Inspection·July 1, 2025

F 0803 Level of Harm - Actual harm Residents Affected - Few R2's progress note titled Health Status Note dated 6/14/25 at 3:17 PM documents Resident (R2) noted to be having difficulty chewing and swallowing during lunch. Nursing intervention in place to downgrade diet to pureed and have ST (Speech Therapy) to eval (evaluate) and treat. Wife notified. R2's incident report titled Choking dated 6/13/25 at 12:43 PM documents under Incident Description; Nursing Description: It was brought to my attention that (R2) was down in the dining room choking on lunch. Upon entering the dining room, I observed (R2) laying on the ground with multiple staff members and NP (Nurse Practitioner) in the dining room. (R2) was purple in color but he was still breathing at the time. Resident Description: (R2) states that he got choked on the bread and sausage. Description: Staff performed Heimlich/abdominal thrusts which was successful. On 6/25/25 at 1:53 PM, V3 (Certified Nursing Assistant/CNA) stated R2 was served a whole bratwurst but can't remember if it was on a bun. V3 stated while she was passing trays someone yelled out that R2 was choking. V3 stated R2 was blue/purple in the face and was staring off so she yelled for help. V3 stated the nurse came and started the Heimlich maneuver. V3 stated the nurse did the Heimlich maneuver until she got tired then she took over. V3 stated the Heimlich maneuver was not working so they laid R2 on the floor on his side and started back thrusts then V2 (Director of Nursing) came in and did a finger sweep and pulled out a piece of the bratwurst and there was still a piece in his mouth that he started chewing. V3 stated his color returned to normal and he started breathing again. V3 stated she does not know what diet R2 had ordered at the time. On 6/26/25 at 12:37 PM, V4 (Speech Therapist) stated she saw R2 prior to the choking incident and he was ordered to be on a mechanical soft diet and thickened liquids. V4 stated she was not at the facility the day of R2's choking incident but she was told he received a whole bratwurst on a bun. V4 stated a whole bratwurst is not considered a mechanical soft texture diet. V4 stated she was in the facility the next day and saw R2 and that time nursing had downgraded R2 to a pureed diet when he came back from the hospital. V4 stated the goal for R2 is to get him back to a mechanical soft diet and she will be trying that diet with R2 today. On 6/26/25 at 1:17 PM, V9 (Dietary Aide) stated she was working the day R2 choked, and she served R2 a whole brat on a bun. V9 stated R2 was ordered mechanical soft textured diet. V9 stated R2 should have received the bratwurst and bun mechanical soft texture and not whole on a bun. On 6/26/25 at 1:42 PM, V2 (Director of Nursing) stated she was notified that there was an emergency in the dining room and when she arrived in the dining room and saw R2 laying in the floor and R2 was choking. V2 stated staff were doing abdominal and back thrust and it was not working so she did a finger sweep in R2's mouth and pulled out a piece of bratwurst and some gummed up bread. V2 stated the staff sat R2 up then they performed another back thrust and R2 then started coughing. V2 stated EMS arrived shortly after that and took R2 to the local emergency room. On 6/26/25 at 2:11 PM, V12 (Cook) stated she was working the day R2 choked. V12 stated she served R2 a whole bratwurst on a bun that day. V12 stated R2 was ordered for a mechanical soft diet and received the incorrect diet texture. V12 stated R2 was supposed to get his bratwurst and bun with mechanical soft texture. On 6/26/25 at 2:44 PM, V1 (Administrator) stated she was not working the day R2 choked. V1 stated she was informed R2 was served a regular texture diet, bratwurst on a bun. V1 stated R2 should have been served mechanical soft texture diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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 0803 Level of Harm - Actual harm R2's emergency department notes from local hospital dated 6/13/25 documents R2 presented from a local nursing home after a choking episode. The nursing home did the Heimlich maneuver, and they were able to expel the sausage the patient choked on. Patient did have an episode of non-responsiveness at the facility, but he was more alert once EMS arrived. Residents Affected - Few The facility Diet Spreadsheet for Day 20 documents the mechanical soft diet served for 6/13/25 was ground bratwurst on bun with gravy (no raw vegetables), potato salad, baked beans, and soft chopped watermelon (no seeds). The facilities recipe for mechanical soft texture diet for 6/13/25 titled Ground Bratwurst on Bun with Gravy documents under 3. Place prepared bratwurst in a washed and sanitized food processor. Pulse/grind to the size and texture of finely ground beef. 4. Place in steam table pan and add a small amount of prepared broth or gravy to keep moist. The facility policy titled Diet Summary dated 2022 documents under Dental Soft (Mechanical Soft) Diet: Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be mixed or served with gravy, broth, or another type of moistening agent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145624 If continuation sheet Page 3 of 3