Inspection·April 4, 2025

F 0600 seen V19 since then. Level of Harm - Minimal harm or potential for actual harm On 4/3/25 at 3:15pm, V23 (Registered Nurse/RN), stated when she came in on 3/27/25at 6:00am, R15 had reported to her that the previous evening, V19 left R15 hanging in a mechanical lift sling during a transfer because V19 was mad at R15. V23 stated she reported the incident to V1 that morning when V1 arrived. Residents Affected - Few On 4/3/25 at 3:50pm, V1 stated she found out about the incident when she arrived for work the morning of 3/27/25. V1 stated she talked to R15 and staff about what had happened, but there was no incident report about the event as R15 told V1 he did not feel V19 had neglected or abused him. V1 stated R15 was verbally abusive to V19 and V19 left the room to de-escalate R15. V1 stated V19 has not been back to the facility as he got in an argument with another employee and V1 told him he is not welcome back. On 4/3/25 at 4:05pm, V20 (Agency RN) stated, on 3/26/25 during the 6pm to 6am shift, unsure of the time, she and V21 (CNA) were standing at the nurses' station when V19 approached, stated that R15 was, Being nitpicky about his (Mechanical lift) transfer and that he didn't want to further escalate him so V19 left the room. V20 stated within seconds, she and V21 entered the room and saw that R15 was in the mechanical lift sling, positioned several inches above the shower chair. V20 stated R15 was not injured, nor did he seem upset. V20 stated she and V21 lowered R15 into the shower chair and proceeded with his care. V20 stated V19 worked the remainder of his shift but did not go back into R15's room. V20 stated she did not notify management about what happened. On 4/3/25 at 6:00pm, V21 corroborated V20's account of the incident. V21 stated she did not notify management about the incident. V21 stated after the event, staff were re-educated on safe mechanical lift transfers. On 4/4/25 at 7:45am, V19 stated he was performing the transfer without other staff present as, That's just the way he always does it. V19 stated he had worked with R15 previously with no issues. V19 stated R15 was becoming verbally aggressive during the transfer, saying V19 wasn't doing it right, so V19 decided to calm the situation down and he would leave and get other staff to continue care. V19 stated when he left the room, R15 was already sitting in the shower chair but was still in the sling. V19 stated less than a minute elapsed between him leaving the room and other staff relieving him. V19 stated V1 later told him he could not return to the facility because, They didn't want me to get in trouble because of (R15) lying on me. He makes stuff up about staff. An Abuse Prevention and Reporting Policy dated 10/24/22 documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: Filing accurate and timely reports. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish .Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness, of a resident .including deprivation of goods and services by staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 2 of 9 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 04/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report to the Administrator an instance of staff to resident neglect for one (R15) of 15 residents reviewed for neglect in the sample of 15. Findings include: R15's Face Sheet documented an original admission date of 6/26/22 and readmission date of 5/10/24 and included diagnoses of morbid obesity, diabetes type 2, and congestive heart failure. R15's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R15 has no deficits in cognition. This MDS also documented R15 has limited range of motion in both lower extremities and is totally dependent on staff for transfers. R15's Care Plan documented a Focus Area of Resident is usually able to perform ADLs (Activities of Daily Living) with maximum assist from 2 staff initiated on 8/30/23, with a corresponding intervention also initiated on 8/30/23 of Assist to transfer resident using mechanical (lift) and 2 staff members. Explain all procedures prior to starting. Advise resident what is expected of him/her during the transfer. Reassure Resident of safety as needed. Keep hand on Resident to reassure of safety if needed. Ensure lift sheet is intact and correct size for resident. May leave lift sheet under Resident if comfort in placing/removing sheet is problematic. There were no problem areas in the Care Plan to indicate R15 reports falsehoods about staff or displays manipulative behavior. There was no documentation in R15's Nursing Progress Notes about issues with R15's 3/26/25 mechanical lift transfer as documented below. On 4/3/25 at 2:55pm, R15 was alert and oriented to person, place, and time. R15 stated on Wednesday 3/26/25 on the 6pm to 6am shift, V19 (Agency Certified Nursing Assistant/CNA) was transferring him from his wheelchair to the shower chair using a mechanical lift. R15 stated there were no other staff members present. R15 stated as the mechanical sling was moving, he was experiencing back pain and was complaining to V19 that R15 didn't feel V19 was doing the transfer correctly. R15 stated V19 was mad, threw up his hands, yelled, That's it, I quit, and walked out of the room shutting the door, leaving R15 elevated several inches away from the shower chair. R15 stated he could not reach the call light and yelled for help for about 10 minutes, until two other staff members responded and lowered him into the shower chair. R15 stated he was not injured nor emotionally traumatized by the event, as several years ago at a different facility he was dropped during a mechanical lift transfer, so nothing phases him anymore. R15 stated the following day in the afternoon, V1 (Administrator) asked him about the event, and asked him if he would be willing to work with V19 again, to which R15 stated no he would not as he didn't feel safe in his care after what happened. R15 stated he has not seen V19 since then. On 4/3/25 at 3:15pm, V23 (Registered Nurse/RN) stated when she came in on 3/27/25at 6:00am, R15 had reported to her that the previous evening, V19 left R15 hanging in a mechanical lift sling during a transfer because V19 was mad at R15. V23 stated she reported the incident to V1 that morning when V1 arrived. On 4/3/25 at 3:50pm, V1 stated she found out about the incident when she arrived for work the morning of 3/27/25. V1 stated she talked to R15 and staff about what had happened, but there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 3 of 9 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 04/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident report about the event as R15 told V1 he did not feel V19 had neglected or abused him. V1 stated R15 was verbally abusive to V19 and V19 left the room to de-escalate R15. V1 stated V19 has not been back to the facility as he got in an argument with another employee and V1 told him he is not welcome back. On 4/3/25 at 4:05pm, V20 (Agency RN) stated, on 3/26/25 during the 6pm to 6am shift, she was unsure of the time, but she and V21 (CNA) were standing at the nurses' station when V19 approached, stated that R15 was, Being nitpicky about his (Mechanical lift) transfer and that he didn't want to further escalate him so V19 left the room. V20 stated within seconds, she and V21 entered the room and saw that R15 was in the mechanical lift sling, positioned several inches above the shower chair. V20 stated R15 was not injured, nor did he seem upset. V20 stated she and V21 lowered R15 into the shower chair and proceeded with his care. V20 stated V19 worked the remainder of his shift but did not go back into R15's room. V20 stated she did not notify management about what happened. On 4/3/25 at 6:00pm, V21 corroborated V20's account of the incident. V21 stated she did not notify management about the incident. V21 stated after the event, staff were re-educated on safe mechanical lift transfers. On 4/4/25 at 7:45am, V19 stated he was performing the transfer without other staff present as, That's just the way he always does it. V19 stated he had worked with R15 previously with no issues. V19 stated R15 was becoming verbally aggressive during the transfer, saying V19 wasn't doing it right, so V19 decided to calm the situation down by leaving to get other staff to continue care. V19 stated when he left the room, R15 was already sitting in the shower chair but was still in the sling. V19 stated less than a minute elapsed between him leaving the room and other staff relieving him. V19 stated V1 later told him he could not return to the facility because, They didn't want me to get in trouble because of (R15) lying on me. He makes stuff up about staff. An Abuse Prevention and Reporting Policy dated 10/24/22 documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: Filing accurate and timely reports. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness, of a resident, including deprivation of goods and services by staff. Internal reporting requirements and identification of allegations: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the Administrator .Any allegation of abuse or any incident that results in serious bodily injury will be reported to the (state surveying agency) immediately, but not more than 2 hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. Under the section titled External Reporting documents The initial report to (state surveying agency) shall include the following information, if known at the time of the report: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated, Type of abuse reported (physical, sexual, neglect, verbal or mental abuse, misappropriation of resident property), Date, time, location and circumstances of the alleged incident, Any obvious injuries or complaints of injury, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 4 of 9 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 04/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Steps the facility has taken to protect the resident, The resident or resident's representative will also be informed of the report of an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property and that an investigation is being conducted. Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the (state surveying agency). Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated, The original allegation (note day, time, location, the specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries), A summary of facts determined during the process of the investigation, review of medical record and interview of witnesses, Conclusion of the investigation based on known facts, The police report, if applicable, If the allegation is determined to be valid and the perpetrator is an employee, a separate sheet listing the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current employment status (still working, suspended or terminated). Event ID: Facility ID: 145624 If continuation sheet Page 5 of 9 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 04/04/2025 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 0610 Respond appropriately to all alleged violations. 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 investigate an allegation of staff to resident neglect for one (R15) of 15 residents reviewed for neglect in the sample of 15. Residents Affected - Few Findings include: R15's Face Sheet documented an original admission date of 6/26/22 and readmission date of 5/10/24 and included diagnoses of morbid obesity, diabetes type 2, and congestive heart failure. R15's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R15 has no deficits in cognition. This MDS also documented R15 has limited range of motion in both lower extremities and is totally dependent on staff for transfers. R15's Care Plan documented a Focus Area of Resident is usually able to perform ADLs (Activities of Daily Living) with maximum assist from 2 staff initiated on 8/30/23, with a corresponding intervention also initiated on 8/30/23 of Assist to transfer resident using mechanical (lift) and 2 staff members. Explain all procedures prior to starting. Advise resident what is expected of him/her during the transfer. Reassure Resident of safety as needed. Keep hand on Resident to reassure of safety if needed. Ensure lift sheet is intact and correct size for resident. May leave lift sheet under Resident if comfort in placing/removing sheet is problematic. There were no problem areas in the Care Plan to indicate R15 reports falsehoods about staff or displays manipulative behavior. There was no documentation in R15's Nursing Progress Notes about issues with R15's 3/26/25 mechanical lift transfer as documented below. On 4/3/25 at 2:55pm, R15 was alert and oriented to person, place, and time. R15 stated on Wednesday 3/26/25 on the 6pm to 6am shift, V19 (Agency Certified Nursing Assistant/CNA) was transferring him from his wheelchair to the shower chair using a mechanical lift. R15 stated there were no other staff members present. R15 stated as the mechanical sling was moving, he was experiencing back pain and was complaining to V19 that R15 didn't feel V19 was doing the transfer correctly. R15 stated V19 was mad, threw up his hands, yelled, That's it, I quit, and walked out of the room shutting the door, leaving R15 elevated several inches away from the shower chair. R15 stated he could not reach the call light and yelled for help for about 10 minutes, until two other staff members responded and lowered him into the shower chair. R15 stated he was not injured nor emotionally traumatized by the event, as several years ago at a different facility he was dropped during a mechanical lift transfer, so nothing phases him anymore. R15 stated the following day in the afternoon, V1 (Administrator) asked him about the event, and asked him if he would be willing to work with V19 again, to which R15 stated no he would not as he didn't feel safe in his care after what happened. R15 stated he has not seen V19 since then. On 4/3/25 at 3:15pm, V23 (Registered Nurse/RN) stated when she came in on 3/27/25at 6:00am, R15 had reported to her that the previous evening, V19 left R15 hanging in a mechanical lift sling during a transfer because V19 was mad at R15. V23 stated she reported the incident to V1 that morning when V1 arrived. On 4/3/25 at 3:50pm, V1 stated she found out about the incident when she arrived for work the morning of 3/27/25. V1 stated she talked to R15 and staff about what had happened, but there was no incident report about the event as R15 told V1 he did not feel V19 had neglected or abused him. V1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 6 of 9 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 04/04/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R15 was verbally abusive to V19 and V19 left the room to de-escalate R15. V1 stated V19 has not been back to the facility as he got in an argument with another employee and V1 told him he is not welcome back. On 4/3/25 at 4:05pm, V20 (Agency RN) stated, on 3/26/25 during the 6pm to 6am shift, she was unsure of the time, but she and V21 (CNA) were standing at the nurses' station when V19 approached, stated that R15 was, Being nitpicky about his (Mechanical lift) transfer and that he didn't want to further escalate him so V19 left the room. V20 stated within seconds, she and V21 entered the room and saw that R15 was in the mechanical lift sling, positioned several inches above the shower chair. V20 stated R15 was not injured, nor did he seem upset. V20 stated she and V21 lowered R15 into the shower chair and proceeded with his care. V20 stated V19 worked the remainder of his shift but did not go back into R15's room. V20 stated she did not notify management about what happened. On 4/3/25 at 6:00pm, V21 corroborated V20's account of the incident. V21 stated she did not notify management about the incident. V21 stated after the event, staff were re-educated on safe mechanical lift transfers. On 4/4/25 at 7:45am, V19 stated he was performing the transfer without other staff present as, That's just the way he always does it. V19 stated he had worked with R15 previously with no issues. V19 stated R15 was becoming verbally aggressive during the transfer, saying V19 wasn't doing it right, so V19 decided to calm the situation down by leaving to get other staff to continue care. V19 stated when he left the room, R15 was already sitting in the shower chair but was still in the sling. V19 stated less than a minute elapsed between him leaving the room and other staff relieving him. V19 stated V1 later told him he could not return to the facility because, They didn't want me to get in trouble because of (R15) lying on me. He makes stuff up about staff. An Abuse Prevention and Reporting Policy dated 10/24/22 documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: Filing accurate and timely reports. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness, of a resident, including deprivation of goods and services by staff. Under the section titled Internal Investigation documents All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 7 of 9 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 04/04/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a safe mechanical lift transfer for one (R15) of two residents reviewed for mechanical lift transfers in the sample of 15. Findings include: R15's Face Sheet documented an original admission date of 6/26/22 and readmission date of 5/10/24 and included diagnoses of morbid obesity, diabetes type 2, and congestive heart failure. R15's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R15 has no deficits in cognition. This MDS also documented R15 has limited range of motion in both lower extremities and is totally dependent on staff for transfers. R15's Care Plan documented a Focus Area of Resident is usually able to perform ADLs (Activities of Daily Living) with maximum assist from 2 staff initiated on 8/30/23, with a corresponding intervention also initiated on 8/30/23 of Assist to transfer resident using mechanical (lift) and 2 staff members. Explain all procedures prior to starting. Advise resident what is expected of him/her during the transfer. Reassure Resident of safety as needed. Keep hand on Resident to reassure of safety if needed. Ensure lift sheet is intact and correct size for resident. May leave lift sheet under Resident if comfort in placing/removing sheet is problematic. There were no problem areas in the Care Plan to indicate R15 reports falsehoods about staff or displays manipulative behavior. There was no documentation in R15's Nursing Progress Notes about issues with R15's 3/26/25 mechanical lift transfer as documented below. On 4/3/25 at 2:55pm, R15 was alert and oriented to person, place, and time. R15 stated on Wednesday 3/26/25 on the 6pm to 6am shift, V19 (Agency Certified Nursing Assistant) was transferring him from his wheelchair to the shower chair using a mechanical lift. R15 stated there were no other staff members present. R15 stated as the mechanical sling was moving, he was experiencing back pain and was complaining to V19 that R15 didn't feel V19 was doing the transfer correctly. R15 stated V19 was mad, threw up his hands, yelled, That's it, I quit, and walked out of the room shutting the door, leaving R15 elevated several inches away from the shower chair. R15 stated he could not reach the call light and yelled for help for about 10 minutes, until two other staff members responded and lowered him into the shower chair. R15 stated he was not injured nor emotionally traumatized by the event, as several years ago at a different facility he was dropped during a mechanical lift transfer, so nothing phases him anymore. R15 stated the following day in the afternoon, V1 (Administrator) asked him about the event, and asked him if he would be willing to work with V19 again, to which R15 stated no he would not as he didn't feel safe in his care after what happened. R15 stated he has not seen V19 since then. On 4/3/25 at 3:15pm, V23 (Registered Nurse/RN) stated when she came in on 3/27/25at 6:00am, R15 had reported to her that the previous evening, V19 left R15 hanging in a mechanical lift sling during a transfer because V19 was mad at R15. V23 stated she reported the incident to V1 that morning when V1 arrived. On 4/3/25 at 3:50pm, V1 stated she found out about the incident when she arrived for work the morning of 3/27/25. V1 stated she talked to R15 and staff about what had happened, but there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 8 of 9 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 04/04/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident report about the event as R15 told V1 he did not feel V19 had neglected or abused him. V1 stated R15 was verbally abusive to V19 and V19 left the room to de-escalate R15. V1 stated V19 has not been back to the facility as he got in an argument with another employee and V1 told him he is not welcome back. On 4/3/25 at 3:55pm, V2 (Director of Nurses/DON) stated mechanical lift transfers are to always be done with 2 staff members present. On 4/3/25 at 4:05pm, V20 (Agency RN) stated, on 3/26/25 during the 6pm to 6am shift, she was unsure of the time, but she and V21 (CNA) were standing at the nurses' station when V19 approached, stated that R15 was, Being nitpicky about his (Mechanical lift) transfer and that he didn't want to further escalate him so V19 left the room. V20 stated within seconds, she and V21 entered the room and saw that R15 was in the mechanical lift sling, positioned several inches above the shower chair. V20 stated R15 was not injured, nor did he seem upset. V20 stated she and V21 lowered R15 into the shower chair and proceeded with his care. V20 stated V19 worked the remainder of his shift but did not go back into R15's room. V20 stated she did not notify management about what happened. On 4/3/25 at 6:00pm, V21 corroborated V20's account of the incident. V21 stated she did not notify management about the incident. V21 stated after the event, staff were re-educated on safe mechanical lift transfers. On 4/4/25 at 7:45am, V19 stated he was performing the transfer without other staff present as, That's just the way he always does it. V19 stated he had worked with R15 previously with no issues. V19 stated R15 was becoming verbally aggressive during the transfer, saying V19 wasn't doing it right, so V19 decided to calm the situation down by leaving to get other staff to continue care. V19 stated when he left the room, R15 was already sitting in the shower chair but was still in the sling. V19 stated less than a minute elapsed between him leaving the room and other staff relieving him. V19 stated V1 later told him he could not return to the facility because, They didn't want me to get in trouble because of (R15) lying on me. He makes stuff up about staff. A Transfers-Manual Gait Belt and Mechanical Lifts Policy dated 1/19/18 documented, In order to protect the safety and wellbeing of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H) Mechanical lift (trade name mechanical lift) with 2 caregivers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 9 of 9