Inspection·April 17, 2025

F 0600 underlying cause, consider location, time of day, persons involved and document behaviors, and provide a program of activities of interest to accommodate residents status. Level of Harm - Actual harm Residents Affected - Few 1. A final incident report sent to the state surveying agency titled Report to (state surveying agency) Regional Office documented on 03/21/2025 at 7:15 P.M. R3 was in the hallway preaching loudly when R1 became agitated. R1 then pushed R3 causing R3 to fall into the handrail and bump his right elbow and back of his neck. An abrasion to R3's right elbow was noted. R1 and R3 were immediately separated and assessed for injuries. A referral to psychiatry was made to address R1's agitation. R3's Behavior Note dated 03/21/2025 timed 8:52 P.M. authored by V13 (Registered Nurse/RN) documented at approximately 7:15 P.M. R3 was in the hallway preaching loudly when a peer suddenly became agitated and pushed R3. R3 fell into the handrail and bumped his right elbow and the back of his neck. R3 was assisted to a stand. R3 was assessed by the RN. R3 has a small new abrasion to the right elbow. No apparent injuries seen or reported to the back of the neck. R3 stated he did not hit his head. R3 denies pain. R3 has unsteady gait and gross tremors that appear to be at his baseline. R3's range of motion appears to have some limitations due to stiffness and tremors, but do not seem to be impaired from the fall. No signs and symptoms of distress. R3 escorted by standby assist to his room. Assistant director of nurse, on-call admin, MD local police, and V12 (Family Member) POA notified, and all appropriate charting completed. At 7:59 P.M. a local official took verbal statement on the incident from this RN on-site. R3's Health Status Note with a date of 03/22/2025 and a time of 2:54 P.M. authored by V14 (Licensed Practical Nurse) documented, R3 complaining of tenderness to left buttock. Assessed area, no signs or symptoms of swelling, bruising, or abrasions. Informed R3 he may be sore for a while. Pain medications given and helped alleviate discomfort. On 04/15/2025 at 12:39 P.M. V2 (Assistant Director of Nursing/Interim Director of Nursing) stated V12 (Family Member) took R3 to an appointment on 03/25/2025 to V15 (Physician). At that appointment R3 told V15 he was pushed down by another person and landed on his buttock. R3 complained of pain in the sacral area at the appointment. V15 ordered an x-ray of the sacrum and coccyx. V12 took R3 to a local hospital to get the x-ray completed on 03/25/2025. R3's Hospital report dated 03/25/2025 documents, Clinical history: patient was pushed down by another person on Saturday. He landed on his bottom. C/O (complaint of) sacral area pain. X-ray of Sacrum and Coccyx were obtained. Impression: Suspected contour irregularity and oblique/transverse radiolucent line of the first segment of the coccyx might be a non-displaced fracture. Correlates with clinical findings. New. R3's Health Status Note dated 03/26/2025 timed 9:56 A.M. authored by V16 (Licensed Practical Nurse) documented that V9 (Nurse Practitioner) examined R3. Resident claimed they are experiencing no pain. Ordered placed for a CBC (Complete Blood Count) and a CMP (Comprehensive Metabolic Panel). R3's Health Status Note dated 03/27/2025 timed 8:11 P.M. authored by V7 (Registered Nurse) documented R3 had a witnessed fall with head involvement. R3 was standing in the dining room, lost balance, struck the edge of the table with his back and hitting his head on the floor. R3 was sent to local hospital for evaluation post fall. A fax transmission from the local hospital dated 3/28/25 at 12:19 PM for R3 documents, Emergency Department notes for 3/27/25 to include: R3 is an [AGE] year-old with a significant past medical (continued on next page) 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 04/17/2025 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 0600 Level of Harm - Actual harm history that presents today with a fall. R3 recently had a fall a few days ago and they did not get the result of the x-rays back yet. The lumbar x-ray showed spondylitic degenerative changes. The x-rays of the coccyx showed a small fracture non-dislocated. Discussed with R3's wife he needs to sit on a donut padding the next few weeks. Residents Affected - Few A final incident report sent to (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/03/2025 at 4:00 P.M. R3 and R1 was in an alleged resident to resident altercation. R1 was in dining room prior to altercation. R1 was observed by V5 (Activity Assistant) leaving the dining room. V5 then heard R3 yell that he was pushed. V5 immediately went to R3's room and R1 was standing in R3's room. R1 was immediately redirected by V5. R3 stated to V5 that he was standing at his closet when R1 came into his room and pushed him. R1 was unable to recall the incident. R3's AIM for Wellness - Event Record dated 04/03/2025 with a time of 5:37 P.M. authored by V10 (Licensed Practical Nurse) documented that at 4:15 P.M. R3 was looking for something in his closet. R3 stated that he was pushed by R1. Residents were immediately separated. A final incident report sent to (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/03/2025 at 5:00 P.M. R3 had a follow up appointment where the physician ordered an X-ray. Results were reported to us today by the spouse. After investigation it was determined that R3 had an altercation with another resident on 03/21/2025 where he was pushed down. At the time of the incident R3 was not complaining of any pain. On 03/25/2025 wife took R3 to a doctor appointment where he was complaining of buttocks pain. The physician ordered an x-ray of the coccyx. Results were made aware to the wife and relayed to the us on 04/03/025. R3's Health Status Note dated 04/03/2025 timed 6:11 P.M. authored by V2 (Registered Nurse/Interim DON) documented Spouse took resident to a follow up appointment on 3/26 where V15 (Physician) ordered an x-ray. Results were reported to us today of a fracture to the coccyx. Notified V9 (Nurse Practitioner) and awaiting additional orders at this time. On 04/16/2025 at 9:31 A.M. R3 was observed to be ambulating in the hallway. R3 stopped V10 (Licensed Practical Nurse) and complained of pain to his coccyx area. R3 asked V10 for pain medication for the pain in his tail bone. On 04/15/2025 at 2:21 P.M. V7 (Registered Nurse/Former DON) stated R1 was not aggressive when he first arrived at the facility. V7 stated he often becomes angry with redirection. V7 stated they were unable to figure out the why R1 is having the increase in behaviors. V7 stated the family lives over by (name of nearby town) and the facility sent a referral over to the facility there and R1 was denied because of behaviors. V7 stated she is unsure what interventions were put into place and when that she would have to refer to the care plan. V7 stated she is not sure what caused R1 to push R3 down. V7 stated at the time of the incident R3 was not complaining of any pain. V7 stated the wife took him to an appointment where R3 told the doctor about his pain. The doctor ordered an x-ray, and the wife took R3 to the local hospital to get the x-ray before returning to the facility. When the wife brought R3 back, she did not tell the facility about the x-ray. V7 stated that the wife came in on 04/03/2025 and was telling the administrator about it. V7 stated she was not aware of what occurred after that. V7 stated that V1 (Administrator) does the investigations and reports, and she is not aware of any of the outcomes. V7 stated she was not aware that the Emergency department report dated 03/28/2025 documented the fracture of the coccyx. V7 stated that she was never given that information. (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 04/17/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few On 04/15/2025 at 3:25 P.M. V5 (Activity Assistant) stated that she was doing an activity on the locked unit and saw R3 run out of his room. R1 was in his room and R3 was stating that R1 pushed him. V5 stated she did not see it but only knows what R3 told her. V5 stated they have been unable to determine the cause of R1's behavior. V5 stated she has noticed it is worse after lunch. V5 stated besides attempts at redirection, the nurses can give R1 medication when he is becoming aggressive. On 04/16/2025 at 9:19 A.M. V10 (Licensed Practical Nurse) stated that she has taken care of R1 before. V10 stated that R1 would get an angry look and then would have behaviors without warning. V10 stated she is not sure what was triggering R1's behaviors. V10 stated it appears that R1 has issues with other male residents. V10 stated she tried to keep R1 and R3 separated when she works because of the number of resident-to-resident altercations they have had. V10 stated the right approach with R1 will change his behavior. V10 stated she does not know the root cause of what was causing R1 to have behaviors and hit other residents. V10 stated she was never made aware if they did any blood work or urine tests to see if that was causing the change in behaviors. V10 stated that when R1 first arrived he would be resistive to care and combative with staff at times. V10 stated that just in the last month he started having resident to resident altercations. On 04/16/2025 at 9:34 A.M. V11 (Certified Nurse Assistant/CNA) stated she has taken care of R1 in the past. V11 stated that R1 was easily triggered by little things. V11 stated there was no warning when R1 was going to have a behavior it was like a light switch going on and off. V11 stated that in the late afternoon to early evening hours R1 would be worse because of sun downing. V11 stated she was never made aware of what was the cause of the behaviors that R1 was having. On 04/16/2025 at 10:15 A.M. V1 (Administrator) stated the incident that happened on 03/21/2025 involving R1 and R3, occurred because R3 was loudly preaching in the hall and that upset R1. R1 went up to R3 and pushed him down. V1 stated the intervention to prevent this from occurring again was to consult psych on R1's behaviors. V1 stated the incident on 04/03/2025 between R1 and R3 was not witnessed by staff. V1 stated that V5 (Activity Assistant) heard R1 state he needed to use the restroom. V1 stated that V5 heard R3 out in the hallway stating that R1 had pushed him. V1 stated that they could not determine a root cause as to why R1 went into R3's room and pushed him. V1 stated they placed a large sign on R1's door alerting him to his room. V1 stated that R1 is a resident who wonders around the facility. V1 stated that R1 did see the psych nurse practitioner and his Haldol was increased. V1 stated that on 03/26/2025, R3's wife took him to a podiatrist doctor appointment. At that appointment the wife told the podiatrist that R3 was complaining about pain in his buttock region. The podiatrist gave the wife of R3 an order to take him to a local hospital and get an x-ray. V1 stated that R3's wife brought him back from the appointment and did not tell the facility that she had taken him to a local hospital for an x-ray of his coccyx. V1 stated on 03/27/2025 R3 had a fall and was to the emergency department for evaluation. V1 stated that upon R3 arriving back to the facility they were still not made aware of the results of the x-ray. V1 stated on 4/03/2025, R3's wife told her that when he was in the emergency department on 03/28/2025, the emergency department looked at the x-ray and had informed her of the new fracture to his coccyx. V1 stated after R3's wife told her of the new fracture, R3's facility nurse practitioner was made aware. 2. R2's admission Record documents that R2 is a [AGE] year-old male that was admitted to the facility on [DATE]. Diagnoses listed are chronic obstructive pulmonary disease, type 2 diabetes mellitus, paroxysmal atrial fibrillation, unspecified dementia, and senile degeneration of the brain. R2's MDS (Minimum Data Set) dated 03/30/2025, documents that R2 has a BIMS (Brief Interview for Mental Status) of 09, indicating that R2 has moderate cognitive impairment. (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 04/17/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few R2's care plan with a date initiated of 08/29/2024 has a focus area of Behavior Management. The interventions listed for the focus are: attempt an alternative time to provide care if refused, consult pastoral care if needed, encourage participation in self-calming behaviors such as breathing exercises, meditation or guided imagery, ensure the safety of resident and others, establish boundaries with resident, evaluate medication schedule and possible pharmacologic cause of behavior, initiate visual supervision during acute episode, provide emotional support, reorient resident to person, place, and time, and utilize diversion techniques. A final incident report sent to the (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/05/2025 at 9:00 P.M. R1 and R2 had an alleged resident to resident altercation. During the investigation, V4 (Certified Nurse Assistant/CNA) stated that R1 was walking by R2, when R1 shoved R2 to the floor. R1 then took R2's walker and hit him with it. V4 stated she immediately intervened and separated the residents. Neither resident is able to recall incident due to cognitive state of mind. R2's Health Status Note dated 04/06/2025 timed 9:01 A.M. authored by V17 (Licensed Practical Nurse) documented, It was reported to this nurse from V2 (ADON/RN/Interim DON) that on 04/05/25 at approximately 2100 (9:00PM) another resident pushed R2 to the ground, took his walker and started hitting him with it. No injuries observed this am. On 04/15/2025 at 10:55 A.M. V6 (CNA) stated she is an agency CNA, and this is her 4th shift at the facility. V6 stated that R2 ambulates around the facility. V6 stated she was not here the day the incident happened between R1 and R2. On 04/15/2025 at 12:39 P.M. V2 (ADON/Interim Director of Nursing) stated R1 was an elopement risk when he first arrived at the facility. V2 stated the longer that R1 had been here he has become more aggressive with staff and residents. V2 stated that one intervention was to have local psych see R1. V2 stated other interventions the facility has done for R1 are medication changes. The Haldol R1 was on went from as needed to scheduled. V2 stated other interventions were trying to keep him separated from his peers, and finally the decision was made to send a referral to out of state behavior hospital because the facility had exhausted all other options. V2 stated that once R1 became aggressive, they referred him to out of state behavior hospital. V2 stated that she does not recall R1 ever being on 1-1 with staff. V2 stated they attempted to move him off the locked unit, but he kept going out all the doors, so they had to move him back. V2 stated she doesn't see any other behavior modifications listed in the care plan for R1. V2 stated after the incident on 04/05/2025, the facility decided a referral to out of state behavior hospital would be the best intervention for R1. V2 stated that R1 was sent to out of state behavior hospital on [DATE] and is not aware of any other interventions put in place to prevent a new behavior from occurring, V2 stated she would have to ask V1 (Administrator) as she does the investigations. V2 stated that R3 went to a doctor appointment with his wife. V2 stated that he had not been complaining to staff of any pain since the resident to resident with R1 when R1 pushed R3, and he fell on [DATE]. At the appointment R3 complained of pain and the doctor ordered an x-ray of the coccyx. The wife took R3 to a local hospital to complete the x-ray. V2 stated upon R3 returning to the facility, the wife nor the doctor notified the facility of an order for an x-ray. V2 stated the facility was notified by the wife on 04/03/2025. V2 stated that V9 (Nurse Practitioner) was made aware of fracture on R3. V2 stated that V9 ordered labs for R3. V2 stated that V9 saw R3 again on 04/09/2025 and there is an order for physical therapy to eval. On 04/15/2025 at 1:35 P.M. V8 (Unit Aide) stated that R1 would get combative sometimes for no reason. V8 stated she is not sure why he would get aggressive and combative. V8 stated she was never told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 04/17/2025 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 0600 or concluded about why R1 was having behaviors. V8 stated they would try to talk him down. V8 stated she was not working on the days that R1 was involved with the resident-to-resident altercation. Level of Harm - Actual harm Residents Affected - Few On 04/15/2025 at 2:21 P.M. V7 (RN/Former DON) stated R1 was not aggressive when he first arrived at the facility. V7 stated he often becomes angry with redirection. V7 stated they were unable to figure out the why R1 is having the increase in behaviors. V7 stated she is not sure what the cause of R1 pushing R2 down and hitting him with his walker. V7 stated she knows there was a referral made to an out of state behavioral hospital for R1 after this incident. On 04/16/2025 at 10:15 A.M. V1 (Administrator) stated the incident on 04/05/2025 between R1 and a peer, where R1 pushed a resident down in the hallway and hit them with their walker, has no root cause. V1 stated that there was no reason or causative factors to contribute to R1's behavior. V1 stated that a referral was sent the next day to an out of state behavior facility for R1. V1 stated that was the only intervention put in place besides monitoring R1. V1 stated that R1 did see the psych nurse practitioner and his Haldol was increased. On 04/16/2025 at 2:40 P.M. V9 (Nurse Practitioner) stated she is in the facility weekly or more often to see the residents. V9 stated she is not sure why R1 is having an increase in behaviors. V9 stated one incident he attacked a resident for preaching in the hallway and the other incident he pushed someone down. V9 stated she is not sure why if any contributing factors have been determined. V9 stated that when an incident occurs, she comes to the facility and evaluates the residents involved. V9 stated that R1 has returned from the out of state behavioral hospital and that facility has completed some medication changes. Facility policy titled Abuse Prevention and Reporting -Illinois with a revision date of 10/24/2022, documented under section titled Guidelines - 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Protection of Residents: Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including but not limited to, the separation of residents. 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 04/17/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 notify the physician of resident having pain after a resident-to-resident altercation with a fall for 1 (R3) of 1 resident reviewed for quality of care in the sample of 3. Residents Affected - Few Findings Include: R3's admission Record documents that R3 is an [AGE] year-old male that was admitted to the facility on [DATE]. Diagnoses listed are Parkinson's disease, unspecified dementia, Alzheimer's disease, anemia, insomnia, and depression. R3's MDS (Minimum Data Set), dated 02/21/2025, documents that R3 has a BIMS (Brief Interview for Mental Status) score of 06, indicating that R3 has severe cognitive impairment. A final incident report sent to the (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 03/21/2025 at 7:15 P.M. R3 was in the hallway preaching loudly when R1 became agitated. R1 then pushed R3 causing R3 to fall into the handrail and bump his right elbow and back of his neck. An abrasion to R3's right elbow was noted. R1 and R3 were immediately separated and assessed for injuries. A referral to psychiatry was made to address R1's agitation. R3's Behavior Note dated 03/21/2025 timed 8:52 P.M. authored by V13 (Registered Nurse/ RN) documented at approximately 7:15 P.M. R3 was in the hallway preaching loudly when a peer suddenly became agitated and pushed R3. R3 fell into the handrail and bumped his right elbow and the back of his neck. R3 was assisted to a stand. R3 was assessed by the RN. R3 has a small new abrasion to the right elbow. No apparent injuries seen or reported to the back of the neck. R3 stated he did not hit his head. R3 denies pain. R3 has unsteady gait and gross tremors that appear to be at his baseline. R3's range of motion appears to have some limitations due to stiffness and tremors, but do not seem to be impaired from the fall. No signs and symptoms of distress. R3 escorted by standby assist to his room. Assistant director of nurse, on-call admin, MD local police, and V12 (Family Member) POA notified, and all appropriate charting completed. At 7:59 P.M. a local official took verbal statement on the incident from this RN on-site. R3's Health Status Note with a date of 03/22/2025 and a time of 2:54 P.M. authored by V14 (Licensed Practical Nurse) documented R3 complaining of tenderness to left buttock. Assessed area, no signs or symptoms of swelling, bruising, or abrasions. Informed R3 he may be sore for a while. Pain medications given and helped alleviate discomfort. On 04/15/2025 at 12:39 P.M. V2 (Assistant Director of Nursing/Interim Director of Nursing) stated V12 (Family Member) took R3 to an appointment on 03/25/2025 with V15 (Physician). At that appointment R3 told V15 he was pushed down by another person and landed on his buttock. R3 complained of pain in the sacral area at the appointment. V15 ordered an x-ray of the sacrum and coccyx. V12 took R3 to a local hospital to get the x-ray completed on 03/25/2025. R3's Hospital report dated 03/25/2025 documents, Clinical history: patient was pushed down by another person on Saturday. He landed on his bottom. C/O (complaint of) sacral area pain. X-ray of Sacrum and Coccyx were obtained. Impression: Suspected contour irregularity and oblique/transverse radiolucent line of the first segment of the coccyx might be a non-displaced fracture. Correlates with clinical findings. New. (continued on next page) 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 04/17/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3's Health Status Note dated 03/26/2025 timed 9:56 A.M. authored by V16 (Licensed Practical Nurse) documented that V9 (Nurse Practitioner) examined R3. Resident claimed they are experiencing no pain. Ordered placed for a CBC (Complete Blood Count) and a CMP (Comprehensive Metabolic Panel). R3's Health Status Note dated 03/27/2025 timed 8:11 P.M. authored by V7 (Registered Nurse) documented R3 had a witnessed fall with head involvement. R3 was standing in the dining room, lost balance, struck the edge of the table with his back and hitting his head on the floor. R3 was sent to local hospital for evaluation post fall. A fax transmission from the local hospital dated 3/28/25 at 12:19PM for R3 documents, Emergency Department notes for 3/27/25 to include: R3 is an [AGE] year-old with a significant past medical history that presents today with a fall. R3 recently had a fall a few days ago and they did not get the result of the x-rays back yet. The lumbar x-ray showed sponylitic degenerative changes. The x rays of the coccyx showed a small fracture non-dislocated. Discussed with R3's wife he needs to sit on a donut padding the next few weeks. A final incident report sent to (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/03/2025 at 5:00 P.M. R3 had a follow up appointment where the physician ordered an X-ray. Results were reported to us today by the spouse. After investigation it was determined that R3 had an altercation with another resident on 03/21/2025 where he was pushed down. At the time of the incident R3 was not complaining of any pain. On 03/25/2025 wife took R3 to a doctor appointment where he was complaining of buttocks pain. The physician ordered an x-ray of the coccyx. Results were made aware to the wife and relayed to the us on 04/03/025. R3's Health Status Note dated 04/03/2025 timed 6:11 P.M. authored by V2 (Assistant Director of Nursing/Interim Director of Nursing) documented Spouse took resident to a follow up appointment on 3/26 where V15 (Physician) ordered an x-ray. Results were reported to us today of a fracture to the coccyx. Notified V9 (Nurse Practitioner) and awaiting additional orders at this time. On 04/15/2025 at 2:05 P.M. V2 (Assistant Director of Nursing/Interim Director of Nursing) stated that she was not aware of R3's emergency department visit documents being in the electronic chart. V2 stated that when a resident goes out to the emergency department, the records get faxed back. The nurse who receives the records are supposed to review them and make sure there is nothing new. Once that is completed, the nurse will give the documents to medical records for them to scan into the chart. V2 stated she was not aware that the emergency department documents that the facility received on 03/28/2025 documented that R3 had a fractured coccyx. On 04/15/2025 at 2:21 P.M. V7 (Registered Nurse) stated she was not aware that the Emergency department report dated 03/28/2025 documented the fracture of the coccyx. V7 stated that she was never given that information. V7 stated she was the nurse who sent R3 to the hospital after the fall and when she received report from the hospital, they did not tell V7 that R3 had a new fracture to the coccyx. On 04/16/2025 at 10:15 A.M. V1 (Administrator) stated he was not aware of a document in R3's medical record that is dated 03/28/2025 with a faxed time of 12:19 on it documenting R3's new fracture. V1 stated that she was made aware by the wife on 04/03/2025 and she went into R3's electronic medical records at the hospital and pulled the x-ray report. On 04/16/2025 at 2:40 P.M. V9 (Nurse Practitioner) stated she is in the facility weekly or more (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 04/17/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few often to see the residents. V9 stated she is not sure why R1 is having an increase in behaviors. V9 stated one incident he attacked a resident for preaching in the hallway and the other incident he pushed someone down. V9 stated she is not sure why if any contributing factors have been determined. V9 stated that when an incident occurs, she comes to the facility and evaluates the residents involved. V9 stated that if she would have known that R3 was complaining of pain to coccyx she could have ordered the x-ray to be done here and possibly increased the dose of pain medications and frequency. V9 stated besides pain management there is no treatment for a fractured coccyx. V9 stated that she has seen R3 frequently lately due to falls and she always asks if he is in pain. V9 stated that she probably would not have given R3 a stronger pain medication due to his age and other health related issues, but V9 stated she could have increased the tramadol or even scheduled it to where he wouldn't have to ask for it. V9 stated she was never made aware by the facility that R3 was complaining of pain following the incident on 03/21/2025. Facility Policy titled Physician -Family-Notification-Change in Condition with a revision date of 11/13/2018 documented under the section titled Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 9 of 9