Inspection·December 18, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many limited physical mobility related to Ataxia, with interventions to provide supportive care, assistance with mobility as needed. R2 has an alteration in musculoskeletal status related to Ataxia with interventions to educate the resident/family/caregivers on joint conservation techniques. Follow the MD orders for weight bearing status. See MD (Medical Doctor) orders and/or PT (Physical Therapy) treatment plan.On 12/17/2025 at 10:40AM, R2 was asked how her care was and R2 stated the nights are rough because they take forever to bring medications or answer call lights. R2 stated she does as much as possible by herself and she gets her showers twice a week. R2 stated she does require help with some tasks. R2 stated the night shift does not always have enough staff to take care of all of us.3.R3's document titled Transfer/Discharge Report documents an admission date of 7/7/2025 and includes diagnoses of Type 2 Diabetes, Major Depressive Disorder, Anxiety, Congestive Heart Failure, and Hypothyroidism.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R3's cognition is intact. Section GG documents R3 requires assistive device of a walker for mobility. R3 requires setup or clean up assistance for eating, oral hygiene, and toileting. R3 is dependent for showers. R3 is independent for position changes, ambulation and transfers. Section H documents R3 is occasionally incontinent of urine and always continent of bowels.R3's current Care Plan documents R3 has self-care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs (Activities of Daily Living), dated 6/6/2024 with revision date of 6/16/2024. Goal is that R3 will participate in bathing and dressing during am and pm cares for the next 90 days with revision date of 10/16/2025 and target date of 1/19/2026. Interventions include: assist with ADLs as necessary with staff assist of one. Set up at bedside, sink side, dated 6/6/2024 with revision date of 6/16/2024. On 12/17/2025 at 12:30PM, R3 was observed sitting up in her recliner in her room with call light within reach. R3 stated she sleeps in her recliner. R3 stated care was pretty good on all shifts but sometimes it takes a while for her call light to be answered. R3 stated if it takes too long and she needs help then she just walks around and finds a staff member. R3 stated sometimes the wait is the same on both shifts.On 12/17/2025 at 10:24AM, V4 CNA (Certified Nurse Assistant) stated there are 3 CNAs total today so one of the CNAs on East Hall is trying to help the other hall too. V4 stated when there are 3 CNA's they cannot get all the work done. V3 stated with 3 CNAs they work hard to get the residents repositioned and fed. V3 stated the documentation doesn't get done. V3 stated yesterday none of the showers were done because they only had 3 CNAs. V3 stated they are going to try to get some of the showers from yesterday done today. On 12/17/2025 at 11:00AM, V1 Administrator (ADM) stated staffing has been challenging with the COVID outbreak. V1 stated we have resorted the use of agency nurses as of lately. V1 stated they are not using agency staff for CNAs yet. V1 was asked to provide their staff/census ratio and V1 stated she just has a budget, and it allows 2 CNAs on the night shift. V1 stated she feels like 2 CNA's can get the work done on the night shift. V1 stated there was 3 CNAs and the Transportation CNA working the floor today.On 12/17/2025 at 11:15AM, V6 (CNA) stated she normally works the dayshift. V6 stated they always run 3-4 CNAs on the dayshift. V6 stated the night shift has been running 1-2 CNAs on the night shift and when the dayshift gets in the nightshift work is not done. V5 stated some residents are wet and the residents that require a mechanical lift are not up because 1 CNA cannot get them up alone. V5 stated it is hard on the dayshift to try to catch up and keep things done especially if there is only 3 CNAs on the dayshift. V6 stated there are times that residents have to wait 20-30 minutes to have their call lights answered. V6 stated that is way too long. V6 denied incontinence due to long wait times.On 12/17/2025 at 11:20AM, V7 (CNA) stated the dayshift normally runs 2-3 CNAS and we are lucky to get 4 CNAs. V7 stated we can't provide good care when there is only 2-3 CNA's. V7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 2 of 4 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 12/18/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated when we have 2-3 CNAs, we have a hard time changing and repositioning the residents every 2 hours. V7 stated we normally have 3 CNAs, and it is very difficult to answer call lights in a timely manner. V7 stated sometimes the residents aren't always changed by the night shift and we can tell when we get here on dayshift, but they are running so short on nights, they can't keep everyone changed. V7 stated there is usually always 2 nurses on the dayshift.On 12/17/2025 at 2:23PM, V9 (Anonymous) stated staffing is really bad. V9 stated 2 CNAs to take care of 47 residents is not ideal and is hard to take good care of them. V9 stated the call lights have to go on for a long time sometimes and we can't help it. V9 stated there are times that there is 1 CNA in the facility at night and that is impossible to get things done. V9 stated it takes 1 CNA at least 2 hours to make a round and then you just start all over again. V9 stated if you are the only CNA then while you are caring for a resident and another resident has on their call light then they have to wait until you finish with the resident you are already helping. V9 stated the nurses try to help too but they are very busy as well. V9 stated just this week there were 2 nights that after 10:30PM to 6:00AM there was only one CNA in the building on 12/14/2025 and just last night 12/16/2025 there was only 1 CNA after 12:00PM until 6:00AM. V9 was asked if residents became incontinent due to waiting on the call light for assistance. V9 stated usually not because while she makes her rounds it not only includes changing residents, but it also includes taking residents to the bathroom. The long time sometimes in between rounds does cause residents to not be changed as quickly as they would be if there were more staff to help with care. On 12/17/2025 at 2:42PM, V10, (CNA) there was only one CNA for several hours. V10 stated it is very hard and rough when there is only one CNA, and we can't provide good patient care. V10 stated the call lights have a long wait time due to low staffing. V10 stated they try to keep 2 CNAs on nights but even with 2 CNAs it is very hard but when there is only 1 it is impossible to take care of all of the residents like they should be taken care of. V10 stated she does not do any mechanical lifts unless another staff member is there to help, it takes 2 staff members to use a mechanical lift. V10 stated that she was by herself on 12/16/2025 after 12AM and on 12/14/2025 she was by herself for several hours.On 12/17/2025 at 2:50PM, V11 (CNA) stated she has not worked at the facility since October 2025, and she is an as needed employee. V11 stated when she worked there was usually 2 CNAs and 1 nurse after 10:30PM or 12:00AM. V11 stated it was rough to care for all of the residents with short staffing and call light wait times were very long at times.The document titled CNA Schedule December 2025 was provided by V1 on 12/17/2025, after request of the actual working schedule. V1 stated some of the call ins may not be reflected on the schedule due to staff being sick with COVID. The CNA's schedule reflects on 12/14/2025, there were 2 CNAs scheduled for 6PM-6AM (V10 and V12). V1 validated that V12 was off on 12/14/2025 due to illness. V1 stated V13 CNA came in and worked to help out. Requested V13's payroll information and payroll reflected V13 clocked in at 5:55PM and clocked out at 10:26PM on 12/14/2025. The document shows on 12/16/2025 there were 2 CNAs scheduled (V10 and V15) for 6PM-6AM. The document shows a line marked through 6PM and has 6PM/12AM wrote in for V15. V1 was asked about this and stated she didn't know at that time that V15 went home sick at 12AM. V1 stated she didn't try to get it covered at 12AM because she did not know that V15 was sick and left the facility. The schedule documents an average of 4 CNAs for the day shift 6AM-6PM and 2 CNAs for the night shift (6PM-6AM).On 12/17/2025 at 3: 33PM an attempt was made to reach V15 via phone without success. On 12/17/2025 at 3:15PM, V1 was asked if it was acceptable for the night shift to run with 1 CNA. V1 stated no it is not acceptable. V1 was asked if she was aware that there was only one CNA in the building just last night after midnight to 6AM and V1 stated, I was not aware of that. V1 was asked if she was aware that on Sunday 12/14/2025 there was only 1 CNA after 10:30PM, V1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145517 If continuation sheet Page 3 of 4 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 12/18/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete stated she knew a CNA came in at 6PM and stayed until 10:30PM to help out. V1 was asked if she was ok with the fact that after 10:30PM there was only 1 CNA in the facility and V1 stated well it is not what I want but we have had some sick people and soon the DON will return from illness, and she should be able to help more. V1 was asked if she gets notified when there is short staffing in the facility and V1 stated usually but I don't know why they didn't notify me last night. V1 was asked if proper care could be provided with only 1 CNA in the facility and V1 stated well, that would be hard to do. V1 was asked about facility assessment and the assessment calls for 10 CNAs for a 24-hour period and as the schedule reflects there is normally 6 CNA so is this acceptable and V1 stated no. V1 stated I just go by the budget numbers, and it shows 2 CNAs for the night shift. V1 was unsure of the census number that was used for her budget.The Facility Assessment Tool with dated 12/4/2025 documents assessment based on 46 residents (6-Dependent, 5-Assistive Device used to ambulate, and 35 in chair most of time.) Resident's Assistance with Activities of Daily Living: Independent: 3 -dressing,0 bathing, 13 transfers, 0 eating, 7 toileting, and 6 mobility. Assist of 1-2 staff: 35 dressing, 24 bathing, 25 transfers, 42 eating, 26 toileting, and 5-mobility. Dependent: 8 dressing, 22 bathing, 8 transfers, 4 eating, 13 toileting, and 35 in chair most of the time. Under Staffing Plan the total number needed for each position documents the following: Licensed Practical Nurse providing direct care: 3, Nurses' Aides: 10, Other nursing personnel 3. Event ID: Facility ID: 145517 If continuation sheet Page 4 of 4