 spent rest of night on the suites. An incident report from the local police department documents: Incident Assault, reported 02/23/25 at 4:16PM. Officer arrived at 02/23/25 at 3:34PM. Report of incident Assault: On 02/23/25 I (local officer) responded to (the facility) for a complaint of possible Elderly Abuse. Upon arrival I was met by two nurses that were witnesses to the complaint. I first spoke to V12. V12 stated that she is one of the head nurses at the business and was made aware of an incident that possibly took place the evening of 02/22/25 involving a male CNA and a resident. V12 stated when she arrived at work that a CNA V13 had taken a wheelchair from R7 which her means of getting around the facility. V12 then said that V22 (CNA) another nurse and complainant to this incident, advised her that V13 was telling her during report this morning that he picked R7 up in her wheelchair the night proper and dumped her into her bed. V12 said she confronted V13 about his behavior towards R7 to which he replied I apologized for taking her wheelchair, but next time she calls me a druggie I'm gonna throw water in her face and shove a bar of soap down her throat. V12 advised that R7 is stating that V13 was pinching her arms and twisting her skin during these events as well. V12 stated her and V22 then both went to their Administrator V1 and filed statements and formal complaints against V13 for his conduct. I did not speak to V22 specifically regarding the events due to her working with patient, but she provided her written statement about her involvement with V13. V12 and V22 both provided their written statements and are attached to (Local Police Department) complaint forms in file. I would like to note at this time that V13 is the son of V1, the administrator for the facility. I would also like to note that I was advised that R7 has serve dementia. I spoke with V1, V1 advised that he was made aware of the situation involving his son and resident the morning of 02/23/25 and soon came into work to start his investigation. V1 stated that his son V13 has been suspended from work pending the investigation into the allegations. He advised that he and nurses at the facility have observed R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with R7 while at the facility due to her medical state. V1 stated that a full investigation would be completed on the facilities behalf and reports would be available to investigation as requested. V1 stated that he would be in contact with R7's POA to advise them of the allegations. V1 also provided his bosses information if investigators were to need to contact her. 2. R2's Face Sheet documents an admission date of 12/23/2024 with diagnoses including in spina bifida, acute kidney failure, crossing vessel and stricture of ureter without hydronephrosis, hypertension, and pressure ulcer of sacral region.R2's MDS dated [DATE] documents a BIMS of 15, which indicates cognitively intact. Section G documents dependent for transfers.R2's Care plan with a created date of 10/22/25 documents that R2 is dependent with transfers and that R2 has ineffective role performance r/t (related to) making false statements.On 11/26/25 at 9:39AM, R2 stated that he hasn't had any staff ask to borrow money, but he did have 200.00 dollars stolen from a cup in his room around 6 months ago. R2 said that he put the money in a green cup he has that had a lid on it which he keeps it on his bedside table. R2 said that he doesn't know who took the money, but it was his fault for having that much money in the building on him. R2 said that he reported it to V1 (Administrator).On 12/03/25 at 2:01PM, V19 (Certified Nurse Assistant/CNA) stated that she was aware of R2 missing money. V19 said that was when he was on another hall. V19 stated that she never saw the money.On 12/03/25 at 2:49PM, V31 (Registered Nurse) stated that he was aware of R2 saying he was missing some money. V31 said that he never observed the money.On 12/02/25 at 12:23PM, V1 (Administrator) stated that he is not aware of any residents missing money. V1 stated R2 reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 26 of 53 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 12/23/2025 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 missing money but doesn't know how much money R2 was missing. V1 stated that he didn't do a formal investigation, he just asked people about it, and he didn't report it to Illinois Department of Public Health. V1 stated the grievance is all he has about the missing money and there isn't any paper trail of who he talked to about it. V1 said that he talked to the business office manager about the missing money, and she told him that R2 didn't have any money to be missing.A facility document titled Grievance/Concern/Complaint Form with a date received of 03/24/25 documents Name of Individual as R2. Reported to: V18 (Activities Director/Assistant Administrator). Describe actual event: stated while R2 was in the hosp. (Hospital) has money missing. Individual designated to take action: V1. Summary/Findings: was found R2 had no money we had to pay for his lunch. All ordering had to be completed with a card. The facility policy titled Abuse Prevention with a revision date of 07/2015 documents 5. Internal reporting requirements and identification of allegations- Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. All residents, visitors, volunteers, family members, or others are encouraged to report their concerns, suspected incidents of potential abuse, neglect, or mistreatment to the administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the administrator. If the resident complains of physical injuries, or if resident harm is suspected, the resident's physician will be contacted for further instructions. 6. Protection of Residents- The facility will take steps to prevent mistreatment while the investigation is underway. A. Residents who allegedly mistreated another resident will be removed the situation and will have limited contact with the targeted individual during the course of investigation. The accused resident's condition shall be immediately evaluated to determine most suitable therapy, care approaches, and placement, considering his/her safety, as well as the safety of other residents and employees of the facility. B. Accused individuals not employed by the facility will be denied unsupervised access to the residents during the course of the investigation. C. Employees of the facility who have been accused of abuse, neglect, or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible abuse, neglect, or misappropriation of property shall not complete the shift as a direct care provider to residents. 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. Event ID: Facility ID: 146045 If continuation sheet Page 27 of 53 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 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a dependent resident timely ADL (Activities of Daily Living) assistance with transfers for 1 of 6 residents (R1) reviewed for ADL assistance in the sample of 44.Findings include:R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including: multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 08, indicating R1 has moderate cognitive impairment. Section GG of the dame MDS documents R1 is dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed to chair transfers.R1's Physician Order Report dated 11/2/25-12/2/25 documents an order for mechanical lift for transfers dated 10/16/23.R1's Care Plan documents R1 is dependent for transfers, R1 uses mechanical lift for all transfers with a start date of 10/3/25.On 11/26/25 at 8:00 AM there was a plate of untouched food sitting at the table in the dining room with no cover on it and no resident was near it. This surveyor asked V7 (Certified Nursing Assistant/CNA) whose food it was, and he stated it was R1's but she wasn't out of bed yet because he needed help to get her up and they hadn't had time yet.On 11/26/25 at 8:25 AM, V5 (Certified Nursing Assistant/CNA) took the plate of food off the table and took it to R1's room to assist her with eating.On 11/26/25 at 8:28 AM, R1 was lying in bed. R1 stated she wanted to get up for breakfast, but the CNA told her she couldn't get her up because there wasn't anyone to help her since she was a mechanical lift transfer. R1 stated she doesn't like eating in her bed, she likes going to the dining room for meals. R1 was orientated to person, place, time, and situation during interview.On 11/26/25 at 8:32 AM, V5 (CNA) stated she was told when she arrived at her shift at 8am that they didn't have enough staff to get R1 up since she was a mechanical lift.On 11/26/25 at 2:34 PM, V7 (CNA) stated night shift doesn't get any 2 assist residents up in the morning and he is the only CNA on the floor from 6am-8am so he must find someone to help him get R1 up since she is a mechanical lift. V7 stated he didn't get R1 up today because she is a 2 person assist, and he would rather get up the other 13 residents that are a 1 assist than get up 1 resident that needs 2 staff to help.On 12/2/25 at 11:22 AM, V2 (Director of Nursing) stated no resident should be left in bed because they are a 2 person assist. V2 stated there are plenty of staff in the building to help, including herself.On 12/2/25 at 12:23 PM, V1 (Administrator) stated he is not aware of staff unable to get mechanical lift residents up due to not having enough staff to help, they should ask someone in the building to help. V1 stated there is always someone in the building to help.On 12/18/25 at 9:10 AM, V2 stated all mechanical lifts should be performed with 2 qualified staff.A facility policy titled Mechanical Lift dated October 2017 documents under Policy: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 28 of 53 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 12/23/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer/apply pain medications as ordered for 1 of 3 residents (R19) reviewed for pain management in a sample of 44. This failure resulted in R19 experiencing pain with the treatment application to R19's leg wounds.The findings include: R19's Face Sheet documents an admission date of 9/26/25 with diagnoses including: cellulitis of right lower limb, weakness, depression, and other specified hearing loss bilateral.R19's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating R19 has severe cognitive impairment. Section J, Health Conditions, documents that R19 experiences pain or hurting frequently.R19's Care Plan documents that R19 has impaired skin integrity related to venous insufficiency and R19 has pain/risk for pain with a start date of 9/26/25 with documented interventions including administer medications, monitor and record effectiveness, and report adverse side effects.R19's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R19 has the following wounds: Venous wound of the right leg with a wound size of 13.6 cm (Centimeters) length x 16.8 cm width x 0.3cm depth , skin tear of the right dorsal foot wound size of 1.3 cm in length x 1.4 cm width x 0.5 cm in depth, arterial wound of the right ankle with a wound size of 2.7 cm length x 2.7 cm in width x 0.4 cm in depth, non-pressure wound of the right medial foot with a wound size of 1.3 cm length x 2.4 cm in width x 0.3 cm in depth, and skin tear to the right, posterior ankle with a wound size of 12 cm in length x 5 cm in width x 0.3 cm in depth.R19's Physician Order Report dated 11/15/2025-12/15/2025 documents and order for Lidocaine cream 4% topical, apply to right lower extremity wounds prior to wound care/treatment change once a day with a start date of 11/17/25 and an end dated labeled open ended, an order for pain assessment every shift with a start date of 10/06/25 with an end date labeled open ended, and an order for hydrocodone-acetaminophen tablet 5-325mg amt (Amount) 1 tablet twice a day PRN (as needed) with a start date of 09/26/25 and an end date labeled open ended. R19's Pain-MDS focused assessment dated [DATE] documents: Pain received schedule pain med regimen: No; Pain management: Received PRN (as needed) pain meds or offered and declined: Yes; Received non-medication interventions: Yes; Should pain assessment interview be conducted: Yes; Res (resident) have you had pain or hurting at any time in the last 5 days? Yes; Res (resident) How much of the time have you experienced pain or hurting over the last 5 days? Occasionally; Res (resident) Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Rarely or not at all; Res (resident) Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? Rarely or not at all; Resident Over the past 5 days, how often have you limited your day-to-day activities? Occasionally; and Resident please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine: 4.R19's Medication Administration Record (MAR) for December 2025 documents: Hydrocodone-Acetaminophen 5-325mg 1 tablet PRN (As Needed) twice a day. Administered on 12/02/25 at 8:45PM for pain, 12/04/25 at 12:28AM for pain, 12/04/25 at 9:40AM for pain, 12/05/25 at 10:52PM for pain, 12/08/25 12:44AM for pain, 12/08/25 10:29PM for pain, 12/09/25 10:31AM for pain, 12/09/25 11:11PM for pain, 12/10/25 10:31AM for pain, 12/10/25 7:40PM pain 4/10 RLE (Right Lower Extremity), 12/12/25 12:50AM for pain 7/10 for RLE, 12/12/25 7:34PM for pain, 12/13/25 7:33PM for pain, 12/15/25 12:54Am for pain, 12/17/25 at 9:47AM for pain 12/21/25 at 12:32AM for pain, 12/21/25 11:40PM for pain 4/10 RLE. The same MAR documents the order for Lidocaine cream 4% topical apply to right lower extremity wounds prior to wound care/treatment change from 6:30PM to 6:30AM was administered on the following dates: 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/26, 12/06/25, 12/07/25, 12/08/25, 12/09/25, 12/10/25, 12/11/25, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 29 of 53 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 12/23/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, and 12/21/25. On 12/08/25 at 11:41 PM, V37 (License Practical Nurse) was observed providing wound treatment on R19 wounds of the right leg and foot. Observed old dressing which was saturated with large amounts of yellowish-green drainage to entire dressing. Topical lidocaine was not observed to be applied during this observation. R19 was observed multiple times throughout the procedure grimacing, grabbing her leg, and saying ouch. Wounds extend to most of R19 lower right leg from front to the back with what appears to be a depth of around 0.25 to 0.5 cm in depth. The area to the back of the right leg around the ankle/heel area looks to have a large amount of slough and possible muscle exposure.On 12/08/25 at 1:30 PM, R19 stated that there have been times when she has not gotten her treatment done to her right leg. R19 stated the nurses won't do it for a couple of days. R19 stated they have told her they have ran out of the medicine they put on her wounds on her right leg before. On 12/17/25 at 1:31PM, R19 stated that she doesn't know if they put the lidocaine on her leg during her treatment or not. R19 said that they just start working on her right leg and she doesn't' t know what all they are doing to her just that they are doing the treatment. R19 said that it always hurts when she gets her treatment done. R19 said that she usually will get a pain pill before her treatment if she requests it. R19 said that she is usually asleep when they come in to do her treatment, so she doesn't get a chance to request the pain pill prior to the treatment. On 12/17/25 at 1:40PM, V40 (Licensed Practical Nurse/LPN) stated that she looked in the treatment cart and she was unable to find any lidocaine gel for R19. V40 said that she found lidocaine gel for other resident, because each lidocaine gel is prescribed to each resident. V40 said that she looked in the medication cart as well and only found a lidocaine gel tube with no resident name on it and didn't know who's gel it was.On 12/03/25 at 2:19 PM, V21 (LPN) stated they run out of wound supplies like prescription creams and medication for wounds at times, and she will have to push off the wound care at nighttime until the next shift.On 12/18/25 at 9:10AM, V2 (Director of Nursing) stated if lidocaine is ordered for pain control to be applied prior to wound treatments it should be applied. V2 stated a residents lidocaine cream will have their name on it and come from their pharmacy, On 12/19/25 at 9:45AM, V48 (Physician) stated that he would expect any medication or treatment that is ordered to be administered as ordered. V48 said if R19 had an order for lidocaine gel to be applied to her right leg before doing the treatment then he would expect it to be applied. V48 said that the lidocaine gel being applied before the treatment performed was probably to help with pain from the treatment as a topical pain medication.The facility policy titled Pain Prevention and Treatment with an effective date of October 2017 documents Policy: To assess for, reduce the incidence of the severity of pain to help resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. The facility will develop and implement a plan, using pharmacological and non-pharmacological interventions to manage pain and/or try to prevent the pain consistent with the resident's goals. Definitions: Pain-an unpleasant sensory and emotional experience that can be acute, recurrent, or persistent. Event ID: Facility ID: 146045 If continuation sheet Page 30 of 53 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 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 73 residents currently residing at the facility. Findings include:1. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment.R1's Physician Order Report dated 11/2/25-12/2/25 documents mechanical lift for transfers. R1's Care Plan documents R1 is dependent for transfers, R1 uses mechanical lift for all transfers. On 11/26/25 at 8:28 AM, R1 was lying in bed. R1 stated she wanted to get up for breakfast, but the CNA (Certified Nursing Assistant) told her she couldn't get her up because there wasn't anyone to help her since she was a mechanical lift. R1 stated she doesn't like eating in her bed, she likes going to the dining room for meals. R1 was orientated to person, place, time, and situation during interview. On 11/26/25 at 8:32 AM, V5 (CNA) stated she was told when she arrived at her shift at 8am that they didn't have enough staff to get R1 up since she was a mechanical lift. On 11/26/25 at 2:34 PM, V7 (CNA) stated night shift doesn't get any 2 person assist up in the morning and he is the only CNA on the floor from 6am-8am so he must find someone to help him get R1 up since she is a mechanical lift. V7 stated he didn't get R1 up today because she is a 2 person assist, and he would rather get up the other 13 residents that are a 1 assist then get up 1 resident that needs 2 staff to help. On 12/2/25 at 11:22 AM, V2 (Director of Nursing) stated no resident should be left in bed because they are a 2 person assist. V2 stated there are plenty of staff in the building to help, including herself. On 12/2/25 at 12:23 PM, V1 (Administrator) stated he is not aware of staff unable to get mechanical lift residents up due to not having enough staff to help, they should ask someone in the building to help. V1 stated there is always someone in the building to help. 2. R38's Face Sheet documents an admission date of 10/18/2023 with diagnoses including in part pain in right foot, hypertension, and tobacco use. R38's MDS dated [DATE] documents a BIMS of 15, indicating R28's cognition is intact.On 11/26/25 at 9:14 AM, R38 stated it can take 30 minutes or more to get his call light answered at times. 3. R27's Face Sheet documents an admission date of 10/17/2023 with diagnoses including in part generalized arthritis. R27's MDS dated [DATE] documents a BIMS of 10, indicating R27's cognition is moderately impaired.On 11/26/25 at 9:16 AM, R27 stated she feels like they could really use more staff, especially nighttime they need staff the most. 4. R30's Face Sheet documents an admission date of 9/30.2025 with diagnoses including in part pain in thoracic spine, nausea with vomiting, dizziness and giddiness, weakness, and other chronic pain. R30's MDS dated [DATE] documents a BIMS of 15, indicating R30's cognition is intact.On 11/26/25 at 9:30, AM, R30 stated she thinks they could use more help on all shifts. R30 stated sometimes when you need assistance you might have to wait a while for help. 5. R4's Face Sheet documents an admission date of 4/30/2024 with diagnoses including in part hypertension, type 2 diabetes, chronic kidney disease, morbid obesity, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, acquired absence of left leg below knee, history of falling, pain in left shoulder, and other chronic pain. R4's MDS dated [DATE] documents a BIMS of 15, indicating R4's cognition is intactOn 11/26/25 at 9:45 AM, R4 stated his call light can be a long wait at times, sometimes up to an hour and it is usually worse on Saturdays and Sundays. R4 stated he asked for a cup of ice water one night recently and he waited about 4 hours before he got it. On 12/01/25 at 3:06 PM, V28 (Cook) stated he has seen the CNA's not getting all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 31 of 53 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 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the residents up for meals. V8 stated a lot of times they don't have enough staff to be able to get all the resident up for meals. On 12/04/25 at 5:18 PM, V32 (License Practical Nurse) stated her last day was in October of 2025. V32 stated they were short of staff often. V32 stated they had times when there was only 2 CNA's in the entire building and management would get mad when we would tell them that we have no staff. V32 stated administration would send out a group text message trying to get someone in to work, they would offer bonus to try and get someone to come in but most of the time they weren't able to get anyone in to work. V32 stated a lot of the time they didn't have any management come in to help, they would just work short. On 12/03/25 at 2:19 PM, V21 (Licensed Practical Nurse) stated she has witnessed where they couldn't get all the residents up or put them back in bed because they only had 1 CNA and 1 nurse on the unit. V21 stated the nurse was busy doing medication pass and couldn't help the CNA out to lay down the residents or get them up. On 12/08/25 at 10:32 AM, V21 stated one nurse went home this morning and now it is only her and one other nurse taking care of all the residents. V21 stated she and the other nurse have 38 residents each to care for. V21 stated if we have an admission or an emergency it can be difficult to get all the resident care completed. V21 stated back on the suites it is very hard because they are higher levels of care. V21 stated she has been yelled at by V2 (Director of Nursing) as she was doing resident care, she was yelling at her to get off the clock and clock out while she was in a residents room. V21 stated a couple of dressing changes have been missed because they didn't have enough staff, and it was too busy. V21 stated she has been in trouble by V1 (Administrator) and V2 when she was trying to get a dressing change completed and V1 was telling her to get off the clock, and she told him that she didn't get a dressing change completed. V1 told her that she needs to pass it on to the next shift. V21 stated V1 has told her that cooperate doesn't want us to stay on the clock and we need to just pass on whatever is not completed. V21 stated she has had to report off to the next shift that she did not get a dressing change or two completed and she doesn't not know if the dressing got done. V21 stated she would feel better about it if she knew it was completed. V21 stated a couple of weeks ago she didn't get R1's wound dressing complete and she had to report it off to another nurse and she doesn't know if it got done. V21 stated she isn't saying it didn't get done but she just doesn't know if it was completed on the next shift or not. V21 stated she doesn't see long call light wait times very often but sometimes the CNAs are busy with another resident, and it may take them longer to get to that call light. On 12/08/25 at 10:55PM, V35 (CNA) stated she usually works 6p-6A on night shift. V35 stated they usually have 6 CNA's and 2 Nurses at night shift to the whole building. V35 stated they are supposed to have 6 CNA's every night but that doesn't always happen. V35 stated they do have call ins sometimes and management will call other CNAs to see if they can get someone to cover. V35 stated at times they end up with just one CNA on each unit and they will have them come to help the other units with resident care. V35 stated when they only have 4 CNAs for the whole building, she doesn't think the residents get proper care. On 12/17/25 at 10:04 AM, V20 (CNA) stated they had a call in today and they didn't know that a staff called off and she was on transportation for the day and didn't have any appointments, so they pulled her to the floor. V20 said management doesn't come in and cover the floor when the CNAs have a call off. V20 said they just have to make it work and cover the halls the best they can. V20 said when they come to work in the morning at 6AM that most of the night shift CNA are already gone.On 12/17/25 at 10:07 AM, V7 (CNA) said that when they come in the morning, most of the 6p to 6am staff are gone and there might be one CNA and 2 nurses in the building when they get here at 6AM. V7 said the 6p to 6a CNAs will just leave and not give any kind of report or anything. V7 said he had a resident that fell the other night, and he didn't know that they were on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 32 of 53 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 12/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete neuro checks and needed vitals done until the nurse told him, because the night shift staff was gone and didn't tell him anything. On 12/17/25 at 10:10 AM, V30 (CNA) stated that no management will cover the floor when they have a call in and can't find anyone to cover the floor. V30 said that management will not work the floor as a CNA. V30 said that they just try to make it work with as many staff as they have. V30 said that when they work short, they always make sure the resident care is done the best they can. V30 said that the resident care will always come first. V30 said that sometimes they don't have anyone one up and it is 7:30AM.On 12/17/25 at 11:30AM, V1 stated he has heard something about night shift CNAs leaving before day shift CNAs get into the building. V1 said that he heard that the nurses and a CNA were in the building still, he said that he should have investigated it. V1 said that he hasn't looked into it. V1 stated he does not get to the facility until around 8:00AM so he doesn't know if they did really leave. V1 said that he thinks it would be ok for 15-20 minutes if there were just the 2 nurses and 1 CNA in the building until the day shift staff come in. V1 said that they have nurse managers that are on call weekly. V1 said that he knows if they have a call off, they call or text the nurse managers. V1 said that he does know that staff has had problems with getting a hold of the nurse managers. V1 said that he did talk to V3 (Assistant Director of Nursing), V17 (MDS Coordinator) and V2 (Director of Nursing) about making sure that they are available. V1 said if the staff call off, he expects the nurse managers to come in to work the floor as a nurse or a CNA if they are short.6. The Resident Council Minutes from 11/10/25 documents under New Business: Nursing: urinals, shower waits, and call light waits.The Facility Resident Council Referral Form dated 11/10/25 documents specific preferences/problems/concerns identified during the resident council meeting: urinals not getting emptied at night, call light wait times, and shower waits. The facility Midnight Census Report dated 11/25/2025 documents 73 residents in the facility. Event ID: Facility ID: 146045 If continuation sheet Page 33 of 53 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 12/23/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all staff have the appropriate competencies and skill sets to provide care and meet the residents' needs. This failure has the potential to effect all 73 residents living in the facility.The findings include: On [DATE] at 9:45 AM, V20 (Certified Nurse Assistant/CNA) stated this past weekend there was a CNA that was not certified working as a CNA, and she was let go on Monday by V1 (Administrator).On [DATE] at 10:06 AM, V1 (Administrator/ADM) stated the BOM (Business Office Manager) checks the CNA registry for their credentials prior to them working. V1 stated V46 (Nurse Assistant/NA) was hired and worked as a CNA but they later found out she never showed up for her certification test, so she is not a Certified Nursing Assistant. V1 stated they have a NA policy, but he is unsure what job duties she actually performed while on the job. V1 stated V46 was hired on [DATE].On [DATE] at 11:30AM, V1 said that they did have a CNA (V46) that was working at the facility he thought she was a CNA. V1 said that they did check the CNA registry, and it said that V46 was eligible for hire, and he said that it wasn't until recently he checked the registry and saw that under her test it said NS. V1 said that he didn't know what NS meant so he emailed the registry to ask them what the NS meant next to testing. V1 said that the CNA registry emailed him back and told him that the NS meant that V46 was a no show to take the CNA exam. V1 said that she had 120 days to take her test and work as a NA with another CNA. V1 said that he thinks the 120 days was up around [DATE]. V1 said that he doesn't know if she worked outside of her qualifications. V1 said they did a lot of hiring at the facility recently. V1 said that she no longer works at the facility now.On [DATE] at 10:10AM, V30 (CNA) stated they had a CNA V46 who was working on night shift who was not certified.On [DATE] at 09:13 AM, V1 provided hire date of [DATE] and a termination date of [DATE] for V46.On [DATE] at 9:32 AM, V3 (Assistant Director of Nursing/ADON) stated V46 (NA) worked primarily on the ARCH unit but she floated so probably would have worked on all hallways in the whole building. V3 stated she heard a rumor that V46 didn't have an active CNA certification, so she went straight to V1 and told him, and she did not work again after they found out she didn't have a current certification. V3 stated V46 was hired as a CNA so she could have provided care as a CNA outside of the NA policy, but she doesn't know for sure because she worked midnights, and she wasn't ever in the building when she was working.On [DATE] at 9:56 AM, V46 (NA) stated she started at the facility the week prior to Thanksgiving this year and she worked as a full CNA. V46 stated when she was hired V2 (DON) knew she hadn't tested yet. V46 stated V2 told her to schedule it as soon as she could. V46 stated she finished CNA school in May of 2025 and her test is scheduled for [DATE]. V46 stated when she interviewed with V2 (DON) she told her she hadn't taken her certification test yet but she really wanted the job. V46 stated V2 hired her on the spot during her interview with the intention she would take her test as soon as she could. V46 stated V2 told her she was okay with her working without her certification for a little while until she could take her test. V46 stated she worked all over the building, she would go where she was needed.The facility document titled Certified Nursing Assistant Job Description documents job summary as The overall purpose of the Certified Nursing Assistant position is to provide each of the assigned residents with routine daily nursing care and services in accordance with the residents' plan of care. Education and Experience Requirements: The Certified Nursing Assistant must have the following: State certification as a Certified Nursing Assistant, CPR (Cardiopulmonary Resuscitation) Certification preferred, ability to read, write, and speak the English language, no disqualifying criminal offenses as defined by regulatory guidelines.The midnight census report dated [DATE] documents there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 34 of 53 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 12/23/2025 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 0726 are 73 residents living in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 35 of 53 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 12/23/2025 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 observation, interview, and record review the facility failed to acquire medication from the pharmacy and administer and document medications as ordered for 4 of 13 residents (R2, R3, R17, R19) reviewed for pharmacy services in a sample of 44.Findings include:1. R3's Face Sheet documents an admission date of 8/22/2018 with diagnoses including: Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R3's cognition is intact.R3's Care Plan documents a problem category of pressure ulcer/injury. Impaired skin integrity related to wound healing with risk of inadequate fluid and nutritional intake as evidenced by delayed wound healing, poor oral intake, and signs of dehydration with a start date of 2/12/25.R3's Physician Order Report dated 11/2/25-12/2/25 documents an order to place on enhanced barrier precautions per guidelines with a start date of 4/1/24. Same report documents an order for silver sulfadiazine cream topical, cleanse the area to the left upper buttock with wound cleanser or normal saline, apply Silvadene cream, collagen powder, calcium alginate, and dry dressing daily with a start date of 11/5/25.On 12/8/25 at 11:45 PM, wound treatment for R3 was observed. V25 (Registered Nurse/RN) mixed collagen and silver sulfadiazine cream that had another resident's name on it and had an expiration date of 9/30/2025. This surveyor asked V25 if the cream belonged to R3, and she stated she doesn't know where his is, so she is going to use the cream that belongs to a different resident since she doesn't use it anymore.2. R17's Face Sheet documents an admission date of 10/16/2023 with diagnoses including: Alzheimer's disease, type 2 diabetes, protein-calorie malnutrition, pain, cellulitis of unspecified part of limb, and need for assistance with personal care.R17's MDS dated [DATE] documents a BIMS score of 04, indicating R17 has severe cognitive impairment.R17's Care Plan documents R17 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility and R17 has pain/risk for pain with a start date of 11/24/23.R17's Physician Order Report dated 11/15/2025-12/15/2025 documents orders for silver sulfadiazine cream topical and clotrimazole cream topical, special instructions: Cleanse the wound to the right abdomen with normal saline or wound cleanser, apply silver sulfadiazine cream, clotrimazole, collagen powder, calcium alginate, and dry dressing daily, once a day, 06:30 PM - 06:30 AM with a start date of 9/17/2025 and an end date labeled open ended, Metronidazole tablet 500 mg and betadine solution topical, special instructions: cleanse the wound to the right third toe with wound cleanser or normal saline, apply betadine, crushed metronidazole, calcium alginate, and dry dressing daily with a start date of 11/3/2025 and an end date labeled open ended, and Povidone-iodine solution topical, special instructions: start betadine, calcium alginate and gauze wrap for the whole foot daily, once a day, 07:00 PM - 10:00 PM with a start date of 12/7/2025 and an end date labeled open ended.On 12/9/25 at 12:09 AM, wound care for R17 was observed. V25 (Registered Nurse/RN) had to go to another unit to find collagen. V25 mixed collagen and silver sulfadiazine cream together. The tub of silver sulfadiazine cream did not have a name on it, V25 stated she didn't know who it belonged to because it doesn't have a name on it, but she doesn't know where R17's cream is, so she is going to use it.3. R19's Face Sheet documents an admission date of 9/26/25 with diagnoses including: cellulitis of right lower limb, weakness, depression, and other specified hearing loss bilateral.R19's MDS dated [DATE] documents a BIMS score of 07, indicating R19 has severe cognitive impairment.R19's Care Plan documents R19 has impaired skin integrity related to venous insufficiency with a start date of 9/26/25.R19's Physician Order Report dated 11/15/2025-12/15/2025 documents orders for silver (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 36 of 53 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 12/23/2025 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 sulfadiazine cream topical, cleanse the wound to the right medial foot, top of right foot, right leg, right posterior leg, and right ankle with normal saline or wound cleanser, apply silver sulfadiazine cream, collagen powder, calcium alginate, gauze roll and secure with tape with a start date of 10/30/2025 and an end date labeled open ended and Lidocaine cream 4% topical, apply to right lower extremity wounds prior to wound care/treatment change once a day with a start date of 11/17/25 and an end dated labeled open ended.On 12/08/25 at 1:30 PM, R19 stated that there have been times when she has not gotten her treatment done to her right leg. R19 stated the nurses won't do it for a couple of days. R19 stated they have told her they have ran out of the medicine they put on her wounds on her right leg before. R19 stated she couldn't remember how many times they have ran out of treatment supplies for her right leg.On 12/03/25 at 2:19 PM, V21 (LPN) stated they run out of wound supplies like prescription creams and medication for wounds at times, and she will have to push off the wound care at nighttime until the next shift. V21 stated she does do wound care, but it might just be on the other shift. V21 stated she has had to borrow wound care supplies from one resident's supplies to use on another resident and then when they get those supplies back in, she will re-supply the resident that she borrowed from with what she borrowed.On 12/9/25 at 12:33 AM, V25 stated sometimes she will use other residents supplies if she can't find the correct supplies.On 12/18/25 at 9:10 AM, V2 (Director of Nursing/DON) stated residents should not run out of medication from the pharmacy, all they need to do it tell her and she will get it ordered.4. R2's Face Sheet documents an admission date of 12/23/24 with diagnoses including: spina bifida, anemia, paraplegia, pressure ulcer of sacral region stage 4, and pressure ulcer of right buttock stage 4.R2's MDS dated [DATE] documents a BIMS score of 15, indicating R2's cognition is intact.R2's Physician Order Report dated 11/2/25-12/2/25 documents an order for oxybutynin chloride 5 mg, 1 tablet three times a day with a start date of 1/14/25 and an end date labeled open ended.R2's December 2025 MAR dated 12/1/25 documents oxybutynin chloride scheduled for 7:00 AM-10:00 AM was not administered due to R2 refused the medication.On 12/01/25 at 11:51 AM, V15 (License Practical Nurse) was passing medication this surveyor observed some of R2's medications were red on the computer in R2's electronic medical record. V15 said that she might have missed his morning medications. V15 said that she did forget to give him his morning medications now that she thinks about it, but she said that she was going to call the nurse practitioner to make sure it was ok to give the medication now.On 12/01/25 at 12:01 PM, V15 called V50 (Nurse Practitioner) observed phone call and V15 told V50 that she just missed R2 and that she didn't give him his morning medications and she asked if she could give the medications now. V15 said that V50 said it was ok to give morning medications now.On 12/01/25 at 12:04 PM, V15 was observed popping out R2's medications from the medication cards. V15 was observed popping out the following medications: multivitamin with iron 1 tablet, arginaid 1 packet in water, vitamin C 500mg 1 tablet, glyburide 2.5mg 1 tablet, senna 8.6mg 1 tablet, oxybutynin 5mg 1 tablet, and Xarelto 10mg 1 tablet.On 12/01/25 at 12:10 PM, V15 took the medications into R2's room. R2 refused to take all the medications. R2 said that it was too late to take his blood glucose check now because he had already eaten. R2 said that he would go ahead and take the oxybutynin 5mg tablet.On 12/1/25 at 12:30 PM, V15 was observed documenting in the Electronic Health Record (EHR) that R2 refused the medications. When V15 went back to look to make sure that all the medication had been marked refused except for oxybutynin she noticed that the oxybutynin was also marked as refused. V15 stated that she did not know how to unmark the refusal on the oxybutynin. V15 said that she doesn't know how to change or edit when refused is marked. V15 stated that R2 had an oxybutynin due again at 1:00 PM-3:00 PM.On 12/02/25 at 2:10 PM, V15 stated she did not call the physician or the physician assistant and tell them R2 refused his medications. V15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 37 of 53 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 12/23/2025 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 stated she did call and tell the Nurse Practitioner that she missed giving R2's morning medications and she told her to go ahead and give them now. V15 stated R2 refused all the morning medications but the oxybutynin but when she went to sign out that R2 refused all the other medications it showed he refused the oxybutynin as well and she couldn't change it. V15 stated R2 had another oxybutynin due at 1:00 PM so she signed that she gave the 1:00 PM dose so he missed getting the morning dose. V15 stated she normally will make a progress note when a resident refuses or they get their medications late, but she forgot this time.On 12/19/25 at 9:45 PM, V48 (Physician) stated he expects that he or his Nurse Practitioner would be notified if any resident missed any medications or treatments. V48 stated that he would expect any medication or treatment that is ordered to be administered as ordered.On 12/18/25 at 9:10 AM, V2 (Director of Nursing) stated all residents should get their medications when they are ordered.A pharmacy policy titled Medication Administration dated 10/25/2014 documents under Procedures, B. Administration, 2) Medications are administered in accordance with the written orders of the prescriber. 15) Medications supplied for one resident are never used for another resident. Under D. Documentation, 4.) The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross referenced to a full signature in the space provided.A pharmacy policy titled Ordering and Receiving Non-Controlled medications from the Dispensing Pharmacy dated 10/25/14 documents under Procedures: 2) Refills are ordered by peeling the reorder tab from the prescription label and placing it in the appropriate area on the reorder form provided by the pharmacy for that purpose and include: a. Date ordered, b. Facility name and nursing station, c. Nurse first and last name. Event ID: Facility ID: 146045 If continuation sheet Page 38 of 53 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 12/23/2025 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 0760 Ensure that residents are free from significant medication errors. 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 administrated medications as prescribed by a physician for 2 of 13 (R11, R12) residents reviewed for medication administration in a sample 44. Findings includeOn 12/1/25 at 11:10 AM, the medication administration observation with V15 (Licensed Practical Nurse/LPN) began. V15 opened the top drawer to her medication cart and there were 2 medicine cups of pills with R11 and R12's names on them. This nurse asked V15 what the pills in the cup were and she stated those are R11 and R12's morning pills. V15 stated she tried to give R11 and R12 their pills and they wouldn't wake up, so she just put the pill cup with their pills in it in the drawer and was going to try to administer them later, but stated she forgot. V15 stated she hasn't tried to give the pills a second time yet. At this time, V2 (Director of Nursing/DON) walked by and saw the pills and stated, pills should not be popped unless they are given at that time, and they should not be placed in cups and left in the medicine cart. V2 took the pill cups and stated she was going to destroy them in the drug buster in her office.1. R11's Face Sheet documents an admission date of 6/6/23 with diagnoses including: anemia, vitamin D deficiency, hypokalemia, psychotic disorder with delusions, hydronephrosis, neuromuscular dysfunction of bladder, retention of urine, dementia, hypertensive heart and chronic kidney disease without failure, type 2 diabetes mellitus, chronic kidney disease stage 3, and history of falling.R11's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 4, indicating R4's cognition is severely impaired.R11's Medication Administration Record (MAR) dated 12/1/25-12/4/25 documents R11 was supposed to receive Eliquis, ferrous sulfate, Macrobid, metoprolol tartrate, MiraLAX, omeprazole, oxybutynin chloride, and potassium chloride every morning.2. R12's Face Sheet documents an admission date of 9/30/21 with diagnoses including: malignant neoplasm of right lower lobe of lung or bronchus, shortness of breath, Alzheimer's disease, atherosclerosis of coronary artery bypass graft, hypertensive heart and chronic kidney disease with heart failure, hypertension, chronic systolic heart failure, chronic kidney disease, edema, and pain.R12's MDS dated [DATE] documents a BIMS score of 14, indicating R12's cognition is intact.R12's MAR dated 12/1/25-12/4/25 documents R12 was supposed to receive 4oz Hi calorie supplement, amlodipine, aspirin, celexa, cranberry extract, vitamin B-12, daily multivitamin, Depakote sprinkles, and furosemide every morning.On 12/02/25 at 11:11 AM, V2 (Director of Nursing) stated when the surveyor was observing V15 start medication pass on 12/1/25 there were two cups with pills already popped out in them that belonged to R11 and R12. V2 stated she brought the medications into her office and put them in the drug buster. V2 stated if medications are not given at all then it would be considered a medication error, but she thinks late medication are not considered a medication error.On 12/02/25 at 2:10 PM, the medications from R11 and R12's MAR that were documented as given on 12/1/25 in the morning were went over with V15 and V15 stated she did not give any of those medications, but she documented she gave them to both R11 and R12. V15 stated she had R11 and R12's pills popped and in a medication cup with their name on it in the medication cart. V15 stated when she was passing morning medications, she went into R11's room to give him his medication and he was asleep. V15 stated she never gave R11 his medication form that morning even though she signed it off in the electronic medical record as given. V15 stated R11 did not refuse his medications he was just asleep when she went in there and she couldn't get him to wake up and she forget to go back and try again. V15 stated the same thing happened with R12 when she went into his room to give him his medications that she had already popped and placed in a medication cup and he was sleeping, and she didn't want to wake him up. V15 stated R12 did not refuse his medications either. V15 stated she signed off R12's medications even though he never Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 39 of 53 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 12/23/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete received them. V15 stated she should have made a note in in R11 and R12's chart regarding the missed medication but she forgot to. V15 stated she normally gives all the residents their medications and isn't normally late like this, but she was very busy. V15 stated she usually works night shift, so she is not familiar with when residents wake up and how they like to take their medications during the day. V15 stated she did not call and notify the physician or nurse practitioner to notify them about R11 and R12 not getting their morning medications on 12/1/25.On 12/18/25 at 9:10 AM, V2 stated she considers not giving medications a medication error. V2 said that cardiac medications, blood thinners, insulin and antibiotics she considers significant medication errors.On 12/2/25 at 12:23 PM, V1 (Administrator) stated medications should not be popped and left in a medication cup in the medication cart. V1 stated if a medication is not given it should be considered a medication error. V1 stated a medication error form should have been completed for late or missed medications.On 12/19/25 at 9:45 PM, V48 (Physician) stated there is a possibility that R12 missing Depakote Sprinkles on 12/1/25 could be considered a significant medication error because R12 could have behaviors from missing that medication. V48 stated he expects that he or his Nurse Practitioner would be notified if any resident missed any medications or treatments. V48 stated that he would expect any medication or treatment ordered to be administered.A facility policy titled Medication Administration dated 10/25/2014 documents Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.An undated facility form titled Medication Error/Discrepancy Report documents under 1. Medication error/discrepancy: A. Medication Error: a medication error occurs when a consumer receives an incorrect drug, drug does, dosage form, quantity, route, concentration, rate of administration: or omission. Event ID: Facility ID: 146045 If continuation sheet Page 40 of 53 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 12/23/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to use accurately labeled medication/cream, use cream that was not expired, and lock the medication and wound treatment carts. This failure has the ability to affect all 73 residents in the facility. Findings include:1. R17's Face Sheet documents an admission date of [DATE] with diagnoses including: Alzheimer's disease, type 2 diabetes, protein-calorie malnutrition, pain, cellulitis of unspecified part of limb, and need for assistance with personal care.R17's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 04, indicating R17 has severe cognitive impairment.R17's Care Plan documents R17 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility and R17 has pain/risk for pain with a start date of [DATE].R17's Physician Order Report dated [DATE]-[DATE] documents orders for silver sulfadiazine cream topical and clotrimazole cream topical, special instructions: Cleanse the wound to the right abdomen with normal saline or wound cleanser, apply silver sulfadiazine cream, clotrimazole, collagen powder, calcium alginate, and dry dressing daily, once a day, 06:30 PM - 06:30 AM with a start date of [DATE] and an end date labeled open ended, Metronidazole tablet 500 mg and betadine solution topical, special instructions: cleanse the wound to the right third toe with wound cleanser or normal saline, apply betadine, crushed metronidazole, calcium alginate, and dry dressing daily with a start date of [DATE] and an end date labeled open ended, and Povidone-iodine solution topical, special instructions: start betadine, calcium alginate and gauze wrap for the whole foot daily, once a day, 07:00 PM - 10:00 PM with a start date of [DATE] and an end date labeled open ended. On [DATE] at 12:09 AM, wound care for R17 was observed. V25 (Registered Nurse/RN) had to go to another unit to find collagen. V25 mixed collagen and silver sulfadiazine cream together. The tub of silver sulfadiazine cream did not have a name on it, V25 stated she didn't know who it belonged to because it doesn't have a name on it, but she doesn't know where her cream is, so she is going to use it.2. R3's Face Sheet documents an admission date of [DATE] with diagnose including: Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis.R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3's cognition is intact.R3's Care Plan documents a problem category of pressure ulcer/injury. Impaired skin integrity related to wound healing with risk of inadequate fluid and nutritional intake as evidenced by delayed wound healing, poor oral intake, and signs of dehydration with a start date of [DATE].R3's Physician Order Report dated [DATE]-[DATE] documents an order for silver sulfadiazine cream topical, cleanse the area to the left upper buttock with wound cleanser or normal saline, apply Silvadene cream, collagen powder, calcium alginate, and dry dressing daily with a start date of [DATE].On [DATE] at 11:45 PM, wound treatment for R3 was observed. V25 (Registered Nurse/RN) mixed collagen and silver sulfadiazine cream that had another resident's name on it and had an expiration date of [DATE]. This surveyor asked V25 if the cream belonged to R3, and she stated she doesn't know where his is, so she is going to use the cream that belongs to a different resident since she doesn't use it anymore. This surveyor asked V25 what the expiration date of the silver sulfadiazine cream is, and she stated [DATE]. On [DATE] at 12:33 AM, V25 stated sometimes she will use other residents supplies if she can't find the correct supplies. V25 stated she probably shouldn't have used expired silver sulfadiazine cream on R3.On [DATE] at 10:55 PM, a cup of white cream with a spoon on top of the treatment cart for A Wing, Long Hall was observed. A tube of Nystatin on top of treatment cart was also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 41 of 53 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 12/23/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete observed with no nurse in the area. The treatment cart was unlocked.On [DATE] at 10:58 PM, the medication cart for A Wing, Long Hall was observed and was unlocked with the top drawer open slightly, with no nurse in the area. 2 Certified Nursing Assistants were observed working on the hall where the treatment cart was located. On [DATE] at 11:09 PM, the medication cart for A Wing, Short Hall was observed to be unlocked, with no nurse observed on the hallway. There were 2 CNA's observed working on the hallway where the medication cart was observed.On [DATE] at 11:10 PM, the medication cart for C Wing, East Hall was observed to be unlocked with no nurse around. There were 2 CNA's observed working on the hallway where the medication cart was observed.On [DATE] at 12:33 AM, V25 (RN) stated she usually doesn't leave the medication cart unlocked when she isn't around it but sometimes, she forgets to lock it.On [DATE] at 9:10 AM, V2 (Director of Nursing) stated medication and treatments carts should be locked when the nurse is not around the cart and there should not be any medications or creams sitting on top of the carts not locked up unless the nurse is with it. V2 stated you should not borrow medications or creams from other residents. V2 stated any medication/cream that is expired should not be used.A pharmacy policy titled Medication Administration dated [DATE] documents under B. Administration, 16) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.A pharmacy policy titled Medication Labels dated [DATE] documents under procedures: B. Each prescription medication label or package includes: 1) Resident's name. 8) Beyond use (or expiration date of medication on the package.The facility Midnight Census Report dated [DATE] documents that 73 residents reside in the facility. Event ID: Facility ID: 146045 If continuation sheet Page 42 of 53 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 12/23/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the approved menu by not providing the approved protein and not serving the correct portion sizes. This failure has the ability to affect all 73 residents residing at the facility. Findings include:The facility Fall/Winter 2025 menu documents on 12/1/25 breakfast: choice of cereal, biscuits and gravy, margarine, orange, apple, or cranberry juice, milk, coffee/tea. The menu documented lunch: country chicken breast, garlic mashed potatoes, California vegetable blend, cornbread, chef's choice of dessert, gravy, margarine, milk, coffee/tea. 1. R3's Face Sheet documents an admission date of 8/22/2018 with diagnose including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis. R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact. On 12/1/25 at 8:26 AM, R3 was in bed eating breakfast. Observed R3 was served scrambled eggs, hot cereal, toast, coffee, and water. R3 stated he hasn't had meat with his breakfast for a while and he likes having meat with his breakfast because he is supposed to have double protein, and the eggs aren't good and are usually cold. R3 stated they have eggs all pretty much every morning. R3 stated on his meal ticket he is supposed to get double protein and milk, and he doesn't get double protein very often and he hasn't had his milk in a long time because one of his special cups started leaking so they had to throw it away and they haven't replaced it. On 12/1/25 at 8:34 AM, R8 was served scrambled eggs, cereal, and toast. R8 who was alert and oriented stated they haven't had breakfast meat with their breakfast in a week or 2 and he likes having meat with his breakfast. On 12/1/25 at 8:34 AM, R9 was served scrambled eggs, cereal, and toast. R9 who was alert and oriented stated they haven't had meat with their breakfast in a week or 2 and she likes having meat with her breakfast. On 12/1/25 at 8:35 AM, R10 was served scrambled eggs, cereal, and toast. R10 who was alert and oriented stated they haven't had meat with their breakfast in a while and she likes having meat with her breakfast. On 12/1/25 at 8:41 AM, V10 (Certified Nursing Assistant/CNA) stated the residents were served scrambled eggs, hot cereal, and toast for breakfast this morning and no meat. On 11/26/25 at 9:39 AM, R2 who was alert and oriented stated they haven't served meat for breakfast for several days, then stated, I told you that the food is terrible. On 12/1/25 at 9:17 AM, V11 (Cook) stated she didn't make meat with breakfast because they do not have any. V11 stated they haven't had meat for breakfast for about a week. V11 stated they did not have what was on the menu for breakfast because she made biscuits and gravy over the weekend, so she didn't have the ingredients to make them today, so she made scrambled eggs, cereal, and toast for today. V11 stated she decided on the menu for today, and did not consult the dietitian. V11 stated she didn't give R3 milk today because he only has 2 cups, so she gave water and coffee. V11 stated R3 needs a 3rd cup ordered and she doesn't know who orders the cups. V11 stated she worked at the facility a while back and R3 had 3 cups at that time but since she's been back this time (about 2-3 months) he has only had 2 cups. V11 stated they are supposed to have chicken for lunch today, but they do not have any, so she decided to serve Salisbury steak, mashed potatoes, and green beans. On 12/1/25 at 9:29 AM, V4 (Dietary Manager) stated they won't get their next food truck until Thursday of this week. V4 stated she was not aware they were out of breakfast meat. V4 stated they are out of chicken for lunch today as well so V1 subbed Salisbury steak. V4 stated she ordered for 2 weeks on her last truck instead of 1 week due to the Thanksgiving holiday falling on the day they normally get their food truck, but she must have not ordered enough. On 12/1/25 at 3:06 PM, V28 (Cook) stated they didn't have any breakfast meats this past week (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 43 of 53 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 12/23/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete for breakfast. V28 stated he did let V4 (Dietary Manager) know that we were out of breakfast meat. V28 stated he thinks the reason they ran out of the breakfast meat was because of the holiday and V4 had to double order back to back. On 12/2/25 at 3:18 PM, V19 (CNA) stated she saw there wasn't any meat served with breakfast for a couple of days, and she stated there were several residents that complained to her, R3 and R4 are the 2 she can remember off the top of her head. 2. The facility Fall/Winter 2025 menu documents on 12/3/25 dinner: smoked sausage, sauerkraut, sweet peas, fruit cocktail, milk, coffee/tea. On 12/3/25 at 4:50 PM, observed dinner meal on the rehab unit. Bite size hot dog/sausage pieces were served. Each resident was served 4 bite size pieces of hot dog/sausage. The hot dog/sausage was thin and small/thin in size. On 12/17/25 at 2:05 PM, V47 (Cook) stated he usually works for lunch and dinner service. V47 stated he has served cut up sausage and sauerkraut before. V47 stated they cook the sausage whole then cut them into bite size pieces. V47 stated when the sausage is cut up, they are cut up into about 9 or so pieces per sausage. V47 stated 4 pieces of sausage is not a whole sausage. On 12/17/25 at 3:50 PM, V4 (Dietary Manager) stated she looked the at the recipe for the sausage and sauerkraut that was served on 12/3/25 for dinner and it did call for a whole sausage. V4 stated the residents were probably not served the correct portion size due to them being cut up and only served 4 pieces. The facility dietary recipe for Sausage Smoked documents a single serving size of one 4 oz smoked sausage. 3. The Resident Council Minutes from 11/10/25 documents menu is not getting done. The Facility Resident Council Referral Form dated 11/10/25 documents specific preferences/problems/concerns identified during the resident council meeting: menu not getting updated was referred to V4. The Resident Council Minutes from 9/9/25 documents menus not always being updated. The Facility Resident Council Referral Form dated 9/9/25 documents specific preferences/problems/concerns identified during the resident council meeting: menus not being updated was referred to V4. A facility policy titled Meal Substitutions dated December 2016 documents under Purpose: To ensure residents receive adequate nutrition and hydration and to ensure resident preferences are honored and monitored. A facility policy titled Menus dated December 2016 documents under Policy menus shall be followed which have been written, reviewed for nutritional adequacy and approved by a Registered, Licensed Dietitian in compliance with Federal and State Regulations and consistent with Standards of Practice on nutritional care. In the same document it documents Changes following the implementation of the menu shall be reviewed and revised, as necessary, by the Registered, Licensed Dietitian. The facility Midnight Census Report dated 11/25/2025 documents 73 residents in the facility. Event ID: Facility ID: 146045 If continuation sheet Page 44 of 53 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 12/23/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 maintain food items served to residents at palatable/hot temperatures for 4 of 4 residents (R1, R2, R3, R14) reviewed for food preferences in the sample of 44. Findings include:On 11/26/25 at 7:00 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. 1. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, unspecified protein-calorie malnutrition, non-pressure chronic ulcer of left heel and midfoot with unspecified severity, vitamin B12 deficiency anemia, nutritional anemia, and weakness. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R1's Care Plan documents a problem category of nutritional status, documenting R1 is at risk for impaired nutrition and hydration. R1's Physician Order Report dated 11/2/25-12/2/25 documents R1 is on a regular diet with regular consistency and thin/regular liquids. On 11/26/25 at 8:00 AM there was a plate of untouched food sitting at the table in the dining room with no cover on it and no resident was near it. This surveyor asked V7 (Certified Nursing Assistant/CNA) whose food it was, and he stated it was R1's but she wasn't out of bed yet because he needed help to get her up and they hadn't had time yet. On 11/26/25 at 8:25 AM, V5 (Certified Nursing Assistant/CNA) put a cover on the food that was sitting at the table for R1, took the tray from the table and took it to R1's room to assist her with eating. V5 poured milk into her cold cereal then this surveyor asked V5 to see if she could get another tray for R1. V5 went to the kitchen and brought back a new tray for R1. The 1st tray was temped at 8:28 AM, the biscuits and gravy were 94.8 degrees Fahrenheit, the scrambled eggs were 93.6 degrees Fahrenheit, and the milk in the cold cereal was 61.3 degrees Fahrenheit. V5 stated she usually microwaves the food if she thinks it is cold. On 11/26/25 at 8:28 AM, R1 stated she gets cold food often. R1 was orientated to person, place, time, and situation during interview. 2. R2's Face Sheet documents an admission date of 12/23/24 with diagnoses including in part spina bifida, anemia, paraplegia, pressure ulcer of sacral region stage 4, and pressure ulcer of right buttock stage 4.R2's MDS dated [DATE] documents a BIMS of 15, indicating R2's cognition is intact.On 11/26/25 at 9:39AM, R2 stated the food is terrible, and it is always cold when he gets it. 3. R3's Face Sheet documents an admission date of 8/22/2018 with diagnose including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis. R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact. On 12/1/25 at 8:26 AM, R3 stated he hasn't had meat with his breakfast for a while and he likes having meat with his breakfast because the eggs aren't good and are usually cold. R3 stated today the eggs were cold so he couldn't eat them. 4. R14's Face Sheet documents an admission date of 8/22/2025 with diagnoses including in part malignant neoplasm of colon, depression, other symptoms and signs concerning food and fluid intake, nausea with vomiting, secondary malignant neoplasm of large intestine and rectum, and generalized anxiety disorder. R14's MDS dated [DATE] documents a BIMS of 14, indicating R14's cognition is intact. On 12/3/25 at 2:38 PM, R14 stated the food is cold all the time and breakfast is always cold. R14 stated lunch and dinner are cold some days and some days it is okay. On 11/26/25 at 3:03, V5 (CNA) stated she has received complaints from residents about cold food before and she will tell kitchen and warm the food up if they tell her before they eat it. On 12/1/25 at 3:27 PM, V10 (CNA) stated she has had residents complain about cold food and usually its breakfast food. On 12/2/25 at 2:26 PM, V20 (CNA) V20 stated she receives resident complaints a lot about their food being Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 45 of 53 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 12/23/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete cold. On 12/03/25 at 2:19 PM, V21 (License Practical Nurse) stated the residents get served cold food daily. V21 stated she would take and heat it up or give them a new tray, but they often don't let her know that the food is cold until after they eat it. On 12/2/25 at 12:23 PM, V1 (Administrator) stated if food is cold, it should not be served to the resident, it should be reheated. V1 stated food should go from the steam table to the resident and not sit on the table if they are not in the dining room at the table ready to eat. The Facility's Cooking Foods- Internal Temperatures policy dated January 2012 documents, Temperature Guidelines: Food- Hot at Point of Service, 120 degrees or higher. Food- Cold at Point of Service, 50 degrees or lower. Event ID: Facility ID: 146045 If continuation sheet Page 46 of 53 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 12/23/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to discard food items in the refrigerator and dry storage that were past the used by/expiration dates. This has the potential to affect all 73 residents living in the facility Findings include:On 11/25/25 at 12:10 PM, observations of the kitchen began. In the reach in freezer there was an unopened bag of crumbled sausage that had an expiration date of 11/9/25. On the storage rack there was an unopened container of strawberry glaze that had an expiration date of 10/25/25. On the storage rack there was an opened bottle of chocolate fudge that had 5/23 on it as the open date and had an expiration date of 11/13/25 on it. There were 2 unopened bags and 1 open bag of cookie pieces that had an expiration date of 11/23/25. There were 2 unopened boxes of cornstarch on the storage rack that had an expiration date of 8/28/23. There was a bag of opened tortilla chips on the storage rack that had an expiration date of 9/17/25 and no open date. V4 (Dietary Manager) was shown the expired food and stated they were no good anymore and she threw them all out. V4 stated expired food should never been kept, it should be thrown out. On 11/25/25 at 12:20 PM, observed refrigerator in kitchen and noted six cartons of eggs, five cartons had an expiration date of 11/17/25 and one had an expiration date of 11/14/25. On 11/25/25 at 12:40PM, V4 stated that she was going to throw away the eggs in the refrigerator that she said she brought the eggs a little while back and was going to cook out on the grill and make some hard fried eggs for some of the residents. She said that she never had a chance to make the eggs, and she was just going to get rid of them. On 11/25/25 at 1:05 PM, a container that had a sauce-like substance in it had a label that was marked Manwich with no date of when placed in the refrigerator or opened. Observed 2 large open containers in the refrigerator, one was coleslaw dressing and one was Italian dressing both dressings were half empty and did not have an open date on either one. A facility policy titled Dry Storage Areas dated January 2012 documents under Procedure: 9. Cans and dried goods will be dated with the date they were received and date they were opened. The facility Midnight Census Report dated 11/25/2025 documents 73 residents in the facility. Event ID: Facility ID: 146045 If continuation sheet Page 47 of 53 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 12/23/2025 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failure to ensure that all licensed staff had a current license while working at the facility. This failure has the potential effect all 73 residents living at the facility.The findings include: On [DATE] at 9:45AM, V20 (Certified Nurse Assistant/CNA) stated that V21 (Licensed Practical Nurse/LPN) is not working at the facility anymore due to the fact that her LPN license was not active. V20 stated she had been working in the facility as and LPN while it was expired. On [DATE] at 10:06AM, V1 (Administrator/ADM) stated the BOM (Business Office Manager) or corporate checks staff nursing licenses. V1 stated V21's license expired at the beginning of the year but he thinks she might have gotten an extension on it but he isn't sure. V1 stated V21 did work as a nurse with an inactive license and passed medications and performed nursing duties during that time. V1 stated V21's LPN license became active again on [DATE]. On [DATE] at 11:30AM, V1 (ADM) said that he suspended V21 (LPN) on [DATE] because she didn't have an active nursing license. On [DATE] at 9:10AM, V2 (Director of Nursing/DON) stated she was not aware V21 did not have an active license. V2 said that typically corporate checks licenses at hire and then when it is renewal time. V2 stated she will have the nurses bring her proof that they renewed their license, but she doesn't keep that proof because she doesn't want to be responsible for that. V2 stated she doesn't remember if V21 provided anything or not. She stated this year things have gotten past her. V2 stated she doesn't know when V21's license expired or how long she worked without and expired license she just knows she did work some without an active license. V2 stated she heard about a CNA working without a certificate, but she doesn't remember who told her and she thinks V1 handled it. V2 stated corporate does the checks on the nurses' license prior to starting to work.On [DATE] at 9:32AM, V3 (Assistant Director of Nursing/ADON) stated she wasn't aware that V21 didn't have an active nursing license until after she was suspended. V3 stated V21 floated around when she worked so she could have worked on all the floors in the whole buildingOn [DATE] at 8:32AM observed V21 administering medications to R10 at the facility. On [DATE] at 8:45AM observed V21 administering medications to R28 at the facility.On [DATE] at 2:19PM observed V21 working on A hall and suites at the facility as an LPN.On [DATE] at 10:32AM observed V21 working C hall at the facility as an LPN. A document titled Licensed Practical Nurse Job description undated, documents Job summary as: The overall purpose of the Licensed Practical Nurse (LPN) position is to perform practical nursing work under the general supervision of a registered nurse. The LPN participates in the assurance of the provision of resident care services consistent with accepted standards of care and assigns duties to C.N.A's (Certified Nurse Assistant's) as appropriate. Essential Duties and Responsibilities: Performs duties and responsibilities with assigned functional area within a nursing home facility which may include, but are not limited to, any combination of the following task: Dedicated to delivering a high level of customer service, Consistent and regular attendance, provided resident care in accordance with accepted standards of practice and within the score of the LPN license, observes and reports on resident's conditions/changes and then documents in accordance with facility policies and as required by regulations, administer medication/treatment as prescribed within the LPN scope of practice, receives, transcribed and executes physician orders, implements and evaluates resident's plan of care, identifies and secures equipment and supplies. Notifies supervisor when supplies are needed, informs subordinate staff about the condition of residents and expectations/needs for the shift assigned at the beginning of each shift and receives report form subordinates throughout and at the end of each shift regarding resident's conditions, directs CNA's to assure care provided according to standards of practice and according to facility policies Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 48 of 53 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 12/23/2025 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete and regulations, rounds with CNA's prior to end of shift to assure unit is in proper order, communicates appropriate and thorough information to oncoming licensed staff so that continuity of care is provided from shift to shift, completes nursing documentation as indicated, i.e, admission paperwork, ongoing pain, documentation, etc., assures residents are as free from pain as possible and advocates for residents with physicians as needed, assures that resident's accident or incident is fully documented, investigated and reported in accordance with facility policies and per regulations, assures that each resident' attending physician and family/responsible party is promptly is notified of any significant changes in the resident's health condition, performs incidental housekeeping or maintenance tasks as may be required to maintain a clean, hazard-free environment for resident's, visitors, and staff, assists in the evaluation of subordinate staff and any necessary counsel /discipline in accordance with facility policies, ensure a safe environment is maintained in accordance with policies and regulations, performs frequent rounds throughout facility to assure that the facility is orderly, odor-free and clean, functions as a team leader/role model, has reviewed the facility abuse policy and understands employer's responsibility to enforce it, and performs other duties as assigned. Education and Experience Requirements: The Licensed Practical Nurse must have the following: A current, valid Illinois Licensed Practical Nurse licensed is required.The midnight census report dated [DATE] documents the facility has 73 residents at the facility. Event ID: Facility ID: 146045 If continuation sheet Page 49 of 53 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 12/23/2025 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 0880 Provide and implement an infection prevention and control program. 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 implement enhanced barrier precautions while providing wound care for 5 of 5 residents (R15, R3, R17, R19, and R1) observed for wound care in a sample of 44.The findings include:1. R15's Face Sheet documents an admission date of 3/17/25 with diagnoses including in part pain, type 2 diabetes, primary hypertension, and venous insufficiency.R15's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 13, indicating R15's cognition is intact.R15's Care Plan documents R15 was admitted with skin ulcer/lesion and is at risk for further skin impairment with a start date of 3/17/25 and R15 requires antibiotic therapy for wound infection with a start date of 3/18/25 with interventions including provide meds as ordered and use good infection control measure with resident.R15's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R15 has the following wounds: diabetic wound of the right calf, diabetic wound to the left calf, and a stage 4 pressure ulcer of the right heel.R15's Physician's Order Report dated 11/15/25-12/15/15 did not document an order for Enhanced Barrier Precautions.On 12/8/25 at 11:14 PM, observed V25 (Registered Nurse/RN) perform wound treatments on R15. An enhanced barrier sign was observed on the wall next to R15's door. V25 pushed the wound treatment cart into R15's room then applied gloves and was observed not wearing a gown, removed the wound dressing to right heel, then cleansed the wound with normal saline wound wash. V25 changed gloves without performing hand hygiene. V25 applied the treatment to the right heel. V25 then removed the old dressing to right calf wound and cleaned wound with normal saline wound cleanser. V25 then changed gloves without preforming hand hygiene. V25 applied the treatment on right calf and applied calcium alginate over the cream mixture. V25 then wrapped with gauze. V25 removed the wound dressing to the left calf then cleansed the wound with normal saline wound cleanser. V25 changed gloves without preforming hand hygiene. There was some bleeding from R15's left calf wound so V25 dabbed it with some gauze. Without removing gloves V25 then opened a drawer on the treatment cart and pulled out the jar of silver sulfadiazine cream. V25 didn't have a spoon to get the silver sulfadiazine cream out with so she left the room to get one with her gloves on, walked down the hall to the medication cart and got a spoon from the medication cart then returned to the room with the same gloves on. V25 then opened all 4 drawers and went through the supplies in each drawer with her gloves on looking for collagen. V25 could not find collagen so she removed her gloves, did not perform hand hygiene, and went to another unit to find collagen. V25 then returned and applied gloves then applied the treatment to the wound on R15's left calf. V25 then threw away supplies and placed the jar of silver sulfadiazine cream in drawer then removed gloves. V25 then pushed the cart out of the room back to the nurse's station. V25 did not perform hand hygiene at any time after leaving R15's room. V25 immediately starting prepping wound supplies for the next resident.2. R3's Face Sheet documents an admission date of 8/22/2018 with diagnoses including in part Parkinson's disease, type 2 diabetes, long term use of insulin, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, and diaper dermatitis.R3's MDS dated [DATE] documents a BIMS of 15, indicating R3's cognition is intact.R3's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R3 has the following wound: Skin tear to the left, lateral, upper buttock.R3's Care Plan documents a problem category of impaired skin integrity related to wound healing with risk of inadequate fluid and nutritional intake as evidenced by delayed wound healing, poor oral intake, and signs of dehydration with a start date of 2/12/25.R3's Physician Order Report dated 11/2/25-12/2/25 documents an order to place on enhanced barrier precautions per guidelines with a start date of 4/1/24 and an end date of open ended.On 12/8/25 at 11:45 PM, observed wound treatment for Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 50 of 53 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 12/23/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R3, this was a continuous observation from the previous wound treatment. R3 had a droplet and contact precautions sign on his door. V25 did not perform hand hygiene between the last resident and R3. V26 (Certified Nursing Assistant) and V25 donned gloves and a mask and V25 stated R3 is on isolation for Rhino virus so you only need to wear gloves and a mask. V26 and V25 was observed not donning a gown prior to entering R3's room. V26 and V25 then entered R3's room and V25 pushed the treatment cart into the room. V26 rolled R3 and there was no dressing on the left upper buttocks wound. V25 cleansed the wound with normal saline wound cleanser then changed gloves without performing hand hygiene. V25 applied the silver sulfadiazine cream and collagen mixture to wound, applied calcium alginate over cream mixture, then placed a dry dressing over wound. V25 then removed gloves and pushed the treatment cart out of the room. V25 then performed hand hygiene with hand sanitizer.3. R17's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part Alzheimer's disease, type 2 diabetes, protein-calorie malnutrition, pain, cellulitis of unspecified part of limb, and need for assistance with personal care.R17's MDS dated [DATE] documents a BIMS of 04, indicating R17 has severe cognitive impairment.R17's Care Plan documents R17 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility with a start date of 11/24/23.R17's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R17 has the following wounds: post-surgical wound of the right lower abdomen, arterial wound of the right 2nd toe, and skin tear wound to the right 3rd toe.R17 Physician Order Report dated 11/15/2025-12/15/2025 documents the following orders: Place on Enhanced Barrier Precautions per guidelines prn with a start date of 4/1/24 and an end date labeled open ended.On 12/9/25 at 12:09 AM, observed wound care for R17. R17 did not have an enhanced barrier sign on the door. V25 entered R17's room and took the treatment cart into the room with her then applied gloves, removed the old bandage, then cleansed wound with normal saline wound cleanser. V25 then changed gloves without performing hand hygiene. V25 applied the treatment to the wound on right side of torso. V25 removed the old bandage on right foot/toe area and cleansed with normal saline wound cleanser then reached into a multi-use gauze pack and removed some gauze squares with dirty gloves on. V25 then applied the treatment to the right foot/toe. V25 then removed gloves and pushed treatment cart out of room to the hallway. V25 was observed not wearing a gown during this observation. V25 did not perform hand hygiene after leaving the room.On 12/9/25 at 12:33 AM, V25 stated when a resident has a wound and they are on enhanced barrier precautions anyone providing care should wear a gown and gloves. V25 stated she forgot to put a gown on when she did wound treatments on R3, R15, and R17, V25 stated she should have worn a gown with each treatment. V25 stated sometimes she uses hand sanitizer between glove changes and sometimes she forgets. V25 stated she should use hand sanitizer between glove changes, before donning gloves, and after removing gloves but she doesn't always think about it and forgets. V25 stated she should have taken her dirty gloves off to go through the supplies in the drawers on the treatment cart. V25 stated she usually takes the cart into the rooms with her when she does wound treatments but will usually clean it with bleach wipes after she leaves the room, but she forgot to do that tonight.4. R19's Face Sheet documents an admission date of 9/26/25 with diagnoses including in part cellulitis of right lower limb, weakness, depression, and other specified hearing loss bilateral.R19's MDS dated [DATE] documents a BIMS of 07, indicating R19 has severe cognitive impairment.R19's Care plan documents that R19 has impaired skin integrity related to venous insufficiency and R19 has pain/risk for pain with a start date of 9/26/25 with documented interventions including administer medications, monitor and record effectiveness and report adverse side effects.R19's Wound Evaluation and Management Summary Report dated 12/10/25 documents that R19 has the following wounds: Venous wound of the right leg, skin tear of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 51 of 53 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 12/23/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the right dorsal foot, arterial wound of the right ankle, non-pressure wound of the right medial foot, and skin tear to the right, posterior ankle.R19's Physician Order Report dated 11/15/2025-12/15/2025 did not document an order for Enhanced Barrier Precautions.On 12/08/25 at 11:41 PM, observed V37 (License Practical Nurse) going to do wound treatment on R19. There was no enhanced barrier sign observed on R19's door and no personal protective equipment observed outside of R19's door. V37 stated that she didn't have all the treatment supplies she needed to perform R19's treatment. V37 stated she needed some wound cleanser and had to try to find some collagen powder for the treatment. At 11:48PM V37 knocked on R19's door and R19 was asleep in her bed, she woke R19 up and told her she was going to do her treatment. V37 took her treatment cart into the room. V37 performed hand hygiene and then donned gloves. V37 then placed a bed pad under R19's right leg. V37 then took a pair of scissors and started to cut the bandage off the right leg which had large amount of drainage coming through the dressing, this surveyor did not observe V37 clean scissors prior to use. V37 placed the scissors on the bed pad next to the right foot as she removed the bandage. V37 removed all the bandage which had a large amount of drainage to the entire bandage which she placed in the trash bag, she removed her gloves and performed hand hygiene, and then she picked up the scissors and placed them on the top of the treatment cart. V37 never cleaned the scissors. V37 then performed the treatments to R19's wounds. While applying the treatment to R19's wounds, V37 then took her scissors which had not been cleaned and started to cut the rope (Fiber) calcium alginate with the dirty scissor then placing the fibers to the wound bed on the right foot and the back of the ankle area and to the top of lower leg below the knee. V37 was observed not wearing a gown for this observation.On 12/08/25 at 12:20AM V37 (License Practical Nurse/LPN) stated R19 should be on enhanced barrier precautions because she has a large wound to her right leg. V37 stated R19 does not have a sign or PPE outside of her door saying that she is on enhanced barrier precautions, and she did not perform treatment like R19 was on enhanced barrier precautions because there was no sign on her door.5. R1's Face Sheet documents an admission date of 10/16/2023 with diagnoses including in part multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and other fatigue.R1's Minimum Data Set, dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R1 was orientated to person, place, time, and situation during interview.On 12/17/25 at 1:28 PM, observed V39 (Certified Nursing Assistant/CNA) and V5 (CNA) perform incontinent care on R1. V39 and V5 removed R1's (incontinent brief) and cleaned her buttocks with wipes then performed incontinent care using warm water, soap, and washcloths. V39 and V5 were observed not wearing a gown during care. There was an enhanced barrier sign on R1's door. V39 and V5 both stated they didn't know they needed to wear a gown when providing care. V39 and V5 stated they didn't know what enhanced barrier precautions meant, they didn't realize it was to protect the resident.A facility policy titled Isolation Precautions/Enhanced Barrier Precautions (EBP) dated April 1, 2024, documents under Policy: It is the policy of (name of facility) to make every effort to prevent the spread of infection in the facility. Enhanced Barrier Precautions are used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The same policy documents under Procedure: 1. EBP will be used for any resident who meets the following criteria: Chronic wounds, such as, pressure ulcer, venous stasis ulcers, diabetic ulcers, unhealed surgical wounds. 2. Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities: dressing, providing hygiene, bathing/showering, transferring, changing linens, changing briefs or assisting with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146045 If continuation sheet Page 52 of 53 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 12/23/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete toileting, indwelling medical devices care, chronic wound care. 3. Place EBP sign at entrance to the room for the resident who meet the criteria. Staff will clean their hands before entering and when leaving the room. Staff will wear gloves and a gown for High-Contact Resident Care Activities. Do not wear the same gloves and gown for the care of more than one person. If only one resident in the room requires EBP, place an EBP sign above the bed of the resident who meets the criteria as well as the entrance to the room.A facility policy titled Wound Management Program dated 1/20/2023 documents under Policy: It is the policy of (name of facility) to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions.A facility policy titled Dressings, Dry/Clean dated January 2018 documents in part; Verify that there is a physician's order for this procedure, review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs, and check the treatment record. The same document under Procedure it documents 1. Adjust bedside stand to waist level. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or open on the bed. 7. Wash and dry your hands thoroughly. 8. Put on clean gloves. Loosen tape and remove soiled dressing. 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 18. Apply the ordered dressing and secure with tape. Event ID: Facility ID: 146045 If continuation sheet Page 53 of 53