Helia Healthcare Of Energy

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:

If continuation sheet

Printed: 04/13/2026 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

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. Resident R3's MDS dated [DATE REDACTED] documents a BIMS of 15, indicating Resident R3's cognition is intact. Resident R3's Care Plan documents Resident R3 is at risk for falls. On 11/25/25 at 2:41 PM, Resident 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. Resident 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 Resident R3 lying in bed and his call light was on the floor out of reach. 4. Resident 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. Resident R4's MDS dated [DATE REDACTED] documents a BIMS of 15, indicating Resident R4's cognition is intact. Resident R4's Care Plan documents Resident R4 is at risk for falls. On 11/26/25 at 9:45 AM, observed one of Resident 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 Resident R4. Resident 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. Resident 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. Resident R7's MDS dated [DATE REDACTED] documents a BIMS of 8, indicating Resident R7's cognition is moderately impaired. On 11/25/25 at 10:44 AM, Resident 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 Resident 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, Resident 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. Resident 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, Resident 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. Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident R7 to stop and took her to her room. I asked Resident R7 at that time to please stop calling me names. Resident R7 proceeded to slap and scratch my face. I transferred Resident R7 to her bed. As I was leaving the room, Resident 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 Resident 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 Resident 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 Resident R7 in room and closed door x 3, returned with w/c after 3rd time, went into room with meds and Resident 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 Resident R7, per V14 V31 was not on the hall at the time of the incident.

V14 returned wheelchair immediately, Resident 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 Resident 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 Resident R7 up in her wheelchair the night prior and dumped her into her bed. V12 said she confronted V13 about his behavior towards Resident 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 Resident 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 Resident 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 Resident R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with Resident 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 Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident 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 Resident 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 Resident R7 for injuries and did not notice any redness or bruising consistent with the allegations. I never visually saw or spoke with Resident 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 Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident R2 reported missing money but doesn't know how much money Resident 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 Resident 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 Resident R2. Reported to: V18 (Activities Director/Assistant Administrator).

Describe actual event: stated while Resident R2 was in the hosp. (Hospital) has money missing. Individual designated to take action: V1. Summary/Findings: was found Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident 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 Resident 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 Resident R2. Reported to: V18 (Activities Director/Assistant Administrator). Describe actual event: stated while Resident R2 was in the hosp. (Hospital) has money missing. Individual designated to take action: V1. Summary/Findings: was found Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 (Resident R1) reviewed for ADL assistance in

the sample of 44.Findings include:Resident 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.Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident R1 has moderate cognitive impairment. Section GG of the dame MDS documents Resident 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.Resident R1's Physician Order Report dated 11/2/25-12/2/25 documents an order for mechanical lift for transfers dated 10/16/23.Resident R1's Care Plan documents Resident R1 is dependent for transfers, Resident 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 Resident 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 Resident R1's room to assist her with eating.On 11/26/25 at 8:28 AM, Resident R1 was lying in bed. Resident 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. Resident R1 stated she doesn't like eating in her bed, she likes going to the dining room for meals. Resident 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 Resident 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 Resident R1 up since she is a mechanical lift. V7 stated he didn't get Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident 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. Resident R19 was observed multiple times throughout the procedure grimacing, grabbing her leg, and saying ouch. Wounds extend to most of Resident 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, Resident R19 stated that there have been times when she has not gotten her treatment done to her right leg. Resident R19 stated the nurses won't do it for a couple of days. Resident 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, Resident R19 stated that she doesn't know if they put the lidocaine on her leg during her treatment or not. Resident 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. Resident R19 said that it always hurts when she gets her treatment done. Resident R19 said that she usually will get a pain pill before her treatment if she requests it. Resident 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 Resident 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 Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident R2's morning medications and she told her to go ahead and give them now. V15 stated Resident R2 refused all the morning medications but the oxybutynin but when she went to sign out that Resident R2 refused all the other medications it showed he refused

the oxybutynin as well and she couldn't change it. V15 stated Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 Resident R11 and Resident 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 Resident R11 and Resident 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 Resident R12 missing Depakote Sprinkles on 12/1/25 could be considered a significant medication error because Resident 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:

If continuation sheet

Printed: 04/13/2026 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

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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] documents that 73 residents reside in the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

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, Resident R3 and Resident 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:

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Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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 REDACTED] documents the facility has 73 residents at the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

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.

1. 18. Apply the ordered dressing and secure with tape.

Event ID:

Facility ID:

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