Inspection·May 31, 2024

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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 2 of 5 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 05/31/2024 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 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). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 3 of 5 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 05/31/2024 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 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 4 of 5 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 05/31/2024 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 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 5 of 5