Health inspection·December 21, 2023

F 0677 for Assistance with Personal Care, Other Reduced Mobility, and Muscle Weakness. Level of Harm - Minimal harm or potential for actual harm R154's Care Plan with an initiation date of 12/19/23 documents R154 is usually able to perform ADLs (Activities of Daily Living) with max (maximum) hands on assist. Interventions document: Bathing/Showering: R154 is totally dependent on staff for bathing twice a week and as needed. Residents Affected - Few R154's Task List Report documents: Shower/Bathe self; Task Schedule: Tuesday and Friday. R154's GG ADL documentation sheet documents: R154 received a shower on the 12th (Tuesday) with NA (not applicable) documented for the shower and refused a shower on the 19th (Tuesday) with no other showers documented between. On 12/21/23 at 1:20 PM V20 (medical records/CNA) stated documentation of the showers would be on the GG ADL documentation sheet. She stated she did not give a shower to R154 on 12/12 (Tuesday) because he did not arrive at the facility until 2:30 PM. On 12/21/23 at 1:15 PM V11 (CNA) stated R154 refused his shower on the 12/19 (Tuesday) because his bottom hurt too much, and she asked him twice. On 12/20/23 at 12:15 PM R154 had uncombed greasy hair and was unshaven. On 12/20/23 at 12:20 PM R105 stated that her and R154 haven't had a shower since they have been at the facility. R154 did not answer any questions when asked. On 12/20/23 at 12:15 PM V21 (family) stated he is not aware of R105 or R154 receiving a shower since they have been at the facility, and he has been with them almost every day. On 12/21/23 at 12:15 PM R105 stated they (R105 and R154) have not received a shower since they have been here until yesterday (12/20) not even a washcloth. 3. R33's Face Sheet documents an admission date of 02/26/23 with diagnoses including: Chronic Obstructive Pulmonary Disease, Adult Pulmonary Langerhans Cell Histiocytosis, Alzheimer's Disease with Early Onset, Unspecified Dementia - mild - with agitation, Delusional Disorders, Acute Coronary Thrombosis not resulting in Myocardial Infarction, Refractory Angina Pectoris, Altered Mental Status, Need for Assistance with Personal Care, and Disorientation. R33's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview of Mental Status) of 3 indicating severely impaired, section GG Functional Abilities and Goals documents: OBRA/Interim Performance: tub/shower transfer (the ability to get in and out of a tub/shower) as a 4 - supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) and Shower/bathe self: the ability to bathe self, including washing, rinsing and drying self (excluding washing of back and hair) does not include transferring in/out of tub/shower as a 03 indicating Partial/moderate assistance - helper does less than half the effort, helper lifts or holds, or supports trunk or limbs and provides less than half the effort. R33's Care Plan with a date initiated of 06/09/23 documents: R33 has an ADL self-care performance deficit with intervention documented of: Bathing/Showering- R33 requires minimal assist by one staff with bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 2 of 3 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 145624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Flora 701 Shadwell Avenue Flora, IL 62839 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 On 12/18/2023, at 9:00 AM, observed R33's hair appeared greasy, not combed and generally unkempt. Level of Harm - Minimal harm or potential for actual harm R33's Task List Report documents: Shower/Bathe self max assist from one staff member with Task Schedule documented as Monday and Thursday. Residents Affected - Few The facility document titled, GG ADL Documentation documents R33's last shower was on 12/08 (Friday) with no shower documented on: 12/11, 12/14, and 12/18. The facility policy titled, Bath/Shower (review date 01/18) documents: Policy: To ensure adequate hygiene needs are met. A bath/shower is scheduled for all residents in the facility at least weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 3 of 3