Inspection·June 2, 2025

F 0698 with (R1), he is in agreeance . Level of Harm - Actual harm 5/19/25 at 3:00 PM: V15 (Medical Records/Transportation) reached out to a local transportation company, and they stated they do not start transporting early enough to transport R1 to dialysis. Residents Affected - Few 5/19/25 at 6:00 PM: Resident returned from (name of local hospital). Nurse on duty stated that resident did not receive Dialysis because labs did not indicate he needed Dialysis at this time and ER cannot do Dialysis. Resident would need to be admitted there was no need for him to be admitted because his condition is stable but resident needs to go to Dialysis tomorrow. Writer informed DON (Director of Nurses). 5/20/25 at 3:05 PM: V15 called a local transportation company, and they told her they do not service their area. 5/21/25 at 5:40 AM: Resident up in dining room at this time awaiting ride for dialysis. Transportation aide here and notified this nurse that transportation van is unavailable for transport at this time and would need to be transported another way to dialysis. DON notified and awaiting further orders. 5/21/25 at 6:34 AM: The dialysis center was called due to R1 missing dialysis treatment today. New orders were received to send R1 to the emergency room. EMS (Emergency Management Service) was called to transport R1 to the local hospital. 5/21/25 at 2:15 PM: Spoke with (name of hospital Case Manager) at (name of local hospital). She states resident is telling them we will not take him to his dialysis appts (appointment), she is wanting to know what is going on with this. This nurse explained resident missed his appt Friday the 16th due to his own refusal, he did not want to go to dialysis that day. Resident missed dialysis Monday the 19th due to the van lift not working that morning. We contacted (name of dialysis center) to let them know what was going on. They stated they would like resident to go to the ER. Resident was sent to (name of a local hospital) for eval and possible dialysis. (Name of a local hospital) reported to us they did labs and he does not require dialysis at this time. Resident missed dialysis this am (Wednesday 21st) due to van lift still being broken and unable to find other transportation. (Name of dialysis center) was notified, they stated to send to ER. Resident was then sent to them at (name of local hospital). (Name of hospital Case Manager) states understanding. I let her know we were having a lot of trouble finding transportation for him while our van is being repaired. (Name of hospital Case Manager) suggested (name of a transportation company), I let her know we have already tried them and they do not service [NAME] County. But if she has any other suggestions for transportation to please let us know and we will try. (Name of hospital Case Manager) said she will call us back with any suggestions. (Name of hospital Case Manager) asked if this will be an issue for Friday as well, are we going to send him back to them for dialysis? I told her I could not say for sure. At this time we do not have transportation for Friday, but we are working on it. (Name of hospital Case Manager) states they may admit and keep (R1) until after her receives dialysis Friday. They are unsure of that plan at this time, they will call us back to let us know. 5/23/25 at 5:30 AM: The dialysis center was called to inform them that the facility's van was still out of service and R1 has no transportation to his dialysis appointment today. The dialysis center's staff stated to monitor intake and output and to monitor for noticeable decline in condition and if condition changes send to the emergency room to get dialysis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 2 of 4 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 06/02/2025 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 0698 Level of Harm - Actual harm Residents Affected - Few 5/26/25 at 6:23 AM: The dialysis center was called related to missed dialysis treatment today. The dialysis center's nurse stated to monitor R1 for nausea, vomiting, diarrhea, and increased shortness of breath and if these symptoms are noted send to the emergency room. 5/27/25 at 11:28 AM: V15 spoke with a local transportation company to see if they could privately pay the transportation company to transport R1 to dialysis and the transportation company said they do not provide transportation that early. V15 then called R1's dialysis center to see if there was a later chair time for R1, they stated they would look and call them back. 5/27/25 at 12:00 PM: V15 spoke with the dialysis center, and they could do a later chair time at a different dialysis clinic location, but the transportation company does not run as late as the appointment and would not be available to transport R1 back to the facility after the appointment. R1's local hospital document titled Hospital Discharge Summary Brief Overview dated 5/22/2025 documents an admission date of 5/21/2025 and a discharge date of 5/22/2025 and a primary discharge diagnosis of End Stage Renal Disease. R1's local hospital Dialysis Note, Hemodialysis Post Treatment Summary dated 5/21/2025 documents R1 received a dialysis treatment with a duration of treatment of 3 hours. R1's Chest Radiograph from local hospital dated 5/21/25 at 10:13 AM-5/21/25 at 10:35 AM documents under impression: 3. Pulmonary venous congestion with equivocal interstitial edema and trace bilateral pleural effusions. On 5/28/25 at 10:16 AM, V6 (Registered Nurse at dialysis center) stated R1 has not been to treatment since 5/14/25 due to transportation. V6 stated the facility told them their transportation van was broken down and they didn't have any other transportation. V6 stated today was his first day there since 5/14/25. On 05/28/25 at 3:25 PM, V3 (Assistant Director of Nursing) stated the facility van has been broken for approximately 1.5 weeks. R1 has been sent to the hospital twice to receive dialysis, one time he received dialysis and one time he did not receive dialysis. The first hospital stated they do not do dialysis, but they did his labs and stated he did not need dialysis immediately, so they returned him to the facility. The next time they sent him out, they sent him to (a different local hospital) he was admitted and stayed overnight and received dialysis the next day. V3 stated, dialysis is always beneficial for a resident that is on dialysis treatment but maybe not always immediately crucial. V3 stated, R1 missed dialysis on the previous Friday (05/16/25) because he refused, on 05/19/25 he was sent to the hospital but did not receive dialysis, on 05/21/25 he was sent to the hospital and received dialysis, on 05/23/25 and 05/26/25 he did not receive dialysis, today (05/28/25) they were able to borrow a van and he went to dialysis. V3 stated he believes he missed four days total of dialysis due to the van not working. V3 stated, the moment they were aware the lift gate on the van didn't work they started looking into other options to get him to dialysis. On 05/28/25 at 11:26 AM, V4 (Licensed Practical Nurse) stated the facility van has been broken for about a week that she is aware of, she has been at school. V4 said that R1 has missed dialysis due to the van being broken. V4 said R1 was able to go to dialysis today due to borrowing a van from another facility. On 5/29/25 at 8:41 AM, V12 (Registered Nurse dialysis center) stated R1 needs to be at dialysis for his scheduled treatment 3 days a week per the physician order. V12 stated R1's creatinine was reasonably high at his last labs so that indicates R1 does need dialysis. V12 stated R1's fluid status wasn't bad when he came to treatment on 5/28/25. V12 stated R1 had lost 4.6 kilograms since the last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 3 of 4 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 06/02/2025 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 0698 treatment. V12 stated there is also the risk of R1 becoming uremic if he doesn't get dialysis as ordered. Level of Harm - Actual harm On 5/29/25 at 10:01 AM, V13 (Nephrologist) stated R1 does need dialysis at this time. V13 stated they drew labs on 5/28/25 at the dialysis center but those labs have not resulted yet. Residents Affected - Few On 5/29/25 at 1:17 PM, V14 (Regional Administrator) stated they have purchased a new accessible van, and it should be here in about one week, it was shipped from another state. On 5/29/25 at 1:17 PM, V1 (Administrator) stated until the new van arrives, they will be borrowing a van from a sister facility. The transportation aide is picking the borrowed van up today and it will be available to transport residents to their dialysis appointments until the new van arrives. V1 stated it is the expectation that if they accept a resident that is on dialysis, they are responsible for providing the transportation to their dialysis appointments. The facility policy dated 2/13/18, titled Dialysis Monitoring and Observation documents under Purpose: To ensure residents receiving hemodialysis are monitored for complications. The facility policy dated 12/19/23, titled Transportation for Residents documents under Guidelines 4. Designated personnel shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 4 of 4