Inspection·March 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 2. R62's admission profile sheet documents an admission date of 2/13/25. This document includes the following diagnosis: presence of other orthopedic joint implants. Residents Affected - Some R165's admission profile sheet documents an admission date of 2/28/2025. This document includes the following diagnosis: Parkinson's disease. On 3/4/25 at 9:20 AM, R62 and R165 were observed in their room as they are roommates. R62 and R165 were both alert to person, place, and time. At this time, R165 stated that this was her second wheelchair since she was admitted and it still won't go. R165 stated, The first one was worse, but this chair isn't any better. R165 went on to state that when she voiced her concerns about this one, she was told they will maybe have to order some new chairs. R165's chair was observed to be missing a right arm rest and the seat was worn with tears in the material all along the portion where R165's legs rest. R165 stated that she was in here after she suffered a stroke and is needing rehabilitation, but she cannot propel herself in this wheelchair and that is an issue for her as she needs to do things for herself. R62 stated that she has not had an arm rest on her chair since admit. It was observed that R62's right arm rest was missing, and a screw was sticking up where R62's would have to lay her arm. R62 stated that while she hasn't scratched her arm yet, she is worried that it will happen with that screw there. On 3/4/25 at 12:30 PM, V1 (Administrator) was notified by surveyor during the lunch meal regarding R62 and R165's wheelchair concerns. V1 stated at this time that she would have maintenance look into finding new arm rests and checking to see if they have a different wheelchair for R165 immediately. V1 stated that they will check on other residents' wheelchairs to ensure they are in good condition as well. 3. R27 's admission profile sheet documents an admission date of 11/16/2024. This document includes the following diagnosis: generalized anxiety disorder, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. On 3/4/25 at 12:15 PM, R27's wheelchair was observed in the dining room to have a large chunk of the right arm rest missing. Based on observation, interview and record review, the facility failed to keep resident care areas and equipment clean and in a good state of repair for 20 (R1, R4, R7, R12, R16, R21, R22, R25, R26, R27, R31, R32, R37, R40, R50, R56, R58, R60, R62 and R165) of 20 residents reviewed for homelike environment in a sample of 66. Findings Included: 1. On 3/4/2025 at 12:01 PM, V20 (Family) stated, the windowpane in the Northwest Shower Room on the closed unit has had a crack with a hole to the outside environment the runs along the bottom of the windowpane since November 2023 and the facility is aware. On 3/4/2025 at 12:03 PM observed the windowpane in the Northwest Shower Room to have a crack on the bottom of the windowpane that is all the way through to the outside environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 2 of 18 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 03/11/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/7/2025 at 12:09 PM, V5 (Maintenance Director) stated, he had been aware of the windowpane in the Northwest shower room needing to be replaced for a long time. V5 stated, he requested through the previous owners of the facility for the whole window to be replaced but no action had been taken by the facility. V5 stated, he had not notified the current owners about the window needing to be replaced. Facility Daily Census Sheet dated 3/4/25 documented that R1, R4, R7, R12, R16, R21, R22, R25, R26, R31, R32, R37, R40, R50, R56, R58, R60 reside on the Northwest Hall of the building where the Northwest Shower Room is located. Event ID: Facility ID: 145624 If continuation sheet Page 3 of 18 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 03/11/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R24's admission profile documents an admission date to the facility of 10/18/2024. This same document includes the following diagnosis: Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Pneumonia, and Cerebral Vascular Accident. This same document lists V21 (Family Member) as the emergency contact. R24's progress notes document that on 11/10/2024 V21 was contacted via telephone and a voicemail left with an update on R24's condition. A progress note from 11/10/24 at 8:43 AM states R24 was being transferred to local hospital to be evaluated and treated. There was no documentation in R24's medical records indicating written notice was given to R24's POA of R24's transfer to the hospital on [DATE]. 3. R27's admission profile documents and admission date to the facility 4/22/2023. This same document includes the following diagnosis: adjustment disorder, unspecified dementia, Type 2 Diabetes mellitus. This same document lists V22 (Family Member) as the emergency contact. R27's progress notes document on 1/15/2025 R27 was sent to the local emergency room for evaluation post fall and was admitted and discharged back to the facility on 1/17/2025. There was no documentation in R27's medical records to indicating written was given to R27's emergency contact or R27 when R27 was sent to the hospital on 1/15/25. On 3/5/2025 at 2:05 PM, V10 (RN) stated she does not complete a written notice of transfer/discharge form with any resident upon transfer/discharge to the local hospital or mail a copy to the family. V10 stated, she is not aware of who handles this process. On 3/6/2025 at 9:00 AM, V8 (Social Service Director) stated she had not been completing written notices to residents or resident representatives of a transfer/discharge to a local hospital or sending a copy of the notice to the ombudsmen. Based on interview and record review the facility failed to notify residents and the residents' representatives in writing of the reason for transfer/discharge to the hospital and failed send a copy of the notice to the ombudsman for 3 (R12, R24, R27) of 4 residents reviewed for hospitalizations in a sample of 66. The findings include: 1. R12's admission record documented an initial admission date to the facility of 8/08/2023. This same document lists V19 (Family Member) as the Power of Attorney (POA). R12's Quarterly Minimum Data Set (MDS) dated [DATE] documents a brief mental status score (BIMS) of 6 which indicates moderate cognitively impairment. On 3/5/2025 at 2:15 PM, V6 (Registered Nurse/RN) stated she did have R12 transferred from the facility via ambulance to the hospital on 9/5/2024 and 1/14/2025 with no written notice for the reason of the transfer/discharge to R12 or R12's family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 4 of 18 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 03/11/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm On 3/7/2025 at 1:30 PM, V1 (Administrator) stated she is aware that the facility had not given written notice to the resident or resident representative for R12's transfer to the hospital on 9/2/2024 and 1/14/2025. V1 stated, she was not aware the facility had to send a copy of the notice to the ombudsmen. V1 stated, the facility does not have a policy for written notice to residents and resident representative for transfer/discharge notice to the local hospital. Residents Affected - Few The was no documentation in R12's medical records indicating written notice was given to R12's POA of R12's transfer to the hospital on 9/5/24 or 1/14/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 5 of 18 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 03/11/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed follow physician dietary orders for 2 residents (R2, R44). The facility also failed to follow their weight policy, timely acknowledge, and report a weight loss greater than 5% in one month for 1 resident (R27) of 3 residents reviewed for nutrition in a sample of 66. Residents Affected - Few Findings Include: 1. R2's admission record documents an admit date of 10/14/2024. This same document includes the following diagnosis: Hyperlipidemia, bipolar disease, and chronic obstructive pulmonary disease. R2's Quarterly Minimum Data Set (MDS) dated [DATE] Section C Documents a Brief Interview of Mental Status (BIMS) of 14, indicating he is cognitively intact. R2's current Care Plan has a focus are of: The resident has arthritis. The goal for this focus area is the resident will maintain acceptable level of comfort and mobility through the review date of 5/04/2024. Interventions for this focus area includes Encourage adequate nutrition and hydration and encourage resident to maintain weight in a normal range for height. R2's Medication Administration Record for March 2025 documents, Diet: Regular diet Regular texture, Regular/Thin consistency, DOUBLE PROTEIN AT MEALS . R2's lunch tray card lists the following diet: Regular diet, thin liquids with double protein at meals. On 3/5/25 at 12:30 PM, during the lunch meal it was observed that R2 was served three Swedish meatballs. At this time R2 stated that he only got three meatballs and usually only gets one serving of meat with his meals. On 3/6/25 at 12:15 PM, during the lunch meal it was observed R2 received one serving of Chicken Cordon Blue. On 3/5/3025 at 12:21 PM, V4 (Dietary Manager) stated, R2 did not get his double protein served to him at lunch today and he did not get the double protein at lunch yesterday. V4 stated, the kitchen did miss this. 2. R27's admission profile sheet documents an admit date of 4/22/2023. This same document includes the following diagnosis: Type 2 Diabetes Mellitus, Unspecified Dementia and Essential Hypertension. R27's current physician order sheet lists a diet order of: Controlled carbohydrate diet, Mechanical Soft, Honey Thickened liquids. R27's care plan has a focus area of: The resident has nutritional problem or potential nutritional problem. The goal is: the resident will comply with recommended diet for weight reduction daily through review date. Interventions for this focus area include explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain the consequences of refusal, obesity/malnutrition risk factors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 6 of 18 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 03/11/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R27's weights are as follows: 1/1/25 204.6 pounds, 2/3/2025 202.0 pounds, 3/3/2025 184.2 pounds and a reweigh requested by surveyor on 3/6/2025 of 189.4 pounds. There is a 6.23% weight loss in one month from 2/3/25 to 3/6/25. On 3/5/2025 at 2:20 PM, when V16 (Registered Nurse/RN) was questioned why the R27's weight loss was not communicated to the Dietitian or Physician she stated that she is unsure why R27's weight was put in by V23 (Resident Care Aide) on 3/3/25 instead of V4 (Dietary Manager). V23 did not communicate this weight loss to any kitchen or nursing staff, so no one was aware the weight loss occurred. On 3/6/2025 at 1:30 PM, V16 stated that R27's weight was 189.4 pounds which showed a weight loss, so the Registered Dietitian was notified, and a supplement was ordered with meals. A Weights policy with a revision date of 10/17/18 documents 3. a re-weight should be obtained if there is a difference of 5 pounds or greater (loss or gain) since previous recorded weight. 4. A re weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling the physician .6. Undesired or unanticipated weigh gains/loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician, Dietician and/or Dietary Manager as appropriate 3. R44's admission record documents an admission date of 12/13/2023. This same document includes the following diagnosis: depression, constipation, and congestive heart failure. R44's care plan has a focus area of having a nutritional problem or a potential for a nutritional problem. The goal is that the resident will comply with recommended diet for weight reduction daily through review date. Interventions for this problem area include, provide, and serve supplements as ordered. R44's Medication Administration Record for March 2025 documents R44 is to have, Fortified pudding one time a day due to weight loss in the afternoon for weight loss. Start date 3/1/24. R44's diet card has a diet order of regular diet, thin liquids, and fortified pudding at meals. R44's Significant Change MDS (Minimum Data Set) dated 2/20/2025 Section C has a Brief Interview of Mental Status (BIMS) of 15, indicating that she is cognitively intact. On 3/4/2025 R44 had her lunch tray delivered to her room at 1:15 PM, and there was no fortified pudding on her tray. On 3/7/2025 R44 had her lunch tray delivered to her room at 1:00 PM, and no fortified pudding was provided on her lunch tray. At this time, R44 stated that she gets the pudding every now and again, but not regularly with meals. On 3/7/2024 at 1:05 PM, V4 (Dietary Manager) confirmed that R44 did not have her pudding on the tray, and he would go get one for her right now. V4 stated that she is ordered to get fortified pudding with all meals, and this must have been missed in the kitchen when serving the trays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 7 of 18 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 03/11/2025 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter for 64 (R57, R30, R39, R43, R56, R40, R266, R52, R54, R267, R6, R8, R38, R47, R35, R50, R4, R2, R51, R33, R10, R12, R62, R29, R19, R7, R59, R36, R3, R53, R18, R55, R27, R34, R16, R17, R165, R14, R28, R9, R46, R13, R61, R48, R31, R21, R22, R60, R268, R32, R49, R269, R23, R1, R58, R45, R24, R26, R270, R5, R41, R42, R15, and R25) reviewed for physician services in the sample of 66. Residents Affected - Many Findings Include: A Medical Professionals list provided by the facility dated 3/7/25 documents 64 residents including R57, R30, R39, R43, R56, R40, R266, R52, R54, R267, R6, R8, R38, R47, R35, R50, R4, R2, R51, R33, R10, R12, R62, R29, R19, R7, R59, R36, R3, R53, R18, R55, R27, R34, R16, R17, R165, R14, R28, R9, R46, R13, R61, R48, R31, R21, R22, R60, R268, R32, R49, R269, R23, R1, R58, R45, R24, R26, R270, R5, R41, R42, R15, and R25 have V17 (Medical Director/Physician) listed as their medical doctor. On 03/07/2025 at 10:15 A.M. R34 stated he has never seen V17 in the facility. R34 stated he always gets seen by the nurse practitioner that is working with V17. R34's MDS (Minimum Data Set) dated 2/10/25 documents that R34 had a BIMS (Brief Interview for Mental Status) score of 15 indication R34 is cognitively intact. On 03/07/2025 at 8:40 A.M. V1 (Administrator) stated that V17 only comes to the building once every three months to complete the quality assurance meeting. V1 stated that he does not see the residents. V1 stated that the Nurse Practitioner is the only one who comes into the building to see the residents. V1 stated she is not sure why V17 only comes to QAPI and not rounding on the residents. On 03/07/2025 at 9:40 A.M. V2 (Registered Nurse/Director of Nursing) stated that V17 has not been to the facility to provide resident visits to any resident. V2 stated that the nurse practitioner was coming once a week to see the residents. V2 stated that she resigned a week or so ago and now there is a new nurse practitioner that is completing tele health visits for residents until the company can find a nurse practitioner to come to the facility. V2 stated that facility utilizes an app to message the nurse practitioner during the day. V2 stated that after hours there is an answering service that the facility has had no problems with. V2 stated she has never had an issue with after hours or the nurse practitioner. V2 stated she was unaware that there was a regulation that required the physician to see the resident. V2 stated she believes that V17 sees 64 of the residents in the facility. Facility undated Medical Director and Management Agreement documented Article 1 Appointment .1.2 manager understands that the function of the Facility is to provide professional medical director services to patients, and shall include, but not limited to those services set forth in Attachment A (Services). Manager is aware of the responsibilities and restrictions placed upon the operation and management of such a practice pursuant to Illinois law and regulation, and manager will be in compliance at all times with these acts and their respective regulations. Attachment A Coordinate and oversee medical care and treatment, including physician services and services of other professionals as they relate to resident care. Collaborate with Facility leadership on the supervision of compliance of attending physicians with requirements for: admission orders, timely reviews of residents' total program of care, including medications and treatments, written, signed and dated orders and progress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 8 of 18 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 03/11/2025 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 0712 notes at each visit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 9 of 18 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 03/11/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure sufficient staff were scheduled/available to provide timely care to meet residents' needs. This failure has the potential to affect all 68 residents residing in the facility. Findings Include: The Long-Term Care Facility Application for Medicare & Medicaid (Form CMS-671) dated 3/4/25 documents there are currently 68 residents living in the facility. 1. R23's admission Record documented R23 was admitted to the facility on [DATE]. Diagnoses listed are type two diabetes mellitus, unspecified asthma, supraventricular tachycardia, calculus of gallbladder, epilepsy, thyrotoxicosis, personality disorder, obstructive sleep apnea, hypokalemia, anxiety, depression, and anemia. R23's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 indicating R23 is cognitively intact. Section GG of R23's MDS documented that R23 required partial to moderate assistance for transfers and showering. R23's Care plan has a focus area of self-care deficit with a date of 12/30/2024. Interventions listed Provide assistance with ADL (activities of daily living) as needed. On 3/5/2025 at 10:35 AM, R23 stated, they do not have a nurse on her hall because they are considered the independent hall. R23 stated, it does take staff a long time to answer the call lights because they have to come from the closed unit. R23 stated, sometimes she will have to go find a nurse if a call light on her hall does not get answered soon. 2. R34's admission Record documented R34 was admitted to the facility on [DATE]. Diagnoses listed are chronic obstructive pulmonary disease, type two diabetes mellitus, morbid obesity, anemia, aortic aneurysm of unspecified site, chronic kidney disease, essential hypertension, and acute on chronic diastolic heart failure. R34's MDS dated [DATE], documented a BIMS of 15 indicating R34 is cognitively intact. Section GG of R34's MDS documented that R34 is dependent for showering, lower body dressing and putting on/off footwear. R34 requires substantial/maximal assistance for oral hygiene, upper body dressing and personal hygiene. Section GG documents that R34 is dependent for transfers and utilizes a mechanical lift. On 03/05/25 09:47 AM, R34 stated that there are times he has to wait over 30 minutes to get his call light answered. R34 stated that sometimes it all depends on who is working. R34 stated it is a big problem on night shift because they have less staff and usually only one nurse. R34 stated that staff that are working work really hard but can only do so much. 3. R43's admission Record documented R43 was admitted to the facility on [DATE]. Diagnoses listed are chronic kidney disease, cerebral palsy, critical illness polyneuropathy, anemia, and depression. R43's MDS dated [DATE], documented a BIMS of 15 indicating R43 is cognitively intact. Section GG of R43's MDS documented that R 43 was partial/ moderate assistance for bathing and upper body dressing. Section GG documents that R43 is substantial/maximal assistance for lower body dressing and putting on/off footwear. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 10 of 18 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 03/11/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R43's Care plan dated 01/09/2024 has a focus area resident is usually able to perform ADLs with max assist from staff. Interventions listed are max assist of two for transfers, max assist of two for toileting and max assist of two for turn and reposition in bed. On 03/05/2025 at 10:10 A.M. R43 stated that the staff take a long time to get to her call light. R43 stated that it is worse on night shift because they have less staff. R43 stated that there are times she waits from 30 minutes up to an hour for a call light to be answered. R43 stated the facility does not have enough certified nurse assistants to take care of them. 4. R44's admission Record documented that R44 was admitted to the facility on [DATE]. Diagnoses listed are chronic kidney disease, acute myocardial infarction, chronic systolic(congestive) heart failure, unspecified atrial fibrillation, hyperlipidemia, depression, constipation, osteoarthritis, dementia, essential hypertension, and presence of cardiac pacemaker. R44s MDS dated [DATE] documented a BIMS of 15 indicating that R44 is cognitively intact. Section GG of the same MDS documented R44 is maximal assistance for showering and taking on and off footwear. R43 is partial/moderate assistance for toileting and dressing. On 3/7/25 at 12:30 PM, R44 stated that the facility staff do not answer the call lights timely throughout the day and night. R44 stated they never get there quick enough; it can take 30 minutes to an hour. On 03/06/2025 at 8:21 A.M. V2 (Director of Nursing) stated that she is the one who completes the schedules for the nurses and certified nurse assistant. V2 stated she tries to have 5 to 6 certified nurse assistants (CNA) counting the unit aide. V2 stated that the staff break down for day shift is one certified nurse assistant and one unit aide for the locked dementia unit. V2 stated that there is a nurse on the unit from 8 a.m. to 4:30 p.m. Monday through Friday but on the weekends, they may only have a nurse for four hours during the day for the locked dementia unit. V2 stated that she tries to have 3 to 4 certified nurse assistants on the women's and men's hall. V2 stated that there are days on the schedule there are only three. V2 stated that the certified nurse assistants work 12 hours usually but there is one on day shift that works from 8 a.m. to 3:30 p.m. V2 stated that on the days that the 8 hour shift certified nurse assistant works, no one comes in after she leaves at 3:30 P.M. V2 stated that on night shift she schedules four certified nurse assistants to work for the entire building. V2 stated that on the bottom of the schedule the line that says need is the shifts that need picked where they are short. V2 stated that herself or V12 (Registered Nurse) will cover any shift that is not covered. V2 stated that the facility utilizes an agency to help cover shifts that are not able to be covered by facility staff. V2 stated that she schedules 2 nurses for the women's and men's hall and has a nurse who covers the unit from 8 a.m. until 4:30 P.M. Monday through Friday. V2 stated that after 4:30 P.M. the other nurses will pick up any care that needs to be given on the unit. V2 stated that if they cannot get another nurse to pick up the weekend shifts on the unit then the nurses who cover the other units cover that area too. V2 stated that on night shift she would like to have two full time nurses but right now they just have one who works most. V2 stated that they will have a nurse come in from 6 p.m. until 10 p.m. to help with medication pass. V2 stated that there are a few nights on the schedule that there are two nurses who work the full twelve-hour shifts. V2 stated they are trying to hire more nurses for night shift, so they always have two. V2 stated the facility is utilizing agency to help cover the cna shifts that are open. On 03/06/2025 at 9:53 P.M. V10 (Registered Nurse) stated that the facility struggles with staffing at times just like every long-term care facility that she has worked at. V10 stated that she assists with care on the unit. V10 stated that the nurses help the certified nurse assistants provide care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 11 of 18 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 03/11/2025 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 0725 to the residents. V10 stated that it is worse when they have call ins and can't get them covered. Level of Harm - Minimal harm or potential for actual harm On 03/06/2025 at 1:22 P.M. V14 (CNA) stated they have enough staff today. V14 stated that having the number of staff they do today is not typically. V14 stated that they have had short staff issues for a while now. V14 stated there have been some staff quit and the facility hasn't been able to replace them. Residents Affected - Many On 03/04/2025 at 9:30 A.M. during facility tour, the time clock was observed to have 5 sheets of white paper hanging by it. The top sheet of papers was dated 02/25/2025 and documented March Nurse Needs: sign below if you are able to help cover any of these shifts. There were 15 dates listed and no staff had signed next to them. The other papers hanging at the time clock were dated 02/25/2025 and documented March CNA Needs: Sign below if you are able to help cover any of these shifts. There were 13 shifts available for day shift and there were 60 shifts available for night shift. On the bottom of the February 2025 Day Shift CNA Schedule, there is a line with need and the following dates are listed: 02/15/2025, 02/20/2025, 02/24/2025. On the February 2025 Night Shift CNA Schedule, on the line documented as need the following dates are listed: 02/17/2025, 02/26/2025. The days that the schedule documents only two CNAs scheduled for night shift are: 02/17/2025, 02/18/2025, 02/20/2025, and 02/26/2025. The February 2025 Nurse schedule documented the following dates as having one nurse on the night shift: 02/01/2025, 02/02/2025, 02/06/2025, 02/21/2025. On 10 nights there was one nurse for 12 hours and a second nurse for the first 4 hours of the shift. The March 2025 Nurse schedule documented the following nights with one nurse on night shift: 03/01/2025, and 03/03/2025. The March 2025 CNA schedule documented the following dates as having two CNAs: 03/04/2024. Facility policy titled Personnel Policy updated on September 2024 documented under the section Policy: It is the policy of the facility to provide adequate number of staff to successfully implement resident functions to meet resident needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 12 of 18 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 03/11/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to maintain accurate records of narcotics for 1 (R15) of 6 residents reviewed for controlled substance medication in the sample of 66. Findings Include: R15's admission Record documented R15 is a [AGE] year-old with an initial admission date of 01/14/2025 to the facility. Diagnoses listed are displaced oblique fracture of right femur, multiple sclerosis, morbid obesity, symptomatic epilepsy, anemia, hyperlipidemia, chronic systolic heart failure, dementia, gastro esophageal reflux disease, and essential hypertension. R15's order summary printed on March 7, 2025, does not document an order for oxycodone. On 03/06/2025 at 9:46 A.M. Medication cart was reviewed for east south hall with V6 (Registered Nurse). Upon doing a narcotic count there was an orange pill bottle with R15's information typed on the label found in the back of the narcotic box of the medication cart. The lid on the bottle was taped shut and the number 20 was written on the top along with the date of 01/16/2025. There was no narcotic sheet in the narcotic binder to count the narcotics on. On 03/06/2025 at 9:46 A.M. V6 stated the bottle of oxycodone in the narcotic box for R15 should have a count sheet and the nurses should be counting the pills every shift. V6 stated that she is not sure why there is no narcotic sheet to count the pills. V6 stated she thinks the medication should have been destroyed or sent home with the R15's family and not just left in the medication cart. On 03/06/2025 at 10:10 A.M. V6 stated her and V2 (Director of Nursing) destroyed the oxycodone. On 03/06/2025 at 10:26 A.M. V2 (Director of Nursing) stated it is her expectation for all narcotics to have a count sheet for all narcotics in the locked medication cart. V2 stated that all medications once they are discontinued should be discarded. V2 stated that it is her expectation for staff to not leave narcotics in the cart not accounted for. On 03/06/2025 at 4:07 P.M. V2 stated that R15 never had an order for the oxycodone. V2 stated that when R15 was admitted her family brought in home medications. V2 stated that the medication should have been sent home with the family as soon as the staff realized that there was not an order for it. Facility policy titled Narcotic Controlled Substances - Counting with a revision date of 11/26/2017. Section titled Purpose: 1. To count controlled substances with a partner to verify the accuracy of the log sheets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 13 of 18 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 03/11/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure medications were securely stored for 1 (R28) of 6 residents reviewed for medication storage in the sample of 66. Findings include: R28's admission Record documented R28 with an initial admission date to the facility of 04/06/2021. Diagnoses listed include type 2 diabetes mellitus, fracture of unspecified part of neck of right femur, nontraumatic subdural hemorrhage, schizoaffective disorder, chronic kidney disease stage 3, major depressive disorder, obstructive sleep apnea, epilepsy, dementia, cognitive communication deficit, chronic systolic heart failure, and essential hypertension. R28's Physician Order dated 01/04/2025 documented an order for Lorazepam (Ativan) oral concentrate 2 milligrams/milliliter. Give 1 milliliter by mouth every 12 hours as needed for anxiety for 5 days. On 03/04/2025 at 10:15 A.M. observed medication room with V2 (Director of Nursing). There was no lock on the medication refrigerator. V2 stated they had to change the refrigerator out because it was not keeping the right temperature. Upon review of medication refrigerator there was a bottle of Lorazepam concentrate in it with R28's name on the label. V2 stated that V5 (Maintenance Director) will be in today to add a lock to it as it has Ativan in it, and it is not locked. On 03/04/2025 at 2:10 P.M. V2 stated that V5 put the lock on the fridge. V2 stated that the refrigerator in the medication room was changed out one day last week, and the lock was never put on the new one. On 03/05/25 at 09:25 AM the medication refrigerator in the medication room was observed to not have a lock on it. V2 stated that the medication refrigerator had to be changed out again last night. V2 stated that the lock should have been changed on the refrigerator. On 03/05/2025 at 9:30 A.M. V6 (Registered Nurse) stated she didn't know there was supposed to be a lock on it. V6 stated that there was not a lock on the refrigerator when she arrived at work on 03/05/2025. On 03/05/2025 at 10:00 A.M. V2 stated that it is her expectation that the medication refrigerator in the medication room be locked. Facility policy titled Medication Policy with a revision date of 07/02/2019, documented under Purpose: to ensure proper storage, labeling and expiration dates of medications, biological's, syringes, and needles. 12. Controlled Substance Storage: .12.2 After receiving controlled substances and adding to inventory, facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable law) and double locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 14 of 18 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 03/11/2025 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review the facility failed to provide therapeutic diets as ordered for 1 of 17 (R9) residents reviewed for therapeutic diets in a sample of 66. Residents Affected - Few The Findings Include: 1. R9's admission record documents an admission date of 10/28/2024. This same document includes the following diagnosis: unspecified severe dementia, depression, hypertension, and Type 2 Diabetes Mellitus. R9's current diet order on his diet card is listed as regular diet, nectar thickened liquids with notes to have small spoons with food to facilitate reduced bite size and rate of intake. Set up assist to cut up foods into bite size pieces. Plate guard used to help load utensils. R9's Medication Administrator Record for March 2025 documented R9 was to receive, Regular diet Regular texture, Nectar/Mildly thick consistency, small spoons with food to facilitate reduced bite size and rate of intake. Set up assist to cut up foods into bits size pieces. Plate guard used to help load utensils. R9's MDS (Minimum Data Set) dated 2/24/2025 Section K documents that R9 has a coughing or choking during meals or when swallowing medications. This same section documents that he is on a mechanically altered diet with a therapeutic diet ordered. R9's care plan has a focus area of having a nutritional problem or potential for a nutritional problem. The goal is that the resident will comply with recommended diet for weight reduction daily through review date of 5/29/2025. The intervention for this problem area as follows: explain and reinforce diet to the resident on the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal and to provide and serve diet as ordered. On 3/4/2025 beginning at 12:35 P.M. continuous observation was made of R9 during lunch, during that time R9 was unable to scoop food onto spoon. R9 continued dropping food on table and hands. R9 put meatballs on spoon with is hand and used both hands to put food in his mouth. The meatballs were noted to by approximately 1 inch by 1 inch in size. Food was on the plate where the opening from the plate guard was and was noted to be spilling on the table. R9 quit eating food on plate and switched to eating apples in the cup. R9 attempted to eat a meat ball again by using both hands to put it in his mouth. At 12:47 P.M. R9 took a drink of his liquids in his cup with lids. When R9 was done eating food was all over his lap. The meal card on R9's tray documented that the lunch meal for 3/4/2025 was Swedish Meatballs, Mashed Potatoes, Capri Blend Vegetables, Baked Apples and Bread and Butter. R9's meatballs were cut in half. On 3/5/2025 the planned lunch meal was chicken cordon bleu casserole, buttered peas, dinner roll/margarine, and orange sherbet per R9's meal ticket. During the lunch meal on 3/5/2025 at 12:30 PM, R9 was served his tray with the chicken cordon blue ham pieces measuring approximately 3 inches by 3 inches and the chicken was not ground but approximately 2 inch by 2 inch pieces of chicken. On 03/05/2025 at 12:45 PM, while in the Dining Room watching over R9, V1 (Administrator) stated she is not sure why R9 must have food cut up in bite size pieces. When asked if she thought the ham on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 15 of 18 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 03/11/2025 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 0808 the plate looked like bite size, V1 smiled and wouldn't answer. Level of Harm - Minimal harm or potential for actual harm On 03/05/2025 at 12:47 PM, V4 (Dietary Manager) stated the lunch meal on 3/5/2025 was cooked according to the recipe and it is served how it should have been. V4 stated the recipe did not call for the ham to be cut into a certain size piece. V4 had the recipe in hand and stated the chicken is supposed to be 1/2 inch diced and the ham is supposed to be chopped. V4 stated that the staff who delivered the lunch tray on 3/5/2025 should have cut anything smaller that did not appear to be bite sized. Residents Affected - Few On 03/06/2025 at 1:40 P.M. V15 (Speech Language Pathologist) stated that R9 is an impulsive eater and was not taking appropriate size bites during meals. V15 stated that a bite size piece should be a half an inch square. V15 stated that she educated the staff that were present that day about cutting up bite size pieces but there was no in service form completed. V15 stated that dietary will receive a sheet with the information on it. V15 stated the sheet did not specifically say what size bite size is. V15 stated that the ham in the chicken cordon bleu casserole on 3/5/25 was larger than she would have cut it. The facility recipe for the Chicken Cordon Bleu Casserole includes the following ingredients: pasta egg noodles, cooked boneless skinless chicken breast, ham chopped, Swiss cheese slices, cream of chicken soup, milk, sour cream, margarine, breadcrumbs and parmesan cheese. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 16 of 18 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 03/11/2025 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 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** 2. R45's admission profile sheet documents and admission date to the facility of 10/27/2023. This same document includes the following diagnosis: unspecified dementia, repeated falls, chronic obstructive pulmonary disease. Residents Affected - Few R45's March 2025 physician order sheet includes a treatment order for the right mid back: cleanse with wound cleanser, apply collagen and cover with bordered gauze daily and as needed. On 3/6/2025 at 10:23 AM, V12 (Infection Prevention Nurse) and V13 (Certified Nurse Assistant) completed wound care on R45 upper right shoulder. During observation, V12 donned gloves, moved the bedside table from the left side of the bed to the right side of the bed while touching an air mattress pump cord on the floor and putting her hands in her pockets. V12 then started cleaning R45's right shoulder with wound cleanser on a 4x4 gauze pad without changing her gloves or washing her hands. The facility's Infection Prevention and Control Program (revised 11/28/2017) documents under Guidelines, 14. All facility personnel are required to routinely wash hands and use appropriate barrier prevention to prevent transmission of infections. Based on observation, interview, and record review the facility failed to maintain aseptic technique while performing wound care for to 2 (R13 and R45) of 7 residents reviewed for wound care treatment in a sample of 66. Findings included: 1. R13 admission Record showed he was admitted to the facility on [DATE]. R13's admission Record documented diagnoses included: chronic venous hypertension with ulcer and inflammation of the right extremity, venous insufficiency (chronic peripheral), cellulitis of right lower limb and other specified peripheral vascular disease. R13's Physician Order Sheet (POS) dated 1/3/2025 documented an order of right, lateral anterior leg: cut (brand name) alginate dressing to fit wound then apply silver sulfadiazine cream to wound then place (brand name) alginate dressing. Cover with gauze and wrap with kerlix and change daily. right, posterior leg: cut (brand name) dressing alginate to fit wound, apply silver sulfadiazine to wound and cover would with (brand name) alginate dressing and cover with gauze and wrap with kerlix, change daily. R13's 2/17/25 Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) showed a score of 15, showing R13 was cognitively intact. On 3/6/2025 at 1:45 PM, V10 (Registered Nurse/RN) completed wound care treatment on R13's right lower leg. V10 observed removing old dressing from R13's right lower leg. V10 then laid R13's leg down on his bed comforter with no barrier. V10 then again raised R13's right leg up to clean the wound with normal saline and laid R13's right leg back down on his bed comforter with no barrier. V10 observed raising R13's right leg to apply silver sulfadiazine cream and again laid R13's leg down on his bed comforter a third time with no barrier during this wound care. On 3/6/2025 at 1:55 PM, V10 (RN) stated, she is not aware if R13 needed a barrier under his right leg during wound care treatment or if the facility Infection Control policy or procedure documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 17 of 18 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 03/11/2025 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 0880 for one. Level of Harm - Minimal harm or potential for actual harm On 03/06/2025 at 2:08 P.M. V16 (RN/Infection Prevention Nurse) stated that she would expect a barrier to be under a wound when the nurse was completing a treatment. V16 stated she would not expect a nurse to clean a wound and then place the extremity on the bed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 18 of 18