Inspection·January 11, 2024

F 0686 Level of Harm - Actual harm Residents Affected - Few R3's Hospital Transfer Chart in the hospital records document an entry dated 12/17/2023, in which R3 is noted to have pressure injuries to his right and left buttock. The origination date of the pressure injuries to R3's right and left buttock were not documented and could not be determined. R3's Nursing admission Assessment, completed on 12/27/2023, with no time entered and no signature on the documentation, documents, 1 inch by 0.5 inch, stage 2 to right buttock and 1.5 inch by 1 inch, stage 2 to left buttock area. On 1/11/2024 at 12:03pm, V6 stated although her assessments were documented in inches she meant to document in centimeters for wound measurements. This would indicate the final measurements as being 1 centimeter (cm) by 0.5 cm to the right buttock and 1.5 cm by 1 cm to the left buttock. V6 also confirms she was the nursing staff who completed the Nursing admission Assessment, dated 12/27/23. R3's wound pictures from the hospital records, dated 1/07/2024 at 12:47 AM, documented a 5.5 cm by 4 cm wound to the right buttock area, and at 12:51 AM a 4 cm by 3.8 cm wound to the left buttock. These photos were taken by the hospital upon an unrelated re-admission R3 had to the hospital on 1/6/23. R3's (Facility Name) Weekly Wound Tracking, dated January 2024 with a late entry date of 1/02/2024, documented right buttock wound as stage 3, 2 cm by 3 cm, 1 cm depth, moderate drainage and odor noted and left buttock wound as stage 3, 4.6 cm by 3 cm, 1 cm in depth, moderate drainage and odor noted. This same document has an entry for 1/05/2024 with same measurements and no change in drainage and odor from 1/02/2024 documentation. R3's Physician Orders, dated from 1/01/2024 to 1/31/2024, documented the following telephone orders from V9 (Physician) dated 1/2/23: 1. cleanse area on right buttock with normal saline, pat dry. Apply calcium alginate, cover with dry dressing daily and prn (as needed). 2. Cleanse area on left buttock with normal saline. Pat dry. Apply Calcium alginate cover with dry dressing daily and prn. 3. Apply betadine to left lateral foot daily. R3's Physician Orders, dated for 12/1/23 - 12/31/23, noted no wound care orders to R3's buttocks were in place. On 1/10/24 at 10:15 AM, V5 stated she does the wound tracking for the facility. V5 stated R3's cognition varies due to being hard to communicate with, as he is Spanish speaking in nature. V5 stated R3 can understand English, but does not speak it well. V5 stated staff are able to communicate using yes/no and pointing gestures to make needs known. V5 stated all residents receive weekly skin checks by nursing staff assigned to that hall. V5 explained prior to R3's most recent hospitalization, no skin breakdown was present, although occasional redness was treated and resolved with barrier cream. V5 stated on 1/2/24, she was made aware of wounds to R3's buttocks by V7 (Certified Nurse Assistant/CNA). V5 stated that V7 reported that the 2 brown bandages to R3's buttocks smelled so bad that he had to take them off during R3's shower. V5 stated she did not view the bandages as they had been thrown away. V5 stated in reviewing R3's re-admission data to the facility on [DATE], V6 (Licensed Practical Nurse/LPN) was determined to have completed the assessment. V6 documented wounds to both buttocks, although no treatment orders were carried out or physician notification of wounds was noted. V5 stated once she had been made aware, she immediately notified V8 (Advanced Practice Registered Nurse), who made the referral to (contracted wound company). V5 stated she viewed the wounds, which were pressure in nature to both buttocks, with tan, foul smelling drainage. V5 stated it is the policy of the facility that wounds are immediately reported to the physician for treatment orders to be obtained. On 1/10/24 at 10:37 AM, V2 (Director of Nursing) stated R3 only speaks mumbled Spanish, so it's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 2 of 4 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 145517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Mount Vernon 1700 White Street Mount Vernon, IL 62864 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 0686 Level of Harm - Actual harm Residents Affected - Few hard to determine his true cognition. V2 stated R3 does not have a history of wounds and was ambulatory in the past, until recently having an overall decline starting around the end of November, where he has routinely been in and out of the hospital and started utilizing a wheelchair. V2 described R3 as being incontinent and developmentally disabled. V2 stated during R3's most recent readmission to the facility from the local hospital, it was brought to nurse's attention on 1/2/24 of R3's presence of wounds to his buttocks by V7. V2 confirmed no wound care orders, no nursing notes, and no physician notification regarding the wounds was in place prior to 1/2/24. V2 acknowledged the untimely wound evaluation, treatment and care provided to R3 upon his return to the facility, and stated a discipline form has been initiated for the nurse (V6) who completed R3's re-admission assessment to the facility on [DATE], notating the presence of wounds, but taking no further action. On 1/10/24 at 10:55 AM, V1(Administrator) stated she would expect residents that have wounds or impaired skin integrity to be evaluated with physician notification for orders and interventions implemented immediately. V1 acknowledges there was a delay in wound care treatment for R3, as R3's wound care had not begun until 1/2/24, when herself and V5 were notified of wounds present to R3. V1 stated a staff education and counseling form has been initiated. On 1/10/24 at 11:20 AM, V7 (Certified Nursing Assistant/CNA) stated he was changing R3 on 1/2/24, and noticed he had foul smelling, visibly soiled, tan/brown bandages, one to each buttock. V7 stated he cannot recall for sure what the dressings were dated. V7 stated he immediately notified V5 that R3's dressings would need changed, in which V5 then expressed she wasn't aware R3 had any wounds. V7 stated he cannot say when the wounds had formed. On 1/10/2024 at 12:15 PM, V5 stated R3 was not seen by (contracted wound company) on 1/2/2024 because the facility had not received orders for R3 to be referred until after (contracted wound company) had left the building for the week, and R3 was transported to the (name of local hospital) on 1/06/2024. On 1/10/24 at 12:26 PM, V6 (Licensed Practical Nurse/LPN) stated she was the nurse who had sent R3 to the hospital for his 12/16/23 hospitalization. V6 described R3 as being lethargic and having emesis. V6 stated she had contacted the physician who ordered R3 to be sent to the local Emergency Department for evaluation. V6 stated R3 had no wounds on his buttocks prior to being transferred to the hospital, and she can say this confidently as he is frequently incontinent during the night, in which she helps assist in his care and views his buttocks routinely. V6 stated she is a newer nurse and confirmed she was the nurse who did R3's re-admission to the facility on [DATE], in which stage 2 pressure wounds were noted to his bilateral buttocks. V6 stated she measured the wounds upon his return, also including depth. V6 stated the wounds did not have any foul odor and the tissue was red in color. V6 stated she documented her wound findings on the nursing home assessment form which is completed upon a resident's admission. V6 stated she then passed on in report the next morning the presence of R3's wounds to V2 (Director of Nursing) or V5 (LPN), stating she cannot remember which one was working. V6 stated she had not contacted the physician for wound care orders because she didn't think it was an urgent matter to disrupt the physician. V6 stated she assumed day shift would contact the physician the next day when she told them in report that R3 had wounds to his buttocks. On 1/10/24 at 1:08 PM, V5 (Licensed Practical Nurse/LPN) stated she was the staff member V6 gave report to upon R3's return from the hospital to the facility on [DATE]. V5 stated no report of R3's wounds was made to her. On 1/10/24 at 3:02 PM, V9 (Physician) stated it would be his expectation to be notified of skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 3 of 4 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 145517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Mount Vernon 1700 White Street Mount Vernon, IL 62864 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 0686 Level of Harm - Actual harm Residents Affected - Few integrity concerns or wounds immediately and have treatment promptly initiated. V9 stated if he was not notified, he would also find it acceptable if the facility notified the wound care physician directly to obtain wound care orders from them. V9 stated he cannot recall if he was notified, but would expect those correspondences to be documented. V9 agreed it is accurate to say that without treatment, a wound has the potential to significantly deteriorate from 12/27/23 - 1/2/24. R3's history of weight loss was also discussed with V9, in which V9 stated nutrition can affect wound healing or formation, but acknowledged, despite nutritional status, determining if a wound is unavoidable is difficult when there is no treatment in place to promote healing. On 1/11/24 at 7:55 AM, V8 (Advanced Practice Registered Nurse) stated she would expect for herself or V9 to be notified of wounds immediately to have interventions and treatment implemented. V8 stated she was notified of wounds present to R3 on 1/2/24, and orders were given at that time for treatment. Review of Supervisor Report of Counsel for V6, dated 1/10/2024, documented a date of occurrence as 12/27/2023, with a description of the occurrence as follows-skin assessment was not signed. No new skin report filled out, no nurse's notes were written, and no treatment orders reviewed for wounds to bottom. No documentation on 24-hour report. Counseling summary for V6 noted for education on skin protocol, how to approach new wounds, when to fill out quality assurance forms, and where to document new wounds. This document was noted to be signed and dated by V6, V1 and V2 on 1/10/24. The facility policy titled, Skin Condition Monitoring with a most recent revision date of 1/18 documented, It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities .1. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses notes and complete the QA (Quality Assurance) form for Newly Acquired Skin Condition. 2. The Nurse will then implement the following procedure: a. Notify the physician and obtain treatment order. b. The treatment order will include: 1. Type of treatment. 2. Location of area to be treated. 3. Frequency of how often treatment is to be performed. 4. How area is to be cleansed. 5. Stop date, if needed .4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 4 of 4