Inspection·April 2, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many isolation with bins noted outside the room with proper PPE equipment. V7 (CNA) was with V9 leaving the room and V7 had on a N95. On 4/1/2024 at 2:07PM, V9 was asked why she only had on a surgical mask and V9 stated R1 is not positive anymore and someone has not taken down the signage for droplet isolation' V9 was asked when she last received training on infection control and Covid training, V9 stated, Not too long ago it seems but I don't know for sure. On 4/1/2025 at 2:07PM, V4 (Registered Nurse/ Resident Care Coordinator) was present for conversation with V9, and stated she did not think R1 was positive for covid. V4 looked back at records and noted R1 tested positive on 3/28/2025 and was negative on 3/27/2025, which is a different date than what is present on the Infection Control Log. On 4/1/2025 at 2:10PM, V7 (CNA) was asked if she had been trained on Infection Control/Covid and V7 stated no but she had only been here a couple of weeks. V7 was asked if she had been advised to change N95 mask after caring for a Covid positive resident, V7 stated No. On 4/1/2025 at 2:45PM, V2 (Director of Nursing) was asked if she expected her staff to change PPE including an N95 mask when they leave a Covid positive room to care for other residents. In reply, V2 stated, Yes, I absolutely expect them to change PPE at the door before leaving the room. V2 was asked if she expected the staff to wear the proper PPE while caring for the Covid positive residents and V2 stated, Yes they must wear the N95's gowns, gloves, and eye protection. V2 was asked if she expected the staff to follow the signage on the door for precautions and V2 stated, Yes I do. 2. R2's admission Record documents R2 admitted to the facility on [DATE] with diagnoses of Osteoarthritis bilateral knees, hypokalemia, muscle weakness, cognitive communication deficit. R2's MDS (Minimum Data Set) dated 3/24/2025 includes a BIMS (Brief Interview for Mental Status) score of 11 suggesting moderate impairment. The Residents Infection Control and Antimicrobial Log documents, R2 tested positive for Covid on 3/26/2025 and isolated. The March 2025, Covid-19+ list documents R2's isolation will complete possibly on 4/2/2025. On 3/28/2025 at 10:30AM observed R2's room with noted droplet isolation signs with bin outside door with all necessary PPE except gloves. R2 was not in her room. Observed a roommate R7 sleeping in bed. Infection Control log documents R7 was positive for Covid on 3/16/2025. The Residents Infection Control and Antimicrobial Log documents, R7 tested positive for Covid on 3/16/2025 and isolated. The March 2025 Covid Positives list did not document when R7 was to come off of isolation. On 3/28/2025 at 10:42AM observed R2 sitting in the dining room with no mask at the dining room table. R2 stated they tested her for Covid and, she was positive. R2 stated she was not offered a mask. R2 remained in the dining room for the lunch meal with other residents present at the table. On 4/1/2025 at 12:17PM observed R2 eating lunch at a table with other residents with no mask present. On 4/1/2025 at 1:03PM, R2 was observed propelling self in wheelchair down the hallway with no mask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 2 of 6 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 04/02/2025 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 on. Level of Harm - Minimal harm or potential for actual harm 3. R3's admission Record documents an admission date of 7/28/2022 and includes diagnoses of Atherosclerotic Heart Disease, Depression, Atrioventricular Block, Hypertension Cognitive Communication Deficit, Unspecified Dementia, Anxiety. MDS (Minimum Data Set) dated 1/18/2025, BIMS (Brief Interview for Mental Status) documents resident is unable to complete due to never or rarely understood. Residents Affected - Many The Resident Infection Control and Antimicrobial Log documents R3 tested positive for Covid on 3/21/2025, and isolated. The March 2025, Covid-19+ list documented R3's isolation to be completed on 3/28/2025. On 3/28/2025 at 10:08 AM observed R3's room with signage of droplet precautions on the door with bins with PPE noted outside the door. Three residents R3, R5, and R6 were present in the room at this time. R6 who was alert to person, place, and time, stated, My roommate (pointing at R3) is the one with Covid. R3 was noted to be sitting up in her wheelchair. R3 did not have a mask on, and the curtain was not drawn. R3 was noted to be coughing several times during observation. R6 stated R3 has been eating meals in the room as well. R6 stated, They said we were far enough apart, so we are safe. R3 was not interviewable. The Resident Infection Control and Antimicrobial Log, did not document R5 or R6 had tested positive for Covid. On 3/28/2025 at 11:15AM, V2 was asked why R3 was in a room with 2 residents that are Covid negative, V2 then stated, We were told we don't separate them anymore and the reason is to avoid spreading the virus. V2 was asked what their policy reads and V2 stated I am not sure I would have to review the policy. On 3/28/2025 at 11:30PM, V1 (Administrator) was asked if their policy gave direction to cohort Covid positive residents with Covid negative residents, V1 stated she was told by the Regional Nurse that the residents don't move anymore to try to avoid the spread of Covid-19. On 3/28/2025 at 2:16 PM, V7 CNA was observed walking into R3's room with only a N95 mask on. V7 was then observed going into the resident's bathroom looking in the mirror, no observation of hand hygiene or changing of mask. V7 did not don gloves or a gown while in R3's room. V7 exited the room and went down the hall into another resident's room without changing her mask. 4. R4's admission Record includes an admission date of 4/28/2023 and includes diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Unspecified Dementia with Anxiety, Hypertension, Cognition Communication Deficit, and Hodgkin's Lymphoma. MDS (Minimum Data Set) dated 3/5/2025 includes a BIMS (Brief Interview for Mental Status) score of 13 suggesting cognitively intact. The Resident Infection Control and Antimicrobial Log documents R4 tested positive for Covid-19 on 3/24/2025 and isolated. The March 2025, Covid-19+ list documents R4's isolation will be completed on 3/31/25. On 4/1/2025 at 12:20PM, R4 was noted to be eating lunch in the dining room with no mask on and was at a table with other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 3 of 6 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 04/02/2025 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 Residents Affected - Many On 4/1/2025 at 1:25PM, R4 stated she had Covid but was doing pretty good. R4 stated she has had it a few days and still had a runny nose. R4 was asked if she stays in her room or goes out to the dining room. R4 stated, I have always gone to the dining room, and nobody has said anything. R4 was asked if she wears a mask while out in the halls. R4 stated, No, and nobody has told me I need to either. 5. On 3/28/2025 at 1:10PM the electronic health records (EHR) were reviewed for R1, R2, R3, and R4. These residents records did not include documentation that R1, R2, R3 and R4 had vital signs checked every shift after being diagnosed with Covid. On 4/1/2024 at 11:45AM, V4 (Registered Nurse/ Resident Care Coordinator) stated the vitals should be done every shift for the COVID positive residents and those that are symptomatic. V4 stated the nurses make the list, the CNA's get the vitals, then the nurses get the vitals put into PCC (Point Click Care/electronic records). V4 was asked to see the list and V4 stated, I don't have one made yet. On 3/28/2025 at 2:10PM, V5 RN (Registered Nurse) stated, When a resident test's positive we should move them, if at all possible, to a room by themselves. V5 stated we should be doing vital signs at least every shift for the residents that are positive. V5 was asked if she had vitals for her shift yet and V5 stated, 'No I have not made the list yet. V5 stated the CNA's get the vitals and we put them in. On 3/28/2025 at 2:30PM, V1 was asked about the policy on vital signs and V1 stated, 'I think we are supposed to get the vital signs on the COVID positive residents once a shift. V1 then confirmed that R1, R2, R3, and R4 did not have vital signs done every shift according the EHR. V1 stated she expects the staff to obtain vital signs every shift on the COVID positive residents. Policy titled Infection Control-Interim Covid-19 dated revised 7/24/2023 documents under Guidelines: the following information is only intended to be used as guidelines to address health care concern of Human Corona virus specifically COVID-19. This policy will address prevention, education, screening, surveillance, investigation, and reporting of persons at risk. As this is an evolving situation, frequent updates may be made to these guidelines as recommendations are released by CDC. Process Surveillance: Infection Preventionist or designee will frequently monitor staff compliance with hand hygiene and PPE practices on varied shifts. Immediate actions and education will be provided as needed when concerns noted. Education: Provide staff, residents, families and visitors with education on COVID-19, including transmission and symptoms of COVID as indicated. Educate staff on current infection control and standard precautions and proper PPE selection, use and donning/doffing as indicated. When caring for residents with suspected or confirmed SARS CO V2 infection, an N95 respirator should be worn and the N95 should be removed and discarded after the patient care encounter and a new one should be donned (out on). PPE Use in Red and Yellow Zone: HCP who enters the room of a resident with suspected or confirmed SARS-COV-2 infection should adhere to Standard Precautions and use a NIOSH- approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. PPE (Personal Protective Equipment) including N95 should be discarded and new applied between residents. In general, residents should be encouraged to wear source control if able until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation. Management and Care of Residents with Suspected or Confirmed COVID-19 Infection: The recommendations described below (e.g., resident placement, recommended PPE) apply to residents with symptoms of COVID-19 (even before results of diagnostic testing). These residents should not be cohorted with patients with confirmed SARS-COV-2 infection unless they are confirmed to have SARS-COV-2 infection through testing. Place a patient with suspected or confirmed SARS-COV-2 infection in a single room if available, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 4 of 6 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 04/02/2025 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 the door should be kept closed (if safe to do so). Monitoring and Assessment: Monitor for signs and symptoms every shift: Fever > 100 degrees Fahrenheit, cough, cold symptoms, new shortness of breath, sore throat, chills, muscle pain, headache, GI upset, nausea/vomiting, diarrhea, new loss of smell/taste. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 5 of 6 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 04/02/2025 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to designate an individual as the Infection Preventionist. This failure has the potential to affect all 44 residents living in the facility. Residents Affected - Many Findings include: On 3/28/2025 at 9:30AM, V2 (Director of Nursing/DON) was interviewed with V1 (Administrator) present. V2 was asked who the infection preventionist was in the facility and V2 stated that V4 (Resident Care Coordinator) was working on getting her certification for Infection Prevention but had not completed it yet and she takes care of the Infection Control stuff. V1 stated I have my Infection Control Preventionist Certification, but I don't use it now that I am the Administrator, I don't think I can do that. V1 stated I don't do anything with the Infection Control Program. On 4/1/2025 at 2:10PM, V4 was asked when she last had Infection Control and Covid training at this facility and V4 stated I have never had training at this facility on either one. V4 stated she has only been employed at the facility since October 2024. V4 stated she has tried to pass the Infection Preventionist certifications test but has been unable to pass. V4 stated she does most of the infection control program but has not provided staff education. V4 stated she does most of the Covid testing for the staff and residents. V4 was unsure of the policies for Infection Control and Covid. The Facility Assessment Tool dated 1/15/2025, documents under section 3.11 We have a certified Infection Control Preventionist nurse that has been trained to track infections and assist in making decisions on exposures and treatments in collaboration with the medical director and their team of nurse practitioners. The policy titled Infection Prevention and Control Program dated 12-5-2024, documents Purpose: to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing service under a contractual arrangement. Guidelines #3 documents The designated Infection Control employee and Quality Assurance Committee is responsible for monitoring the effectiveness of the program and continually improving outcomes. The facility Census Report documents on 3/28/2025 there are 44 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 6 of 6