Inspection·August 5, 2024

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review the facility failed to provide a sufficient number of dietay staff to ensure meals are served at the facility designated meal times. This failure has the potential to affect all 29 residents living in the facility. Findings include: The facility policy revised 6/06 for mealtimes documents breakfast is to be served at 7:00am, Lunch 11:30am, and Supper at 5:00pm. On 08/01/24 the breakfast service was observed. Service began at 7:25am, there were two dietary workers, including the V3, Dietary Manager in kitchen. At 07:35am, there were still several residents without trays. Three residents were served on Styrofoam plates, all residents had Styrofoam bowls. On 08/01/24 the lunch service was observed. Service began at 11:50am, and the first lunch trays were served. At that time there were two dietary workers in the kitchen. At 12:30pm, trays were still coming out a few at a time and people were finished with their meals while other people were still waiting. On 08/05/2024 the first lunch trays were served at 11:42am, there were three dietary workers in the kitchen including the V3, Dietary Manager. On 08/01/2024 at 10:36am, R3 who was alert to person and place stated in the morning breakfast runs a little late sometimes. On 08/01/2024 at 10:42am, R5 who was alert to person, place and time stated supper is the only meal that is on time. On 08/01/2024 at 10:46am, R6 who was alert to person, place and time stated breakfast is always late, but the other meals aren't usually on time either. On 08/01/2024 at 10:57am, V3, Dietary Manager stated she cannot keep staff, they hire people and then they usually do not pass background check. V3 stated that she interviews like crazy and then cannot get anyone to call her back. V3 stated that she uses the Styrofoam bowls because when it is just one or two staff in the kitchen it is the only way that it gets done. On 08/01/2024 at 01:35pm, V6 (Certified Nurse Assistant/CNA) stated meals are late often due to not having adequate kitchen staff. (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 4 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 08/05/2024 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)