Health inspection·May 31, 2024

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 investigate and/or initiate investigations on allegations of resident to resident abuse and allegations of staff to resident abuse for three residents (R4, R6, R9) reviewed for abuse in a sample of 9. Residents Affected - Few Findings Include: 1. R4's admission Record dated 03/24/2024 documents R4 was admitted to the facility on [DATE] with diagnoses that include Unspecified systolic (congestive) heart failure, chronic obstructive pulmonary disease, essential primary hypertension, type 2 diabetes mellitus, Urinary tract infections, anemia, acquired absence of left leg above the knee. R4's MDS (Minimum Data Set) dated 03/29/24 documents R4 has a BIMS (Brief Interview for Mental Status) score of 12, which indicates a moderate cognitive impairment. On 05/28/2024 at 01:53PM, R4 stated she had an incident on 05/26/2024 with R9. R4 stated after several times of asking R9 to move, he shoved his chair back into her. R4 was observed having a small area of discoloration to her right forearm. R4 stated she reported it to V1. On 05/29/2024 at 10:00am, V1 (Administrator) stated that she did not do an investigation on a resident-to-resident allegation involving R4, because she didn't feel that it warranted one. V1 stated that R4 was threatening to call the police, so she came out to talk to her. R4 stated that she was trying to get past R9 as he was in her way. R4 stated after several times of asking R9 to move, she brushed her arm on his wheelchair. V1 stated she didn't feel like it warranted an investigation and that R4 can be problematic at times. 2. R6's admission Record dated 04/15/2024 documents R6 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, anemia in chronic kidney disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic diastolic (congestive) heart failure. R6's MDS dated [DATE], documents a BIMS (Brief Interview for Mental Status) of 12, which suggests R6 is moderately cognitively impaired. On 05/30/2024 at 10:27am, R6 stated one evening she had asked V9 (Certified Nursing Assistant/CNA) what was on the snack cart that night. R6 stated that V9 stated she had just got there and had no idea, and asked her, what did she want? R6 told V9 she wasn't sure what was on the cart, but she wanted yogurt. R6 stated that V9 screamed and cursed at her and said to R6 that you knew damn well there Page 1 of 5 145517 145517 05/31/2024 Axiom Healthcare of Mount Vernon 1700 White Street Mount Vernon, IL 62864

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wasn't yogurt on the cart anymore. R6 stated that V7 (LPN/Licensed Practical Nurse) asked V9 to leave the room. R6 stated the next day, V1 (Administrator) came to her room and asked what had taken place the night before, R6 asked V1 how she knew, and she stated someone was already waiting at her door this morning. R6 stated that she feels like all of V9's friends think that she reported her, and she did not. R6 stated that when she found out there was an investigation, she did not want to be a part of it because she doesn't want anybody to get in trouble and there are staff who have been treating her differently since this all happened. R6 commented that she told V1 she felt like a whistle blower, and we all know what happens to them, they get shot. R6 stated she did not want anyone to get in trouble, she just wanted to go back to being treated normal. Undated facility abuse investigation involving R6, documents the following findings by V1 (Administrator): On 05/23/2024 at approx 8:15am .(R6) wanted to speak to me . she also complained that she asked for a snack from the snack cart. (V9-CNA) got angry and kept asking what do you want in a mean tone of voice, (R6) said yogurt, (V9) got red faced and yelled that she doesn't have yogurt and that (V7-LPN) had to tell (V9) to leave (R6's) room. (R6) stated .(V9) and (V8-CNA) are the only ones that are always mean. The Others are only mean when (V9) is there. I told (R6) that I would talk to night shift about these issues. Also included in the investigation was the following: it is documented that R6 stated V8 (CNA) is always mean to her. There is no other documentation in this investigation that this statement was investigated any further or that an interview was done with V8. On 05/30/2024 at 02:05pm V1 denied suspending or investigating any other staff besides V9 in regards to findings of abuse investigation initiated on 05/23/2024 involving R6. On 05/29/2024 at 06:33pm, V8 (CNA) stated she had not every witnessed any verbal abuse, residents reporting verbal abuse, or she herself verbally abusing anyone. V8 stated she was interviewed in regards to abuse investigation on 05/23/2024, but that she was not investigated or suspended. 3. Facility abuse investigation initiated on 05/23/2024 involving R4 and R6 documents the following anonymous staff interviews. On 05/25/2024 at 08:00am an anonymous staff interview stated, Has heard staff tell residents that they can't have a shower when they ask for one. Has heard staff talk about leaving a resident in bed, leave someone for last, then leave them in bed for meals. On 05/29/2024 at 02:40pm V1 denied investigating the anonymous interviews any further. She stated she felt they did not warrant an investigation. A facility document titled, Abuse Prevention Program, dated 03/05/09, documents the purpose of this policy is to ensure that the facility is doing all within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. It further documents this will be done by identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identified reports of possible abuse; Making the necessary changes to prevent future occurrences; and filing accurate and timely investigative reports. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. 145517 Page 2 of 5 145517 05/31/2024 Axiom Healthcare of Mount Vernon 1700 White Street Mount Vernon, IL 62864

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 pressure ulcer treatment according to physicians orders for 1 of 1 resident (R5) reviewed for pressure ulcers in the sample of 9. Residents Affected - Few Findings include: R5's Face Sheet documented an admission Date of 1/20/24 and listed diagnoses including Diabetes Type 2, Anxiety Disorder, Depression, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Hypertension. R5's Minimum Data Set, dated [DATE] documented R5 has two Stage 2 pressure injuries which were present on admission to the facility. R5's May 2024 Physicians Order Sheet (POS) documented a 5/22/24 order to,Cleanse area to left buttock and sacrum. Pat dry well. Apply zinc barrier cream every (12 hour) shift and as needed. Cleanse right buttock, pat dry well, apply zinc barrier cream to periwound, apply calcium alginate to wound bed, and cover with dry dressing twice daily and as needed. R5's Treatment Administration Record (TAR) documented that from 5/22/24 to 5/28/24, the treatments to R5's left buttock, sacrum and right buttock were only done once daily. On 5/29/24 at 11:20am, V18, Registered Nurse, was observed providing wound care for R5. R5 was noted to have pressure ulcers to both the right buttock and the sacrum, with excoriation noted to the left buttock. On 5/30/24 at 8:30am, V2, Director of Nurses, stated when she was transcribing orders on 5/22/24 from the POS to the TAR she inadvertently wrote the wrong order on the TAR. The facility's Decibitus Ulcer/Pressure Area Policy dated January 2018 documented,4. Notify the Physician for treatment orders. Initiate the Physicians orders on the treatment sheet (TAR). 145517 Page 3 of 5 145517 05/31/2024 Axiom Healthcare of Mount Vernon 1700 White Street Mount Vernon, IL 62864

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to monitor the food intake for a resident with a history weight loss for 1 of 9 residents (R5) reviewed for weight loss in a sample of 9. Residents Affected - Few Findings include: R5's Face Sheet documented an admission Date of 1/20/24 and listed Diagnoses including Diabetes Type 2, Anxiety Disorder, Depression, Hypertenstion, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease. R5's Care Plan with an initiation date of 2/7/24 and a revision date of 5/30/24 documented a problem area, of Nutrition: (R5) Has a risk of weight loss related to sometimes preferring not to eat. At times, resident chooses to order foods on his own. R5's 2024 Weight Log documented the following weights: February: 272.5 lb (pounds), March 258lb, April 239.5lb, May 232.5lb. R5's Meal Intake Record for May 2024 contained no documentation on the following dates and times: 5/1/24 and 5/2/24, all three meals; 5/3/24 and 5/4/24, lunch; 5/6/24, breakfast; 5/8/24, supper; 5/10/24, breakfast and lunch; 5/17/24, breakfast and supper; 5/22/24, lunch; and 5/23/24, supper. On 5/28/24 at 12:35pm, V4, Certified Nursing Assistant (CNA) was observed in the dining room documenting the meal intake percentages of residents who had finished eating. V4 stated R5's meal intakes were not documented on 5/1/24 and 5/2/24 as V5, Dietary Manager, is the staff member responsible for putting the new sheets for the month in the binder, and V5 did not do that until 5/3/24. On 5/28/24 at 1:00pm, V3, CNA, stated the CNA's take turns documenting the meal intakes, but nobody is specifically assigned to the task. On 5/29/24 at 9:35am, V5 confirmed she is the staff member responsible for putting the meal intake sheets in the binder. V5 stated in late April of 2024, she had three staff members quit and she had not gotten around to putting the sheets in until 5/3/24. On 5/30/24 at 1:45pm, V2, Director of Nurses, confirmed all meal intakes are to be documented. V2 stated she was going to start assigning specific CNA's for the task of documenting meal intakes. A Meal and Supplement Consumption Documentation Policy dated October 2020 documented,It is the policy of (the facility) that all resident's intake of food and fluids will be documented every meal. 145517 Page 4 of 5 145517 05/31/2024 Axiom Healthcare of Mount Vernon 1700 White Street Mount Vernon, IL 62864

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to serve meals as per there designated schedule. This has the potential to affect all 27 residents living at the facility. Findings include: A Meal Time Policy dated June 2006 documented, Meal service begins at: Breakfast 7:00am, lunch 11:30am, Supper 5:00pm. On 5/28/24 at 11:30, lunch service was observed in the dining room. The first tray did not leave the service window until 11:55am. On 5/28/24 at 12:25pm, V5, Dietary Manager, stated breakfast is scheduled at 7:00am, lunch is scheduled at 11:30am, and supper is scheduled at 5:00pm. V5 stated, Meals are usually on time. We try not to be more than 15 minutes late. V5 stated the kitchen currently needs to hire three cross trained staff members, meaning staff who function as both Cooks and Dietary Aids. On 5/28/24 at 1:05pm,V12, Family Member of R9, stated he and his siblings visit R9 at nearly every meal. V12 stated he and his siblings have discussed the fact that all three meals are consistently served late on a daily basis. V12 stated he normally visits at lunch time. V12 stated lunch is supposed to be served at 11:30, but it is usually served from 12:15pm to 12:30pm. V12 stated it makes it difficult for him to schedule around his visits as he never knows when the food will come out, and R9 is a slow eater who has to be fed. On 5/29/24 at 9:10am, R4 was alert and oriented to person, place and time. R4 stated meals are consistently late because there is not enough kitchen staff. On 5/29/24 at 9:35am, V5 stated breakfast was 30 minutes late because she had been the only one working that morning. On 5/29/24 at 9:45am, R6 was alert and oriented to person, place and time. R6 stated all meals are late because the kitchen is short of help. On 5/30/24 at 1:45pm, V2, Director of Nurses, stated all of the facility's 27 residents eat meals from the facility kitchen. A Room Roster dated 5/29/24 documented a total of 27 residents living at the facility. 145517 Page 5 of 5