Health inspection·August 19, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Physician to the get the order changed. When asked how long R5 was receiving the Ocuvite instead of the Preservision, V2 stated she didn't know. When asked if the physician order was still Preservision and if the facility nursing staff were signing, they administered Preservsion instead of Ocuvtie, V2 stated she didn't know.On 8/19/25 at 10:57 AM, V14 (ADON) stated V2 wasn't in the facility today but she was familiar with R5 and the Preservision order. V14 stated the pharmacy was providing the Preservision initially and then they stopped providing it. V14 wasn't sure why but she thought it had something to do with R5 reaching her maximum allowed amount. V14 stated she was made aware on 8/8/25 by R5 that she was receiving Ocuvite and not Preservision as ordered.On 8/19/25 at 11:08 AM, V15 (Pharmacist) stated R5's Preservision was filled on 4/28/25 for a 30-day supply and had not been filled by their pharmacy since then. V15 stated the Preservision has a different formula than Ocuvite with different concentrations of vitamins and minerals. V15 stated they didn't send any to the facility after 4/28/25 because they didn't have any refills and if the facility would fax over a new prescription for the Preservision they would fill it.The facility Medication Administration through Certain Routes of Administration policy dated 11/15/24 documents, Applicability: Policy 6.7 establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care (LTC) facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations. Event ID: Facility ID: 145664 If continuation sheet Page 2 of 5 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 08/19/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 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 they had RN (Registered Nurse) coverage 8 hours/day, 7 days/week. This failure has the potential to affect all 50 residents who reside at the facility. Findings Include:The undated facility Room Roster documents 50 residents currently reside at the facility. On 8/18/25 at 3:20 PM, V2 (Director of Nurses) stated she didn't have a Registered Nurse on staff. V2 stated she does have agency Registered Nurses that work at the facility at times. The facility schedules dated July 2025 and August 2025 documents the facility did not have RN coverage on 7/18, 7/19, 8/9, 8/10, and 8/23/25. On 8/18/25 at 4:25 PM, V2 confirmed in email the facility did not have RN coverage on the above listed dates. Event ID: Facility ID: 145664 If continuation sheet Page 3 of 5 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 08/19/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were available to be administered as ordered for 1 of 1 (R5) resident reviewed for pharmacy services in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability.R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact.R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Softgel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement).R5's Medication Administration Records (MAR) dated 4/1/2025 through 4/30/25, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, 7/1/2025 to 7/31/2025, and 8/1/2025 to 8/31/2025 document a physician order for Preservision AREDS 2 Soft gel to be given once daily by mouth. These same MAR's document initials on each indicating R5 was administered Preservision AREDS 2 one capsule daily.R5's current Care Plan does not document a Focus area related to the diagnosis of Macular Degeneration.On 8/18/25 at 11:29 AM, R5 stated she called the State Survey Agency yesterday because the facility was giving her Ocuvite for her Macular Degeneration, instead of the Preservision her physician had ordered. R5 stated she had told nursing (unknown), Administration (V1), Director of Nursing/DON (V2), and the Assistant Director of Nursing/ADON (V14) and they hadn't done anything to correct it. R5 asked this surveyor to walk with her to the medication cart to see they were administering the wrong medication. At the medication cart, V8 (Licensed Practical Nurse/LPN) pulled out a bottle of medication at R5's request and showed this surveyor it was Preservision. V8 told R5 we got the Preservision this morning. The bottle had a date of 8/18 handwritten on the lid. R5 stated the V8 so you got it after I called it in to state.On 8/18/25 at 12:56 PM, V8 (LPN) stated the pharmacy stopped sending stock medications in the cards and she had ordered the Preservision but all she could get was the Ocuvite. V8 stated they called the pharmacy and were told it was the same formulary and were told to use the Ocuvite by V2 (Director of Nurses) so they administered the Ocuvite in place of the Preservision. When asked how long R5 received the Ocuvite in place of the Preservision, V8 stated she wasn't sure. V8 stated they tried to call the physician who prescribed it but they hadn't received a call back. V8 stated it had been weeks, maybe months.On 8/18/25 at 1:13 PM, V10 (LPN) stated when she got to work on the night of 8/17/25, R5 was worked up, about the Preservision. V10 stated she tried calling R5's physician on 8/18/25 and notified V2 (DON) and V14 (ADON). V10 stated they went out and purchased the Preservision this morning.On 8/18/25 at 3:20 PM, V2 (DON) stated R5 had an order for the Preservision and was getting it from the pharmacy and then it wasn't covered by her insurance anymore. V2 stated the only thing she was able to order was the Ocuvite. V2 stated the pharmacy was called and they said it was the same thing. V2 stated they tried to reach out to R5's Primary Physician to the get the order changed. When asked how long R5 was receiving the Ocuvite instead of the Preservision, V2 stated she didn't know. When asked if the physician order was still Preservision and if the facility nursing staff were signing, they administered Preservsion instead of Ocuvtie, V2 stated she didn't know. On 8/19/25 at 10:57 AM, V14 (ADON) stated V2 wasn't in the facility today but she was familiar with R5 and the Preservision order. V14 stated the pharmacy was providing the Preservision initially and then they stopped providing it. V14 wasn't sure why but she thought it had something to do with R5 reaching her maximum allowed amount. V14 stated she was made aware on 8/8/25 by R5 that she was receiving Ocuvite and not Preservision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 4 of 5 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 08/19/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete as ordered.On 8/19/25 at 11:08 AM, V15 (Pharmacist) stated R5's Preservision was filled on 4/28/25 for a 30-day supply and had not been filled by their pharmacy since then. V15 stated the Preservision has a different formula than Ocuvite with different concentrations of vitamins and minerals. V15 stated they didn't send any to the facility after 4/28/25 because they didn't have any refills and if the facility would fax over a new prescription for the Preservision they would fill it.The facility Medication Administration through Certain Routes of Administration policy dated 11/15/24 documents, Applicability: Policy 6.7 establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care (LTC) facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations. Event ID: Facility ID: 145664 If continuation sheet Page 5 of 5