Helia Healthcare of Energy: Fall Fractures Resident's Face - IL
The resident, identified in inspection records as R1, had been placed in a high back wheelchair. The nurse, identified as V9, told inspectors after the October 18 fall that the chair "sits too high up" for R1 and that R1 "had no core muscle control and is unable to reposition or balance herself." V9 said she had assessed R1 following the fall. What she described was not a mystery. It was a mismatch between a resident's body and a piece of equipment that staff had already recognized as wrong.
R1 fell face-forward onto the dining room floor.
An occupational therapy evaluation conducted just six days earlier, on October 12, had documented R1's condition in precise terms. R1 could sit unsupported for five seconds. She needed moderate assistance to sit at the edge of a bed. She could not sit unsupported with her feet flat on the floor and no back support. The evaluation listed impairments in balance, fine motor coordination, gross motor coordination, mobility, and strength.
That evaluation was in R1's record when she was placed in the high back wheelchair on October 18.
Emergency room records from that day show what the fall produced. Imaging of R1's facial bones revealed a left nasal bone deformity. Her left arm sustained both an ulnar fracture and an olecranon fracture, meaning she broke two bones in the same arm, one in the forearm and one at the tip of the elbow.
She had been sitting in the dining room.
The facility completed a Serious Injury Incident Report, finalized on October 24. The conclusion, as documented in the attached report titled "Final Reportable to IDPH - Fall with Fracture," was that the fall was accidental and "related to forward momentum during wheelchair movement." The facility's own investigation, in other words, attributed the fall to physics, not to the placement of a resident with five-second sitting ability into a chair her nurse had already identified as inappropriate.
Inspectors cited the facility under F0689, the federal tag covering accidents and supervision, at a level of actual harm.
Helia Healthcare of Energy's falls management policy, last revised in July 2017, states that the facility will assess and manage resident falls through prevention, investigation, and implementation of interventions. The policy existed. The occupational therapy evaluation existed. The nurse's own assessment of the wheelchair existed. R1 still fell, face-first, in the dining room, and came back from the emergency room with a broken nose and a fractured arm.
The inspection was triggered by a complaint and conducted on October 28, 2025.
What the record does not show is any documentation that the wheelchair mismatch had been flagged, escalated, or corrected before R1 fell. V9 knew the chair was wrong. The occupational therapist had measured R1's balance in seconds, not minutes. Someone placed R1 in that chair anyway, in a dining room, where she had no back support and no ability to catch herself.
She fell forward. She hit the floor with her face.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Helia Healthcare of Energy from 2025-10-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
HELIA HEALTHCARE OF ENERGY in ENERGY, IL was cited for violations during a health inspection on October 28, 2025.
The resident, identified in inspection records as R1, had been placed in a high back wheelchair.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.