Inspection·May 15, 2024

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 ensure the Physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter for 3 of 3 residents (R1, R2 and R3) reviewed for physician services in a sample of 7. Residents Affected - Few The findings include: 1. R1's admission record documents R1 was admitted to the facility on [DATE] and documents R1's primary physician as V3. The same document lists R1's diagnoses in part as unspecified systolic (congestive) heart failure, chronic obstructive pulmonary disease, Type 2 diabetes mellitus with unspecified complications, acquired absence of left leg above knee, peripheral vascular disease, and anxiety disorder. R1's MDS (Minimum Data Set) dated 4/25/24 documents that R1 has a BIMS (Brief Interview of Mental Status) of 12, indicating R1 has mild cognitive impairment. On 5/14/24 at 9:00am, V1(Administrator) said V3 (Medical Director) has not been coming to the facility to see residents for a while. V1 said he will answer calls when needed after hours, when the Nurse Practitioner is not working. V1 said the only progress notes from visits by V3 she can produce for R1 is 6/7/23 and 7/21/23. V1 said there is no other physician notes in R1's chart. On 5/14/24 at 1:30pm, R1 said she has been seen several times by V4 (Nurse Practitioner). R1 said that she usually sees her once a week but usually every other week. R1 said she has not seen V3 in a long time. R1 said she has no complaints about V4 and she is easy for nurses to get a hold of and she follows up. R1 said she likes V4 better than V3. R1 was alert and oriented to person, place and time. 2. R2's admission record documents that R2 was admitted to the facility on [DATE] and lists her primary physician as a physician that is no longer practicing at the facility. The same document notes some of R2's diagnoses as cellulitis of left lower limb, Type 2 diabetes mellitus without complications, unspecified atrial fibrillation, chronic kidney disease, stage 3 unspecified, dysphagia following cerebral infarction, essential (primary) hypertension. R2's MDS dated [DATE] documents that R2 has a BIMS of 14, indicating R2 is cognitively intact. On 5/14/24 1:00pm , V1 said the physician that is listed as R2's primary physician was the previous Medical Director and has not been here since around May 2023. V1 said that V3 is R2's primary physician and the admission record has not been updated. V1 said she can not produce any documents where R2 was seen by V3. On 5/14/24 at 2:00pm, R2 said she has not seen V3 that she knows of. R2 said she has seen the Nurse (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145517 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 05/15/2024 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)