Inspection·December 19, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R27) of 2 resident reviewed for hospitalization in the sample of 24. Findings Include: R27's admission Record documented R27 is [AGE] years old with an Initial admission Date to the facility of 08/27/2021. R27's Nurse's Notes documented on 09/11/2024, that R27 was sent out to the local emergency department for an episode of choking. R27's Nurse's Notes documented on 11/11/2024, that R27 was admitted to the local hospital with a diagnosis of preseptal cellulitis. On 12/13/2024 at 10:09 A.M. V1 (Administrator) stated they do not have the bed hold / notice of discharge on R27 for dates 9/11/2024 and 11/11/2024. V1 stated that she is not sure why R27's representative was not notified of the bed hold. V1 stated that it is her expectation for the facility to notify the resident / resident representative as per the regulation. The facility policy titled Bed Hold and Return to Facility with a revision date of 09/16/2017 documented under guidelines The facility bed hold policy will be given to the resident and or resident representative at the time of a transfer from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 2 of 22 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 12/19/2024 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 0641 Ensure each resident receives an accurate assessment. 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 ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (R21) of 2 residents reviewed for accuracy of assessments in the sample of 24. Residents Affected - Few Findings Include: R21's admission Record documented R21 is [AGE] years old with an Initial admission Date to the facility of 11/08/2024. Diagnoses listed on this document included Schizophrenia, depression, unspecified dementia, essential hypertension, anxiety disorder and hyperlipidemia. R21's (name of company) Notice of PASRR (Preadmission Screening and Resident Review) Level I Outcome dated 06/04/2024, documented PASRR Level I Determination: Refer for Level II onsite. R21's (name of company) Notice of PASRR Level II Outcome dated 06/06/2024, documented PASRR Determination: level II - excluded from PASRR - Primary Neurocognitive Disorder - No LOC (loss of consciousness). R21's MDS with an Assessment Reference Date of 11/15/2024 documented this MDS as being an admission assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability .or a related condition? This question had a 0 marked to indicate the answer No. This same MDS in Section I Active Diagnoses had a checkmark under Psychiatric/Mood Disorder with an X marked for I6000 Schizophrenia, indicating this was an Active diagnosis for R21. On 12/12/2024 at 9:07 A.M. V7 (Licensed Practical Nurse / MDS) stated that she was the nurse who completed the MDS for R21 dated 11/15/2024. V7 stated that she was not aware that R21 had a Level II PASRR. V7 stated that she has only been the MDS nurse for a couple weeks and when she asked who had a Level II she was not told that R21 had one. V7 stated she knows that she has to code that on the MDS. On 12/18/2024 at 10:05 A.M. V2 (Director of Nursing / Registered Nurse) stated it is her expectation for the MDS's to be coded accurately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 3 of 22 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 12/19/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 toileting assistance to dependent residents for 1 (R33) of 12 residents reviewed for activities of daily living in the sample of 24. Residents Affected - Few Findings Include: R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnoses: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS Section GG documents that R33 is dependent on staff for toileting, hygiene, and bed mobility. Section H, Bladder and Bowel, documents that R33 always has urinary and bowel incontinence. On 12/10/24, intermittent observations were made of R33 at: 8:30AM, 11:00 AM, 12:00 PM, 2:30 PM and 3:30PM in his wheelchair. On 12/11/24, intermittent observations were made of R33 at: 8:05 am in dining room eating breakfast in his wheelchair, 8:58AM in hallway by his room in wheelchair ,9:30 am in his room in front of television, 9:51 AM in his room in front of television in his wheelchair, 10:40 AM in his room in front of television in his wheelchair, 11:05 AM in room in front of television in his wheelchair, 12:50 PM in dining room in his wheelchair with at table, 1:20 PM by his room in hallway in his wheelchair, 1:40 PM by his room in hallway in his wheelchair, 1:53 PM by room in in hallway in his wheelchair and stated that he got up at 5 am and that is the last time he went to the bathroom and was out of his chair. At 2:06 PM, R33 was taken to the dining room to play bingo still in chair, 2:47pm still in bingo and told V2 (Director of Nursing) that R33 had been in the chair since 5 AM with no peri care or repositioning, and 3:03 PM R33 was transferred by mechanical lift to bed and peri care was observed. On 12/11/2024 at 3:17 P.M., V5 CNA (Certified Nurse Assistant/CNA) and V6 (CNA) provided peri care to R33. R33 was rolled to left and the right to remove his clothes and adult brief. R33's adult brief was saturated with foul smelling, orange-brown colored urine. V6 then cleaned R33 with a perineal cleaner. V6 stated that she got R33 up around 7:00 A.M. on 12/11/2024 and did not get a chance to check or change him before she was pulled to go to the other hall and work. V5 stated that she got to work at 11:00 A.M. on 12/11/2024 and did not check him to provide incontinence care before lunch. V6 stated that the adult briefs were moisture wicking and pulled the urine away from the skin. On 12/18/24 at 11:30AM, V1 (Administrator) stated that all residents are to be checked on every two hours to offer toileting or peri care if they are incontinent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 4 of 22 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 12/19/2024 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess, treat, and implement interventions to prevent pressure ulcers for 2 of 3 (R33 and R18) residents reviewed for pressure ulcers in the sample of 24. This failure resulted in R33 developing a Stage 3 pressure ulcer to his right Ischium and R18's left heel pressure wound worsening/declining. Residents Affected - Few The Findings Include: 1. R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnosis: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS Section GG documents that R33 is dependent on staff for toileting, hygiene and bed mobility. Section M0100 of this MDS documents R33 is at risk for developing pressure ulcers/injuries and that he has unhealed pressure ulcer/injury at the time of this assessment. Section H, Bladder and Bowel, documents that R33 always has urinary and bowel incontinence. R33's Braden Scale dated 8/16/24 documents a score of 14, which indicates R33 is at high risk of skin breakdown. R33's Care Plan has a focus area with an initiation date of 7/11/24, that R33 has potential impairment to skin integrity relate to incontinence of bowel and bladder. The goal for this focus area, with an initiation date of 7/11/24, documents that R33 will maintain clean and intact skin by the review date. Documented interventions for this focus area include: Keep skin clean and dry, use lotion on dry skin PRN (as needed), pressure relief device for w/c (wheelchair) and bed, skin risk assessment: Braden Scale weekly x 4 weeks upon admission or readmission and then quarterly and PRN, and weekly skin assessment with documentation. R33's Care Plan also documents a focus area with a revision date of 7/11/24 of the resident has limited physical mobility related to Parkinson's, weakness, and arthritis. The goal, with a revision date of 11/21/24 for this focus area, is that the resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The interventions for this focus area includes: 1/2 side rails per resident request related to safety, nursing restoratives as ordered, the resident is weight bearing and up as needed with one assist. R33's Wound Assessment and Plan, with a visit date 11/4/24, documented by V24 (Nurse Practitioner) lists a left ischium Stage 3 pressure injury with an onset date of 10/21/24 for the wound that is in the Active/initial phase of treatment. The treatment order included preventative wound recommendations: air mattress and pressure reduction chair cushion, and to offload as tolerated. The same assessment also documents a right ischium Stage 3 pressure injury with an onset date of 10/17/24 with wound measurements of 2.1 cm. (centimenters) Length x 1.7cm. Width x 0.1 cm. Depth. The treatment order is for preventative wound recommendations of air mattress and pressure reduction cushion. A Wound Assessment and Plan, with a visit date of 11/19/24, documented by V24 that a right ischium Stage 3 pressure injury with an onset date of 10/17/24. Treatment order for preventative wound recommendations include an air mattress and a chair pressure reduction cushion. The same assessment also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 5 of 22 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 12/19/2024 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 documents a left ischium Stage 3 pressure injury with an onset date of 10/21/24 is healed. Treatment order for preventative wound recommendations include an air mattress and chair pressure reduction cushion. Level of Harm - Actual harm Residents Affected - Few A Wound Assessment and Plan, with a visit date of 11/26/24, documented by V24 that a right ischium Stage 3 pressure injury with an onset date of 10/17/24 is healing. Treatment order for preventative wound recommendation includes an air mattress and chair pressure reduction cushion. A Wound Assessment and Plan, with a visit date of 12/3/24, documented by V18 (Physician Assistant) that a right Stage 3 pressure injury to right Ischium with an onset date of 10/17/24 is stable with measurements of 3.3cm. Length x 2cm. Width x 0.1 cm. Depth. Treatment ordure for preventative wound recommendation includes an air mattress a chair pressure reduction cushion. On 12/12/24 at 2:30 PM, V2 (Director of Nursing) stated that the wound group that comes in weekly leaves their progress notes and orders to be filed in the chart. V2 went on to state that those are considered the physician orders and are to be carried out as noted. On 12/10/24-12/11/24, R33 was observed to be seen on a mattress that was scooped but not an air mattress. On 12/11/24 at 11:30AM, V4 (Registered Nurse) confirmed that this was not an air mattress nor did R33 have an extra pressure relieving cushion on his wheelchair seat. V4 went on to state that she has not seen a cushion in R33's chair ever and this is the scoop mattress he normally has. On 12/10/24, intermittent observations were made of R33 at: 8:30AM, 11:00 AM, 12:00 PM, 2:30 PM and 3:30PM in his wheelchair with no pressure reduction cushion in his wheelchair. On 12/11/24, intermittent observations were made of R33 at: 8:05 am in the dining room eating breakfast in his wheelchair with no pad in his chair, 8:58AM in the hallway by his room in the wheelchair with no pressure reduction pad, 9:30 am in his room in front of the television in his wheelchair with no pressure reduction pad, 9:51 AM in his room in front of television in his wheelchair with no pressure reduction pad, 10:40 AM in his room in front of television in his wheelchair with no pressure reduction pad, 11:05 AM in room in front of television in his wheelchair with no pressure reduction pad, 12:50 PM in dining room in his wheelchair with no pressure reduction pad at table, 1:20 PM by his room in hallway in his wheelchair with no pressure reduction pad, 1:40 PM by his room in hallway in his wheelchair with no pressure reduction pad, 1:53 PM by room in in hallway in his wheelchair with no pressure reduction pad stated that he was got up at 5 am and that is the last time he went to the bathroom and been out of this chair, 2:06 PM took to bingo still in chair, 2:47pm still in bingo and told V2 (Director of Nursing) that R33 had been in the chair since 5 AM with no peri care or repositioning, and 3:03 PM R33 was transferred by mechanical lift to bed and peri care was observed. On 12/17/24 at 1:00PM, V18 (Wound Physician Assistant) stated that she was not aware that R33 did not have the recommended seat cushion or the mattress to promote wound healing. V18 stated that these interventions help off load the weight and aide in wound healing. V18 stated at this time she would expect them to follow the recommendations/doctor orders. On 12/17/24 at 3:00PM, V1 (Administrator) stated that she found a gel pad that fits the wheelchair seat and they will start using that for R33 when he is sitting up in the wheelchair. 2. R18's admission Record documents an admission date to the facility of 2/28/23 with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 6 of 22 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 12/19/2024 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 including type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, type 2 diabetes mellitus with diabetic nephropathy, Parkinson's disease, and end stage renal disease. Additional diagnoses include osteomyelitis left heel dated 11/12/24. R18's MDS dated [DATE] documents R18 has a Brief Interview for Mental Status (BIMS) score of 4, which indicates R18 has severe cognitive impairment. This same MDS documents R18 required substantial/maximal assist for roll left to right, sit to lying, and lying to sit, and dependent for sit to stand and transfers, and was at risk for developing pressure ulcers. Section M, Skin Conditions, documents that R18 has 1 unstageable pressure ulcer. R18's current Care Plan documents a Focus area of (R18) has potential /actual impairment to skin integrity r/t (related to) decreased mobility, incont (incontinence) of B&B (Bowel and Bladder) dated 5/06/2024 and currently has an unstageable pressure area to left heel revision date 10/21/2024. This same focus area documents an intervention initiated on 8/15/2024 of Grape (protein) liquid (nutritional protein supplement drink) as ordered. R18's Wound Assessment and Plan dated 11/4/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured). Wound Measurement: 6.1 cm. (centimeter) Length x 1.5cm. Width x 0.2 cm. Depth Wound Bed Tissue Composition at Beginning of Visit: 80% Granulation / 20% Eschar R18's Wound Assessment and Plan dated 11/19/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured), and Wound Bed Tissue Composition at Beginning of Visit: 20% Granulation / 10% Slough /70% Eschar R18's Wound Assessment and Plan dated 11/26/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured), and Wound Bed Tissue Composition at Beginning of Visit: 10% Granulation / 90% Eschar R18's Wound Assessment and Plan dated 12/3/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured) and Wound Bed Tissue Composition at Beginning of Visit: 5% Granulation / 95% Eschar R18's Wound Assessment and Plan dated 12/10/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: 4 (F/Thk (full thickness) Exposed Underlying Structure), Wound Measurement: 6cm. Length x 1 cm. Width x 0.1 cm. Depth. Wound Bed Tissue Composition at Beginning of Visit: 5% Granulation / 95% Eschar On 12/11/2024 at 8:05 AM, V4 (Registered Nurse/RN) stated, the dietary department had been out of protein supplement for some time. V4 stated, R18 had not been getting the protein supplement for at least a few weeks, if not longer. V4 stated, R18's physician had not been notified that R18 had not been getting the ordered supplemental or to request a different protein supplement. On 12/11/24 10:42 AM, V2 (Director of Nursing/DON) stated, the facility had not had any protein supplement since 12/1/2024. V2 stated, there has been some issues in dietary and she is not sure why it had not been ordered. V2 stated, R18 had orders to receive a protein supplement and had not been receiving it since 12/1/2024 to her knowledge. V2 stated, R18 physician had not been notified that the facility had been out of protein supplement or to request a new supplement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 7 of 22 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 12/19/2024 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 On 12/17/2024 at 12:17 PM, V18 (Wound Physician Assistant) stated, she had not been notified via telephone or during her weekly rounds in the facility that R18 had not been receiving their protein supplement. V18 stated, she could not speculate, but in general, protein supplements do aid in promoting wound healing. Residents Affected - Few R18's December 2024 Physician's Order Sheet (POS) documents an order dated 11/14/24 for (High protein supplement) Liquids Sugar Free (SF) Grape take 30 milliliters (mL) by mouth twice daily with an administration time of 0800 (8:00 AM) and 1800 (6:00 PM). R18's November 2024 through December 2024 Medication Administration Record (MAR) documents the order for high protein supplement Sugar Free (SF) Grape take 30 milliliters (ml) by mouth twice daily with an administration time of 0800 (8:00 AM) and 1800 (6:00 PM). The November MAR indicated missed doses 11/5/24 through 12/12/24. The facility policy titled Skin condition Assessment & Monitoring-Pressure and Non-Pressure (revision 6/8/18) documents under Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and non-pressure skin conditions and assuring interventions are implemented. The facility policy titled Pressure Ulcer Prevention, with a revision date of 1/15/18, documents the Purpose: To prevent and treat pressure sore/pressure injuries. Guidelines: .5. Turn dependent resident approximately every two hours or as needed and position resident with a pillow or pads protecting bony prominence as indicated .9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds .10. Use pressure reducing pads in chairs (all types) to protect bony prominences for residents identified as Moderate/High/Severe risk .12. Encourage resident to maintain proper nutrition and hydration, providing supplements as ordered and necessary assistance at mealtime as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 8 of 22 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 12/19/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement treatment and services to a resident with limited range of motion to maintain or improve range of motion for 1 of 1 (R33) residents reviewed for positioning and mobility in the sample of 24. Findings Include: R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnoses: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS documents in Section GG that R33 is dependent on staff for toileting, hygiene, showering, lower body dressing, oral hygiene, toilet transfer, chair/bed transfer, roll left and right and bed mobility. Section GG0115 is coded as having impairment on both sides for upper and lower extremities. Section M, Skin Conditions, documents R33 is at risk for developing pressure ulcers/injuries and that he has unhealed pressure ulcer/injury at the time of this assessment. R33's Annual MDS dated [DATE] Section GG documents that R33 is dependent on staff for toileting, hygiene, showering, lower body dressing, oral hygiene, toilet transfer, chair/bed transfer, roll left and right and bed mobility. This same MDS Section GG0115 is coded as having impairment on both sides for upper and lower extremities. R33's care plan documents a focus area a focus area with a revision date of 7/11/24 the resident has limited physical mobility related to Parkinson's, weakness, and arthritis. The goal with a revision date of 11/21/24 for this focus area is that the resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The interventions for this focus area include: 1/2 side rails per resident request related to safety, nursing restoratives as ordered, the resident is weight bearing and up as needed with one assist. On 12/20/24 at 8:00AM, R33 was observed in his room sitting in his wheelchair with clothing that had spilled food and crumbs all over his shirt and pants. At this time his room was also cluttered with papers and trash items scattered on the floor. R33 was unable at this time to tell me the last time he had changed his clothing. On 12/11/2024 at 3:17 P.M. V5 (Certified Nurse Assistant/CNA) and V6 (CNA) provided peri care to R33. V6 then stated that R33 really needs a restorative program because he is getting stiff. On 12/12/24 at 1:30 PM, R33 was alert to person and stated that he has been up in his wheelchair since 5:00 AM without being repositioned or toileted and was ready to lay down. On 12/13/24 at 1:30PM, V25 (CNA) stated that they have not had a restorative program for two years now in this facility. V25 stated that residents do not get range of motion exercises daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 9 of 22 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 12/19/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The Restorative Nursing Program policy with a revision date of 1/4/2019 documents the Purpose: to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. This includes, but is not limited to, programs in walking/mobility, communication, dressing/grooming, eating/swallowing, transferring, med mobility, splint or brace assistance, amputation care and continence program. each resident will be screened for a restorative nursing upon admission, annually, quarterly, and with any significant change in function each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Event ID: Facility ID: 145517 If continuation sheet Page 10 of 22 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 12/19/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain communication and collaboration with an offsite dialysis center and failed to provide meals as ordered for a resident receiving dialysis for 1 (R8) of 1 residents reviewed for dialysis in the sample of 24. Residents Affected - Few Findings Include: R8's admission record documents an admission date of 4/19/22. This same document includes the following diagnosis: muscle weakness, end stage renal disease, dependence on renal dialysis. R8's care plan documents a focus area revised on 10/22/24 that R8 needs dialysis related to ESRD (end stage renal disease). The goal for this focus area with the same revision date of 10/22/24 is for R8 to have no signs or symptoms of complications from dialysis through the review date. The interventions for this focus area are as follows: Check and change dressing daily at the access site and document, do not draw blood or take blood pressure in arm with graft, encourage R8 to go to scheduled dialysis appointments, midodrine 10 milligrams as needed, monitor bruit and thrill every shift, monitor vital signs as ordered and as needed, monitor and report and signs or symptoms of infection to access site, monitor and document as needed for signs and symptoms of renal insufficiency/changes in level of consciousness/skin turgor/oral mucosa/hear and lung sounds, monitor any signs or symptoms of bleeding/hemorrhage/bacteremia/septic shock, monitor new/worsening peripheral edema, regular/no added salt diet with double protein three times a day, and work with R8 to relieve discomfort for side effects of the disease and treatment. R8's quarterly MDS (Minimum Date Set) dated 10/11/24 in Section G documents a BIMS (Brief Interview of Mental Status) of 12, indicating that she is cognitively intact. On 12/10/24 at 9:30AM, R8 stated that she no longer has a permanent dialysis access site in her arm and only has the catheter in her chest. R8 stated that only dialysis takes care of her catheter to limit any risk of infection. R8 also stated at this time that she has been ordered by her nephrologist at the dialysis center medication to take with meals about a month ago, but still has not received them. R8 stated that she does not have any type of communication log that she is aware of between the facility and the dialysis center. R8 stated occasionally they will give her things to take to/from dialysis and facility. On 12/11/24 at 10:30 AM, V2 (Director of Nursing/DON) stated that she is unaware of any order for a phosphorous binder currently. V2 stated that she has been on them in the past, but they were discontinued. V2 stated she can look into whether her nephrologist has restarted them. V2 stated that the communication between the facility and dialysis is poor and they have no system set up for regular communication. On 12/11/24 at 11:14 AM, V8 (Dialysis Registered Nurse) stated that the only time the office gets communication from the facility is when they need something from dialysis. V8 stated that the office does not send any type of flow sheet or communication back with resident on a routine basis to/from the facility/dialysis clinic. V8 stated at this time on 11/20/24 they have charted multiple attempts to call the facility to give the new order for the phosphorous binder and stated she faxed the order. V8 stated that no one has followed up to see if the order was received or is being given. On 12/12/24 at 8:45AM, V9 (Dialysis Registered Nurse) provided a copy of R8's patient note from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 11 of 22 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 12/19/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dialysis clinic that documents, R8 to start Renvela 800mg three times daily with meals, and have a bedtime snack to reduce hypoglycemia. Attempted to call nursing home several times to give orders. Faxed information, and will give report to next nurse. This patient note was documented by V8. On 12/12/24 at 10:00AM, V2 (DON) stated that yesterday the dialysis resent the patient profile sheet via fax that was dated 11/20/24 and the phosphorous binder was ordered and the physician orders are now up to date with the binders on them. The dialysis unit faxed a document titled Patient Profile Worksheet dated 11/20/24 that documents an order from the Nephrologist that stated, Ask nursing home to start Renvela 800mg po (by mouth) 3x (times) daily with meals. R8's November 2024 physician orders do not have include an order for Renvela 800 milligrams (mg) Current December 2024 physician orders have a new order written on 12/11/24 for Renvela 800mg (milligram) by mouth 3 times a day with meals and includes the diet order for regular no added salt diet with double protein three times a day. Observations on 12/12/24 at 8:30 AM were of R8 receiving one slice of bacon. R8 stated at this time that she never gets double meat portions at meals and the only snacks that she receives are things she keeps in her room to eat. Observation on 12/13/24 at 12:30PM, R8 received her lunch tray of a pork fritter with gravy, rice and mixed vegetables. At this time, V11 (cook) confirmed that R8 only received one portion of pork at that meal. V11 also confirmed at this time that R8's meal card had double protein listed on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 12 of 22 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 12/19/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day seven days a week. This failure has the potential to affect all 48 residents living in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid document dated 12/10/2024, documents 48 residents residing in the facility. Review of the nursing schedules document that no RN was on shift 4/6/2024, 5/4/2024, 5/12/2024, 6/1/2024, 6/29/2024, 6/30/24, 8/3/2024, 8/4/2024, 8/10/2024, 8/11/2024, 8/17/2024, 8/18/2024, 8/24/2024, 8/25/2024, 8/31/2024, 9/7/204, 9/8/2024, 9/21/2024, 9/22/2024, 9/23/2024, 9/25/2024, 9/26/2024, 9/27/2024, 9/29/2024, 10/1/2024, 11/3/2024, 11/17/2024. On 12/10/24 at 2:17 PM, V2 (Director of Nursing/DON) stated the facility had been having issues with having daily Registered Nurse (RN) coverage. V2 stated, work schedules dated April 1st, 2024 - December 1st, 2024, had multiple days with no 8 hours of daily RN coverage. On 12/10/2024 at 2:23 PM, V4 (Registered Nurse/RN) stated the facility had not had the services of a Registered Nurse (RN) eight hours a day, seven days a week for months. On 12/10/2024 at 2:28 PM, V1 (Administrator) stated she is aware that the facility had been struggling with the services of a Registered Nurse (RN) eight hours a day, seven days a week. The facility policy titled Personnel Policy and Procedure (September 2024) documents under Guidelines step 1 The facility operates in compliance with applicable federal, state, and local laws, regulations and codes with accepted professional standards and principals that apply to professionals. Standards for individual positions may be found with appropriate department staffing patterns in the departmental manuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 13 of 22 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 12/19/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a gradual dose reductions (GDR) for 1 (R20) of 5 residents reviewed for unnecessary medications in the sample of 24. Findings Include: R20's admission Record documented R20 was [AGE] years old with an Initial admission Date to the facility of 04/28/2023. Diagnoses listed are chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, chronic diastolic heart failure and generalized anxiety disorder. R20's Physician's Order with a date of December 2024 documented an order for lorazepam 0.5 mg (milligram) by mouth twice a day. Company Consultant Report dated 05/10/2024 documented under section titled comment, R20 has received Lorazepam 0.5 mg po BID from 10/2023. Please attempt a GDR (gradual dose reduction) to Lorazepam 0.5 mg at bedtime. Under section titled physician's response, a check mark is next to I accept the recommendation above, please implement as written signed by V22 (Nurse Practitioner) on 06/10/2024. Handwritten on the bottom of the form it states POA does not want to decrease medication, initialed by V4 (Registered Nurse/RN) and dated 6/13/2024. R20's Nurse's Note dated 06/13/2024 authored by V4 documented contacted power of attorney in regard to attempt a GDR on R20's Lorazepam. POA does not want to decrease medication. POA wants her to continue taking it as it is ordered. R20's Behavior Tracking Record for January 2024 - November 2024 documented the target behavior for tracking as No Behavior. The form has 0 in the frequency column indicating the resident is not having any behaviors. On 12/18/2024 at 10:33 A.M. V4 (RN) stated that when she called R20's family regarding the gradual dose reduction, the power of attorney did not want the reduction of the Lorazepam. V4 stated as far as she has been taught, if a family doesn't want a medication reduced, the facility does not reduce it. V4 did not notify the physician that the medication was not reduced. Company policy titled Psychotropic Medication - Gradual Dose Reduction with a revision date of 02/01/2018 documented under Gradual Dose Reductions: Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions unless clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful, or reduction is clinically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 14 of 22 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 12/19/2024 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 0760 Ensure that residents are free from significant medication errors. 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 that residents are free from significant medication errors for 1 (R20) of 4 residents reviewed for medication administration in the sample of 24. Residents Affected - Few Findings Include: R20's admission Record documented R20 was [AGE] years old with an Initial admission Date to the facility of 04/28/2023. Diagnoses listed are: chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, and chronic diastolic heart failure. R20's Nurse's Note dated 10/06/2024 authored by V2 (Director of Nursing) documented R20 returned to the facility from being in the hospital. R20 returned with orders to discontinue Eliquis due to R20 having a positive occult blood and anemia. R20's Nurse's Note dated 11/08/2024 authored by V4 (Registered Nurse/RN) documented messaged NP (Nurse Practitioner) related to Eliquis being given this month so far and it was discontinued on 10/06/2024. Corrected on medication administration record and physician order sheets. New order to obtain CBC (Complete Blood Count) on Monday. R20's MAR (Medication Administration Record) with a date of October 2024, documented that Eliquis 5 mg (milligram) by mouth twice daily was given on 10/01/2024, 10/02/2024 and 10/03/2024. On 10/04/2024, 10/05/2025 and 10/06/2024 it is documented as an H indicating that R20 was in the hospital. In the middle of the box for Eliquis it has discontinue on it and a line through the remaining of the month. R20's MAR with a date of November 2024, documented Eliquis 5 mg by mouth twice daily was given from 11/01/2024 - 11/07/2024. There is a line marked through the remainder of the box and discontinued written. On 12/18/2024 at 8:47 A.M. V3 (RN/Assistant Director of Nursing) stated that she is the staff member responsible for checking the new MAR and physician order sheets for the next month. V3 stated that she usually checks the new MAR against the old MAR to make sure the orders are correct. V3 stated that she is not sure how she missed that the Eliquis was discontinued. On 12/18/2024 at 9:00 A.M. V2 (RN/Director of Nursing) stated he was made aware of the medication error by V4 (RN). V2 stated that V4 then notified V21 (Nurse Practitioner) and received new orders for labs. V2 stated that she did not do a medication error report. V2 stated she is not sure why the medication was still in the cart, that it should have been removed when it was discontinued. V2 stated it is her expectation for staff to only give medications that they have an order for. On 12/18/2024 at 9:09 A.M. V4 (RN) stated that she was getting R20's medication ready the morning of 11/08/2024 when she realized that the Eliquis was discontinued. V4 stated that she went back to the chart and looked to make sure that there wasn't a new order for it. V4 stated she then notified V2 and V21 of the medication error. Company policy titled Medication Administration General Guidelines with no date documented under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 15 of 22 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 12/19/2024 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 0760 section titled Administration .Medications are administered in accordance with written orders of the prescriber. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 16 of 22 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 12/19/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review the facility failed to prepare food according to planned menu/recipe. This has the potential to affect all 48 residents living in the facility Residents Affected - Many Findings Include: The Week at a Glance menu documents Chicken Cordon Bleu Casserole for lunch on 12/12/24 and Sweet and Sour Pork for lunch on 12/13/24 On 12/12/24 at 12:30PM, V19 (Family Member) questioned what the standards for the food is in a long term care setting because it is poor quality here. V19 went on to state that that her concern is the food quality is low and that makes it hard for the residents to eat. On 12/12/24 at 12:42PM, V12 (Cook) stated that they did not have the chicken or the ham the recipe called for. V12 stated at this time that they used frozen luncheon style ham and just sliced it up to add to the casserole, and the chicken that was used was chunk chicken that was cooked down and not very visible in the casserole. V12 went on to state that she is unsure of how much protein was added, or if it was enough because the packages of frozen ham lunch meat did not have the packaging label with amount on the bag. V12 stated that the box the meat comes in has the nutrition facts label that was likely thrown away when they put up stock. V12 stated that she is unsure of how much chicken was added to the casserole either because she just used what was left in the bag and it was chunk pieces not chicken breasts as the recipe calls for. V12 stated that she made the recipe for 50 servings. The Chicken Cordon Bleu recipe for 50 servings calls for the following ingredients: 3 pounds 5 ounces of pasta, 16 3/4 each chicken breast (boneless/skinless 4 ounces cooked and 1/2 inch diced), 3 pounds 5 ounces of ham buffet chopped, 3 pounds 5 ounces of Swiss cheese sliced, 2 50 ounce cans of cream of chicken soup, 3 cups 2 Tablespoons of 2% milk, 2/3 cup margarine, 3 cups of bread crumbs, 1 2/3 cups grated parmesan cheese. The directions for assembling/baking the casserole is as follows: 1. Lightly spray pans. 2. [NAME] noodles in lightly salted water; drain well. 3. Layer noodles in pans; top with chicken, ham and Swiss cheese. 4. Mix soup, milk, and sour cream and spoon over noodle/meat/cheese mixture in each pan. 5. Melt margarine and sprinkle in Parmesan cheese and bread crumbs. Sprinkle evenly over the chicken mixture in each pan. 6. Bake approximately 30 minutes until bubbly and the internal temperature reaches 165 degrees Fahrenheit. On 12/13/24 at 12:15PM, V11 (Cook) stated that he had to substitute the sweet and sour pork for a pork fritter with brown gravy because they did not have the right pork and ingredients. At this time V11 stated that he often times has to substitute food items due to not having the correct ingredients available. The Long Term Care Application for Medicare and Medicaid dated 12/10/24, documents that 48 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 17 of 22 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 12/19/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 48 residents living in the facility. Residents Affected - Many Findings Include: On 12/10/24 at 7:50AM, during the initial tour of the kitchen the following concerns were noted: The back door was propped open with no screen in place. The kitchen window was open. The window had a screen but the screen had holes in it allowing anything from the outside in. The refrigerator in the store room had a dried spilled puddle that was brown under a bottle of worcestershire sauce that only had loose plastic wrap as a lid and was laying on its side. Milk with a date of 11/10/24 was in the refrigerator crisper drawer in the store room refrigerator. Cups with a clear milky liquid were on the bottom shelf in the door not dated or labeled. Spilled pink puddles were dried on the bottom shelf of the refrigerator. Dried spilled splatters that were yellow in color were on various items inside the refrigerator door in the store room. Temperature logs hanging on the refrigerator were from November 2024 and not filled in for every day of the month. A Bulk sugar bag was open and just rolled up, not secured or in an airtight container. On 12/10/24 at 10:30AM, a cooler was found in the kitchen next to the stove that had cloudy water (no ice) with two bags of diced chicken and a bag of ravioli floating in it. At this time V12 (Cook) stated that she has not used the cooler since she started working her on 11/26/24. On 12/10/24 at 12:30PM, V1 (Administrator) stated that the stationary refrigerator went down on 11/28/24 and the beverage portable cooler was used during this time the refrigerator had to be serviced. V1 went on to state that the door should be closed to kitchen to prevent any rodents or insects. On 12/10/24 at 9:00AM, V1 (Administrator) stated that she had seen the non labeled cups in the refrigerator door last week and wondered what was in them, and that she expects the refrigerators to be wiped down and clean/sanitary. The Food Storage policy dated 2020 documents the Guidelines: Food shall be stored on shelves in a clean, dry area free from contaminates. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 18 of 22 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 12/19/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete the date by which it should be sold, consumed, or discarded .discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration . The Long Term Care Application for Medicare and Medicaid dated 12/10/24, documents that 48 residents reside in the facility. Event ID: Facility ID: 145517 If continuation sheet Page 19 of 22 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 12/19/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This has the potential to affect all 48 residents residing in the facility. Residents Affected - Many Findings Include: On 12/12/24 at 9:00 AM, V1 (Administrator) stated she is not able to provide any documentation of minutes or attendance sheets for the facility's quarterly QAPI meetings for January 2024 and April 2024. V1 further stated her employment in the administration role at this facility began in July 2024 and she is not aware if a meeting had been held. During the survey, a review of facility records revealed no documentation quarterly QAPI meetings were held in January 2024 and July 2024. No meeting minutes or attendance sheets were found. The facility was unable to provide reproducible evidence QAPI meetings had been scheduled or occurred. The facility's QAPI Plan revised on 10/24/2022, documents under Standards Committee shall meet at least quarterly to assure activities are performed and identified problems have correction actions taken or an appropriate action plan is developed as indicated. Minutes, related reports, and attendance of the Committee members shall be maintained on file in the Administrator ' s office. The Long-Term Care Facility application for Medicare and Medicaid dated 12/10/2024, documents 48 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 20 of 22 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 12/19/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to follow infection control protocol per current standards of practice for 2 of 2 residents (R33 and R197) reviewed for infection control practices in the sample of 24. Residents Affected - Few Findings Include: 1. R197's admission Record documented R197 is [AGE] years old with an Initial admission Date to the facility of 11/25/2024. Diagnoses listed on this document included presence of urogenital implants, colostomy status, neurogenic bowel, bladder - neck obstruction, paraplegia, pressure ulcer of sacral region, right hip, right buttock, left buttock, and personal history of transient ischemic attack. R197's Physician Orders with a date of December 2024 document an order for #16 Fr urinary catheter with 5 cc (cubic centimeters) bulb. There is also an order for coccyx pressure injury, loosely pack with gauze moistened with Dakins half strength solution. Cover with calcium alginate and dry dressing daily and as needed. Left hip pressure injury, cleanse wound with normal saline, apply alginate to wound bed and cover with dry dressing daily. Left ischium loosely pack with gauze moistened with Dakins half strength solution. Cover with calcium alginate and dry clean dressing daily and as needed. Right ischium loosely pack with gauze moistened with Dakins half solution. Cover with calcium alginate and a dry dressing daily and as needed. On the initial tour of the facility on 12/10/2024 beginning at 8:30 AM, R197 did not have an enhanced barrier precaution sign outside of his door. On 12/10/2024 a Matrix for Providers (Form CMS 802) was provided by the facility. R197 had a check mark next to pressure ulcer and indwelling catheter. There was no mark under transmission-based precautions. On 12/12/2024 at 2:27 P.M. V3 (Registered Nurse (RN)/Assistant Director of Nursing) brought equipment into room without PPE (Personal Protective Equipment) on to do wound treatments. Neither V25 (Certified Nurse Aide/CNA) nor V3 placed PPE on to come into the room to do wound care. V8 rolled R197 to the right and V3 removed the old dressings. Old dressings had moderate amount of drainage noted. V3 then discarded her gloves, sanitized and put new gloves on. V3 then cleansed the first wound and placed new dressing on,discarded gloves, sanitized hands and put new gloves on. V3 then cleansed the second wound and placed new dressing on, discarded gloves, sanitized hands and placed new gloves on. V3 repeated this process for the other three wounds. V3 then sanitized her hands and exited the room. On 12/18/2024 at 3:13 P.M. V3 stated she did not realize that R197 should have been on enhanced barrier precautions. V3 stated R197 was not on any type of isolation on the day she did the treatment. On 12/12/2024 at 3:00 P.M. V2 stated that R197 should be on enhanced barrier precautions because he has open wounds and a suprapubic catheter. On 12/12/2024 at 4:00 P.M. V2 stated that R197 was now on enhanced barrier precautions. Company policy titled Enhanced Barrier Precautions with a revision date of 05/07/2024 documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 21 of 22 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 12/19/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm EBP (Enhanced Barrier Precautions) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: Chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Residents Affected - Few 2. R33 admission Record documented R33 is [AGE] years old with an Initial admission Date to the facility of 07/12/2022. Diagnoses listed on this document include parkinsonism, type 2 diabetes mellitus, dementia, and essential hypertension. On 12/11/2024 at 3:00 P.M. V5 (CNA) and V6 (CNA) and V4 (RN) - went into R33's room to provide perineal care and wound treatment. While V5 and V6 were transferring R33 in bed, he started to cough. V6 lifted his head up and he coughed out thick yellow mucous. V4 then looked at R33 and asked him to continue to cough. V4 then went to look at the suction machine and there was no canister or tubing on the suction machine. V4 left the room to go get the proper supplies needed to suction R33. V4 came back a few minutes later and attached the tubing, canister and yankeur. V4 turned on the suction machine on with her left hand and hand the yankeur in her right hand. The suction machine was not working correctly. V4 attempted to move the tubing around and it still would not work. V4 directed V6 to go get V1 (Administrator). V4 then realized the tubing was not connected right, with the yankeur in her right hand she went to readjust the tubing to the right spot and hit the tip of yankeur on the wall. V4 then used the same yankeur to provide oral suction to R33. V4 continued to provide oral suctioning for 3 minutes then placed the yakeur in a glove and put it on the nightstand. On 12/18/2024 at 9:48 A.M. V2 (RN /Director of Nursing) stated it is her expectation if the yankeur hits the wall or becomes contaminated the nurse should throw it away and get a new one. On 12/18/2024 at 10:31 A.M. V4 stated she was not aware that the yankeur hit the wall when she was preparing to suction R33. V4 stated that if she realized she had she would have thrown it away and gotten a new one. On 12/18/2024 at 2:29 P.M. V1 (Administrator) stated the facility does not have a policy on suctioning. V1 stated the facility follows the regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 22 of 22