Health inspection·March 22, 2024

F 0578 sustaining measures were not accurately reflected throughout her record. V7 stated an audit will be conducted to ensure no other residents are affected. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 2 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 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. Based on observation, interview and record review, the facility failed to keep resident care areas clean and in a good state of repair for 14 (R7, R18, R10, R16, R23, R21, R41, R45, R29, R22, R25, R35, R15, and R20) of 14 residents reviewed for homelike environment in the sample of 36. Findings Include: On 03/19/24 09:56 AM, R7's room was observed to have two brown stained ceiling tiles, a missing cover on the baseboard heater, and a brownish-orange discoloration to the floor near the baseboard under the sink. In R7's room and bathroom, chipped paint was noted on multiple areas of the walls as well as chipped wood on the door inside bathroom. On 03/19/24 at 10:17 AM, R18, R10 and R16's adjoining bathroom had missing baseboard with stained drywall exposed. On 03/19/24 10:21 AM, R23's room revealed the front cover was missing off the baseboard heater. The cover for a portion of the heater was lying on the floor in front of the heater. There were wood chunks missing out of the corner of the door and missing paint with wood exposed. On 03/21/2024 at 11:30 AM, R21, R41, and R45's shared room was noted to have three-fourths of the ceiling tiles with brown stains and all of the room's base boards were missing. R29's room was observed this same date and time and was also noted to have three-fourths of the ceiling tiles with brown stains and all of the room's base boards are missing. On 3/21/2024 at 11:33 AM, R22, R25 and R35's shared room was noted to have all of the base boards missing. On 3/21/2024 at 11:35 AM, R15 and R20's shared room revealed one brown stained ceiling tile and all of the base boards were missing. On 03/20/24 at 02:20 PM, V1 (Administrator) stated that there are building repairs scheduled to be made. On 3/21/2024 at 11:50 AM, a tour with V9 (Maintenance) was conducted. V9 acknowledged the brown stained ceiling tiles, missing base boards, discoloration of the floor, chipped paint and doors, and base board heating system that is missing the front cover. V9 stated all need replaced and/or removed. V9 stated that she took this position in July 2022 and is still in the process of trying to complete construction projects throughout the facility. V9 stated that she does not have a budget with funds specific to her department. V9 stated, the process to be approved for funds is to fill out a request form with a list of construction supplies needed, then she will fax the request form to V10 (Vice President of Operations). V9 stated the company has been struggling financially and (V9) has not been able to get approval for supplies. The facility policy titled Facility Physical Plant and Environmental Policy & Guidelines (undated) documents under Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 3 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (National Fire Protection Association) codes . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 4 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for 3 (R32, R23 and R151) of 3 residents reviewed for comprehensive assessments and timing in the sample of 36. Findings Include: 1. R23's Profile Face Sheet documents an admission date of 4/3/20, and includes the following diagnoses: Major Depressive Disoder, Dementia, Muscle Weakness and Aphasia. R23's most recent completed Minimum Data Set (MDS) was dated 10/11/23 and coded as a quarterly assessment. On 3/21/24 at 11:30 AM, V4 (MDS Coordinator) stated that R23 was due for a comprehensive annual MDS 1/16/24, but this was not completed and transmitted until 3/14/24. R23's current comprehensive annual MDS Section Z was reviewed and noted to be signed by V4 and dated 3/14/24. 2. R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Anxiety, Depression, Skin Rash and Memory Impairment. On 3/20/24 at 2:00 pm, V4 stated that R151's MDS assessment had not been started yet. Review of R151's medical record revealed no MDS assessment had been completed as of 3/20/24. 3. R32's Profile Face Sheet documents an admission date of 9/1/20 and includes the following diagnoses: Sepsis, Hallucinations, and Weakness. On 3/21/24 at 11:30 AM, V4 stated that R32 was due for a comprehensive annual MDS on 11/14/23, but this was not completed and transmitted until 3/6/24. R32's current comprehensive annual MDS Section Z was reviewed and noted to be signed by V4 and dated 3/6/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 5 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure timely completion of quarterly assessments for 4 (R5, R7, R26, R45) of 4 residents reviewed for quarterly assessments in the sample of 36. Residents Affected - Some Findings Include: 1. R5's Profile Face Sheet documents an admission date of 5/21/19. This same document includes the following diagnoses: Schizoaffective Disorder, Major Depression Disorder, Anxiety, and Dementia. On 2/21/24 at 11:00 AM, V4 (Minimum Data Set/MDS Coordinator) stated that R5's quarterly MDS (Minimum Data Set) assessment was due on 2/7/24 and it was not completed and transmitted until 3/20/24. R5's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/20/24. 2. R7's Profile Face Sheet documents an admission date of 9/23/22. This same document includes the following diagnosrs: Major Depressive Disorder, Anxiety, and History of falling. On 2/21/24 at 11:00 AM, V4 stated that R7 had a quarterly MDS assessment due on 1/2/24 and it was not completed and transmitted until 3/11/24. R7's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/11/24. 3. R26's Profile Face Sheet documents an admission date of 8/23/19. This same document includes the following diagnoses: Alzheimer's Disease, Hypertension, Major Depressive Disorder. On 2/21/24 at 11:00 AM, V4 stated that the quarterly MDS assessment was due 1/23/24 but was not completed and transmitted until 3/19/24. R26's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/19/24. 4. R45's Profile Face Sheet documents an admission date of 7/28/23 and includes the following diagnoses: Schizophrenia, Cachexia, and Bipolar Disease. On 2/21/24 at 11:00 AM, V4 stated that the quarterly MDS assessment was due on 2/6/24 and it was not completed and transmitted until 3/18/24. R45's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/18/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 6 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0655 Level of Harm - Minimal harm or potential for actual harm Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on record review and interview, the facility failed to implement a baseline care plan for 1 (R151) of 12 residents reviewed for baseline care plans in a sample of 36. Residents Affected - Few Findings Include: R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Spinal Stenosis, Physical Deconditioning, Anxiety, Memory Impairment and Depression. Review of R151's medical record revealed no care plan could be found. On 3/20/24 at 2:34 PM, V4 (Minimum Data Set [MDS]/Care Plan Coordinator) stated that she does not have a care plan (Comprehensive or Baseline) started. V4 further stated that usually the nurses start the baseline care plan on admission or within 24-48 hours of admission, and then she creates the comprehensive care plan. The Baseline Care Planning policy with a revision date of 3/16/22 documents 3. the 'Baseline Care Plan' and 'Care Plan Summary' shall be completed within 48 hours of admission by the admitting nurse or designee . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 7 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to revise a comprehensive plan of care to meet current resident needs for 2 (R28 and R34) of 13 residents reviewed for care plan timing and revision in the sample of 36. Findings Include: 1. Review of R28's admission and Discharge Record documented an original admit date to the facility of 10/20/23. R28's Cumulative Diagnosis Log documented diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Hyperglycemia, Weakness, Developmental Disorder, etc . R28's Nurse's Notes document on 11/13/23 at 2:00 PM, an entry detailing the onset of a new 1 centimeter by 1 centimeter open area on his left buttock. An additional entry on 3/20/24 at 6:00 PM, documented an evaluation was made by V11 (Wound Physician), in which the wound to R28's left buttock was determined to be resolved as of this date. On 3/21/24 at 1:10 PM, V4 (Minimum Data Set/Care Plan Coordinator [MDS/CPC]) confirmed that R28's current plan of care did not, and had not included a revision to incorporate a focus area for current or the potential impairment of skin integrity. On 3/21/24 at 1:32 PM, V2 (Director of Nursing) stated that a resident experiencing actual or being at risk for skin breakdown should have a plan of care developed to address those concerns. 2. R34's Profile Face Sheet documented an original admit date to the facility of 9/17/21. Diagnoses listed on this same document included, but were not limited to: Unspecified Dementia, Parkinson's disease, Essential Hypertension, etc . On 03/19/24 at 09:49 AM, R34 was observed lying in bed, with Jevity 1.5 calorie observed running at 45 milliliters (mL)/hour (hr) via gastrointestinal tube. R34 was observed as not being alert or oriented to person, place or time during this observation. R34's Physician Orders for 3/1/24 - 3/31/24 documented an active dietary order starting 11/23/23 for Jevity 1.5 running at 45 mL/hr x 23 hr. Review of R34's current plan of care documented a Problem/Need area with a start date of 9/29/21 for, Resident in need of nutrition in form of REGULAR DIET . An additional Problem/Need area on the same plan of care with a start date of 10/14/22 for, Restorative Nursing Program - Eating Problem/Need Needs reminders to pick up utensils and to take drinks . On 3/20/24 at 11:37 AM, V4 (MDS/CPC) stated that R34 receives nutrition via gastrointestinal tube, and does not eat by mouth. V4 confirmed that R34's Plan of Care was not revised/updated to reflect her current status, as R34's current plan of care listed a regular diet with a restorative nursing eating program involving the use of utensils in place. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 documented stated, 4. Comprehensive Care Plans shall strive to describe: .b. The resident's medical, nursing, physical, mental and psychosocial needs and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 8 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 hours a day, 7 days per week. This failure has the potential to affect all 44 residents who reside in the facility. Residents Affected - Many Findings Include: The facility's nursing schedules for February and March 2024 documented the following dates were lacking 8 hours of Registered Nurse (RN) coverage: 2/4/2024, 2/5/2024, 2/11/2024, 2/25/2024, 3/9/2024, 3/10/2024, 3/16/2024 and 3/17/2024. On 3/19/24 at 2:40 PM, V2 (Director of Nursing/DON) confirmed that the facility's February and March 2024 nursing schedules were accurate. On 3/19/24 at 2:46 PM, V1 (Administrator) confirmed the lack of Registered Nursing coverage on the above listed dates. V1 stated the weekend dates are difficult for them to get RN coverage. The Long-Term Care Facility Application for Medicare and Medicaid dated 3/19/24 documented a facility census of 44. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 9 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to date and label opened food items/leftovers. This failure has the potential to affect all residents residing in the facility who receive food from the kitchen. The Findings Include: On 3/19/24 at 9:00 AM, during the initial tour of the kitchen, items in the refrigerator were found to be opened without identifying and dating the food. Items found not dated and labeled after opening were salad dressing, corn, tortillas, shredded cheese and a container of meat. At this time, V3 (Dietary Manager) stated that she has new employees that maybe do not know they need to do this. V3 further stated she was unsure what was even in the one container that appeared to be a type of meat. The facility's storage policy with a revision date of 10/20 documents that it is the policy of (Facility Name) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food cost .5. Store leftovers in covered, labeled and dated containers under refrigeration or frozen. 6. When using only part of a product, the remaining product should be in the original package or air tight container and labeled and dated The Long Term Care Application for Medicare and Medicaid, dated 3/19/24, documents 44 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 10 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 offer pneumococcal and/or covid vaccinations in accordance with guidelines for 2 (R15 and R41) of 5 residents reviewed for immunizations in a sample of 36. Residents Affected - Few Findings include: 1. R15's Profile Face Sheet documents an admission date of 7/27/2018, and a date of birth (DOB) indicating R15 is [AGE] years of age. R15's face sheet documents diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Atherosclerosis of the aorta, Atherosclerotic Heart Disease of native coronary artery. The facility document titled Resident Immunization Tracking Log dated 10/1/2023 through 3/31/2024 documents R15 received the PCV13 (Pneumococcal Conjugate Vaccine) on 12/20/2022. No documentation could be found in R15's medical record of R15 having been offered or administered a PCV (Pneumococcal Conjugate Vaccine) 20 or PPSV (Pneumococcal Polysaccharide Vaccine) 23 vaccine. 2. R41's Profile Face Sheet documents an admission date of 9/6/2023 and a DOB indicating R41 is [AGE] years of age. R41's cumulative Diagnosis Log (undated) documents diagnoses including Schizophrenia, Anxiety Disorder, Major Depressive Disorder, Heart Failure, Essential Hypertension, Atrial Fibrillation, and Venous Insufficiency (Chronic) (Peripheral). R41's Resident Influenza and Pneumonia Vaccine Consent dated 9/27/2023, indicated that R41 refused to sign consent for Influenza Vaccine, PPSV23 and PCV13 vaccine. On 3/19/24 V2 (Director of Nursing/DON) provided the Resident Immunization Tracking Log. This document indicated that R41 refused the influenza, PCV13 and PPSV23 vaccines, however it did not indicate the COVID or PCV20 vaccines were offered. R41's Physician Order Sheet (POS) dated for March 2024 documents an order for Influenza Vaccine Yearly. On 3/20/2024 at 1:15pm, V2 stated that she recently took the position of Director of Nursing, and after review there is no documentation of R15 or R41 receiving Prevnar 20 vaccinations, and confirmed that R15 has only received the PCV13. According to https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo, the following recommendations were retrieved as of 3/20/24: Age 65 years or older who have: Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 11 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0883 Previously received only PCV7: follow the recommendation above. Level of Harm - Minimal harm or potential for actual harm Previously received only PCV13: 1 dose PCV20 OR 1 dose PPSV23. If PCV20 is selected, administer at least 1 year after the last PCV13 dose. Residents Affected - Few If PPSV23 is selected, administer at least 1 year after the last PCV13 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak). Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20. Administer either PCV15 or PCV20 at least 1 year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended. Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 OR 1 dose PPSV23. If PCV20 is selected, administer at least 5 years after the last pneumococcal vaccine dose. If PPSV23 is selected, see dosing schedule at cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. For guidance on determining which pneumococcal vaccines a patient needs and when, please refer to the mobile app, which can be downloaded here: cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html. Age 19-64 years with certain underlying medical conditions or other risk factors who have: Not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak). Previously received only PCV7: follow the recommendation Previously received only PCV13: 1 dose PCV20 OR 1 dose PPSV23. If PCV20 is selected, administer at least 1 year after the PCV13 dose. If PPSV23 is selected, see dosing schedule at cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 12 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0883 Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20. Administer either PCV15 or PCV20 at least 1year after the last PPSV23 dose. Level of Harm - Minimal harm or potential for actual harm If PCV15 is used, no additional PPSV23 doses are recommended. Residents Affected - Few Previously received PCV13 and 1 dose of PPSV23: 1 dose PCV20 OR 1 dose PPSV23. If PCV20 is selected, administer at least 5 years after the last pneumococcal vaccine dose. If PPSV23 is selected, see dosing schedule at cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf For guidance on determining which pneumococcal vaccines a patient needs and when, please refer to the mobile app which can be downloaded here: cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html *Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronicrenal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF leak, diabetes mellitus, generalized malignancy, HIV infection, Hodgkin disease, immunodeficiencies, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplant, or sickle cell disease or other hemoglobinopathies COVID-19 vaccination: Routine Vaccination Age 19 years or older Unvaccinated: 1 dose of updated (2023-2024 Formula) Moderna or Pfizer-BioNTech vaccine 2-dose series of updated (2023-2024 Formula) Novavax at 0, 3-8 weeks Previously vaccinated with 1 or more doses of any COVID-19 vaccine: 1 dose of any updated (2023-2024 Formula) COVID-19 vaccine administered at least 8 weeks after the most recent COVID-19 vaccine dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 13 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This has the potential to affect all 44 residents residing in the facility. Residents Affected - Many The findings include: On 03/19/24 at 09:56 AM, R7's room was observed to have gnats flying in the bathroom above the toilet. On 3/20/2024 at 08:54 AM, gnats were seen flying around in the dining room around a table and near the coffee bar. On 03/20/24 at 08:54 AM, V3 (Dietary Manager) stated there was a big problem with gnats and the facility has had them all winter. V3 stated, the gnats are always around the coffee station and garbage cans and there is a problem with one of the drains in the kitchen. V3 stated corporate maintenance is supposed to come fix it, but V3 didn't know when. On 03/20/24 at 02:20 PM, V1 (Administrator) acknowledged that the facility has had gnats. V1 stated that they do have an active pest control contract, and the facility was recently serviced. V1 stated that a kitchen drain had recently been replaced, with other building repairs scheduled to be made, which she hopes will help with the gnats in the facility. On 3/22/2024 at 9:45 AM, V9 (Maintenance) stated that the outside pest control company does a monthly evaluation and treatment for gnats. V9 acknowledged there was a gnat problem in the building, but stated it had improved since the pest control company came last month. V9 stated there had been standing water on the outside wall of the kitchen due to the water lines needing to be replaced. V9 stated the line was repaired in [DATE] which helped the water to drain, and the gnats have decreased throughout the building. A statement of the summary of services from the contracted pest control company dated 2/05/2024 documents services of .Targeted Pest: Flies, Drain/Moth Flies. Device of Application: Drains. Equipment Used: Aerosol. Recommendations: The divot in the floor under the dishwasher is holding water. Please repair to prevent pest entry. The facility policy titled Facility Physical Plant and Environmental Policy & Guidelines (undated) documents under Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping . The facility Pest Control Policy dated April 5th, 2021, documented under Routine Services-Specification Services for insect Management is scheduled monthly. Insect management procedures includes, the use of insect monitoring devices, strategic placement of insect management bait, application of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 14 of 15 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 145664 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of West Frankfort 601 North Columbia West Frankfort, IL 62896 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 0925 Level of Harm - Minimal harm or potential for actual harm insects management dust formulations, .Under Section, Call for Additional Service: In the event additional services are necessary between our regularly scheduled visits, such services will be rendered promptly without an additional charge . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 15 of 15