Health inspection·January 9, 2026

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some two, but then it goes back to how it was.A concern/complaint form dated 11/25/25 from R5 documents the following beside the heading Nature of Concern/Compliment: Today drinks were not put out until around 3:30ish. I've asked them half the day to put them out so we can stop knocking on the door and making them mad. There is no consistency here. We don't know who to listen to and who not. Everything changes daily.4. R3's admission Record documents an admission date of 06/06/25 and included diagnoses of protein calorie malnutrition, chronic obstructive pulmonary disease, muscle wasting and atrophy, pain in right shoulder, type 2 diabetes mellitus with diabetic neuropathy, age related osteoporosis, sleep apnea, gastroduodenitis, intestinal adhesions, adult failure to thrive, gout, low back pain, and aortocoronary bypass graft. R3's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment. On 01/05/26 at 11:42 AM, R3 stated sometimes if residents ask for help, the CNAs will snap your head off. R3 stated when pushing their (call light) button they take a while. R3 said sometimes they say they will come back but it can take a long time and then they (residents) will still get attitude about it from them. R3 stated the CNA's are not always nice, adding that it depends on the CNA's so it can be different shifts, but nights and evenings can be the worst. On 01/07/26 at 9:10 AM R3 stated, they did not bring up the staff's attitudes in resident council last month. R3 said the staff in the meeting just want to keep moving on with topics, but the residents have told staff this concern.A resident concern/complaint form from R3 dated 11/25/25 documents the following beside the heading Nature of Concern/Compliment: They never put the menu up on the board till late, then get mad when we ask for the sub (substitute) close to the mealtime. It's so high (menu board) we can't read it. The kitchen worker (girl) told me if I wanted ice to go to the room before my room to get it. That's the break room that's locked. I stopped asking for drinks because they get so mad.5. R6's admission Record documented an admission date of 05/28/25 and included diagnoses of epilepsy, anxiety disorder, major depressive disorder, polyneuropathy, dysphagia, age related osteoporosis, atrial fibrillation, encephalopathy, and mild intellectual disabilities. R6's MDS dated [DATE] documented a BIMS score of 14, indicating cognition is intact.On 01/05/26 at 11:47 AM, R6 stated the staff are not always nice, they can rush you sometimes. R6 stated they (residents) have talked about the staff's attitudes and being nicer in resident council before.6. R7's admission Record documented an admission date of 04/04/25 with diagnoses including anxiety disorder, muscle wasting and atrophy, cerebral infarction, depression, schizoaffective disorder, bipolar disorder, convulsions, and blindness one eye. R7's MDS dated [DATE] documented a BIMS score of 11, indicating moderate impairment.On 01/05/26 at 12:37 PM, R7 stated sometimes the staff are nice and sometimes they are not as nice.7. R8's admission Record documented an admission date of 04/04/25 and included diagnoses of major depressive disorder, depression, and chronic pain syndrome. R8's MDS dated [DATE] documented a BIMS score 15, indicating cognition is intact.On 01/07/26 at 8:48 AM, R8 stated sometimes getting the CNA's to get something for you or help you with something is like pulling teeth. R8 stated the night CNA's can be the worst and you definitely cannot get a glass of milk at night. The night staff can definitely have attitudes, and they can take a long time to answer your light.8. R9's admission Record documented an admission date of 11/29/25 and included diagnoses of anxiety disorder, depression and muscle wasting and atrophy. R9's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 8:50 AM, R9 stated the night CNA's get to do anything they want, they have the worst attitudes. R9 stated he has asked for ice before at night and got an attitude for asking. R9 stated it can sometimes be 45 minutes to an hour before they answer your call light at night. 9. R11's admission Record documented an admission date of 04/12/23 and included diagnoses of anxiety disorder, major depressive disorder, age related osteoporosis, pan lobular emphysema, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 2 of 7 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 01/09/2026 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some restless legs syndrome, intervertebral disc degeneration lumbar region, and dementia. R11's MDS dated [DATE] documented a BIMS score of 03, indicating severe cognitive impairment.On 01/05/26 at 11:55 AM, R11 was alert to situation at the time of this interview. R11 stated some of the staff are not nice or gentle, but she does not remember their names. R11 stated they take a while to answer your light or will say they will come back and they do not.it is so aggravating. R11 stated just the other day she asked for ice and she did not get it, she was told they were out.10. R12's admission Record documented an admission date of 09/01/20 and included diagnoses of schizotypal disorder, syncope and collapse, protein calorie malnutrition, and assistance with personal care. R12's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 9:06 AM, R12 stated the staff are typically too busy on their phones to pay attention to a lot of things. R12 said there are staff that are not always nice to R3 and R6. The times R12 has seen it, it has been V8 (CNA), adding that V8 just doesn't have patience with them. R12 stated some of these residents have nothing else and they just need to be patient with them.11. R13's admission Record documented an admission date of 07/15/25 and included diagnoses of anxiety disorder, depression, and chronic pain syndrome. R13's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 7:52 AM, R13 stated the kitchen staff can be unhappy with you for knocking on the kitchen door when they are busy, but if you want a substitute you have to tell them before 10:30 AM. R13 stated they don't always know what is for lunch so sometimes they have to knock more than once because they will not answer the door, then they are more unhappy. R13 stated the CNA's can be snappy and have an attitude with you, depending on the CNA.12. R14's admission Record documented an admission date of 06/28/19 and included diagnoses of dementia, heart failure, and Parkinson's disease.On 01/07/26 at 8:20 AM, R14 stated they have talked about CNA's attitudes in resident council before. R14 stated some of the CNA's attitudes have gotten better and some of the CNA's attitudes have stayed the same. R14 stated it has been brought up in resident council about the CNA's being too rough and rushed with some of the older more fragile residents.13. R15's admission Record documents an admission date of 08/27/25 and included diagnoses of malignant neoplasm of retroperitoneum, malignant neoplasm of unspecified testis, depression and generalized anxiety disorder. R15's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 8:29 AM, R15 stated the night shift CNA's can be short with you and not always polite. R15 stated sometimes they will just ignore you or just act like they are better than you. R15 stated he cannot help that he is in here; he has cancer but he doesn't think they need to act like they are better than him.On 01/06/26 at 6:28 PM V7 (CNA) was attempted to be called with no answer and no return call. At 6:29 PM, V11 (CNA) was attempted to be called with no answer and no return call, and at 6:30 PM, V12 (CNA) was attempted to be called with no answer. On 01/07/26 at 7:11 PM, V7 was again attempted to be called with no answer and no return call.On 01/07/26 at 7:12 AM, V2 (Director of Nursing) stated she is not aware of poor attitudes regarding any CNAs. On 01/07/26 at 1:12 PM, V6 (CNA) stated he has not seen any CNAs having attitudes with residents.Resident Council meeting minutes dated 10/29/25 documented under Complaints, Concerns, and Compliments there were None regarding Activities, Administration, Business Office and Social Services. Next to Nursing was a documented complaint of 2nd shift not passing ice waters. Resident Council meeting minutes dated 11/6/25 documented ice water being passed has improved. Under Complaints, Concerns, and Compliments, next to Admin was documented sometimes hard to get in to see her and next to Nursing was documented None. Resident Council meeting minutes dated 12/4/25 documented no Complaints, Concerns and Compliments for Nursing, adding Staff doing well addressing concerns.On 01/07/26 at 1:26 PM, V5 (Activities Director/Acting Dietary Manager) stated she has been filling in as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 3 of 7 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 01/09/2026 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dietary manager for the last couple of weeks. V5 stated she still does the resident council meetings. V5 stated she doesn't remember residents talking about the staff or the staff attitudes in the last couple meetings, but she knows they have in the past. V5 stated she will take more detailed minutes in the future.On 01/07/26 at 2:58 PM V1 (Administrator) stated, she would expect the residents to be treated with dignity and respect. V1 stated, she would not expect the staff to act exasperated or give the residents attitudes if they ask them for something. V1 stated, she will discuss this with them.An untitled facility document dated 07/2024 provided by V1 (Administrator) includes a heading of Employee Standards of Conduct and documents (company name) expects that each employee's conduct and performance will conform with the highest standards of professionalism with respect to the treatment of all residents, visitors and their families and our ethical practices; the requirements of their job; published and common-sense health and safety rules; and applicable federal, state and local lows, rules and regulations. Event ID: Facility ID: 145664 If continuation sheet Page 4 of 7 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 01/09/2026 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide food in a manner that was palatable for 14 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, R14, R15) of 15 residents reviewed for palatable food.Findings include:1. R1's admission Record documented an admission date of 03/31/25 with diagnoses that included muscle wasting and atrophy, iron deficiency anemia, vitamin deficiency, vitamin B12 deficiency anemia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status) score of 15, indicating cognition is intact.On 01/07/26 at 10:45 AM, R1 stated they have talked about the facility food and the issues with it in the Resident Council meeting he attended. R1 said they were supposed to have a food council, but he does not know what happened to that. R1 stated he has told the facility staff about the food issues, like the quality of the food, the temperature of the food, and there not being enough meat in the food several times.On 01/05/26 at 1:20 PM, R1 stated the food is not hot. R1 stated he sends his food back several times because it is cold. R1 said his room is too far from the kitchen and that is why his food is cold. R1 stated it is cold and looks gross.2. R2's admission Record documented an admission date of 03/02/23. R2's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment.On 01/05/26 at 12:11 PM, R2 received her lunch which included beef stew, peas, and bread. At 12:12 PM, R2 stated she was not eating the peas, she doesn't like them, and they are cold. R2 stated to this surveyor, you should try them, feel them. R2 said the beef stew was not hot, but it was warmer so she would eat it, but said you can see where the grease is solidifying on the top. R2 said the food is generally bad and usually cold.The facility document titled, Week at a Glance dated day 16 documented: beef stew, green beans, biscuit/margarine, fudge brownie and beverage.On 01/05/26 at 9:15 AM a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 01/05/26 at 12:12 PM, the temperature of the R2's peas were measured with R2's permission, and the temperature registered 83 degrees Fahrenheit.3. R4's admission Record documented an admission date of 12/02/25 and included diagnoses of hypocalcemia, anemia, acute metabolic acidosis, vitamin D deficiency, hypokalemia, and unspecified severe protein calorie malnutrition. R4's MDS dated [DATE] documents a BIMS score of 15, indicating cognition is intact.On 01/05/26 at 12:17 PM, R4 stated the food is typically cold. R4 said look, I put the margarine on the peas and it is not even slightly melting. The peas on R4's plate were observed to have solid margarine spread over them, with no signs of the margarine melting onto the peas.4. R5's admission Record documented an admission date of 08/18/25 and included diagnoses of muscle wasting and atrophy and gastro-esophageal reflux disease. R5's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/05/26 at 11:10 AM, R5 stated she generally eats in her room. R5 said the food doesn't look great sometimes, but it has been better the last week or so. R5 stated the food is generally not warm, and that's sad when the butter won't melt on the food, even a little. R5 said It's sad, food is one of the only things we have to look forward to in here. Food, activities.and TV, so food is pretty important to us.5. R3's admission Record documented an admission date of 06/06/25 and included diagnoses of protein calorie malnutrition, muscle wasting and atrophy, type 2 diabetes mellitus with diabetic neuropathy, deficiency of other specified B group vitamins, vitamin D deficiency, fatty liver, and adult failure to thrive. R3's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment.On 01/05/26 at 11:42 AM, R3 stated the food can be awful sometimes and added that it is also cold at times.6. R6's admission Record documented an admission date of 05/28/25 and included diagnoses of gastro esophageal reflux disease, iron deficiency Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 5 of 7 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 01/09/2026 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some anemia, vitamin D deficiency, dysphagia, atrial fibrillation, and mild intellectual disabilities. R6's MDS dated [DATE] documented a BIMS score of 14, indicating cognition is intact.On 01/05/26 at 11:47 AM, R6 stated the food is not always good and there are times it is not hot and sometimes it is barely warm.On 01/07/26 at 8:12 AM, R6 stated they have discussed the food, it's quality and the temperature in Resident Council meetings before.7. R7's admission Record documents an admission date of 04/04/25 and included diagnoses of muscle wasting and atrophy, gastro esophageal reflux disease, and pyridoxine deficiency. R7's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment.On 01/05/26 at 12:37 PM, R7 stated the food was hotter today than usual, but the peas are cold.8. R8's admission Record documented an admission date of 04/04/25. R8's MDS dated [DATE] documented a BIMS score 15, indicating cognition is intact.On 01/07/26 at 8:48 AM, R8 stated the food is not good when it is cold and there are a fair amount of times when the food is cold.9. R9's admission Record documented an admission date of 11/29/25 and included diagnoses of type 2 diabetes mellitus with diabetic polyneuropathy, and muscle wasting and atrophy. R9's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 8:50 AM, R9 stated sometimes the food is not good, especially when it is cold. R9 stated, the food can be cold a lot.10. R11's admission Record documented an admission date of 04/12/23. R11's MDS dated [DATE] documented a BIMS score of 03, indicating severe cognitive impairment.On 01/05/26 at 11:55 AM, R11 was alert to situation and stated the food is not good and there is not enough of it. R11 stated the food is barely warm most of the time.11. R12's admission Record documented an admission date of 09/01/20 and included diagnoses of protein calorie malnutrition, and assistance with personal care. R12's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 9:06 AM, R12 stated the food they get is not always hot. R12 said she's been told that if she would eat in the dining room, her food would be hotter. R12 stated she doesn't think that is right, if she wants to eat in her room she should be able to have hot food there also. R12 stated she believes the quality of the food was brought up at the last Resident Council meeting she attended.12. R13's admission Record documented an admission date of 07/15/25 and included diagnoses of type 2 diabetes mellitus, and iron deficiency anemia secondary to blood loss. R13's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 7:52 AM, R13 stated the food is just barely warm. R13 stated they have discussed the food with the staff before and discussed it during Resident Council meetings.13. R14's admission Record documented an admission date of 06/28/19. R14's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 8:20 AM, R14 stated when the food is not hot it is not good and the food is not hot somewhat often. R14 stated they have talked about the food in resident council before.14. R15's admission Record documents an admission date of 08/27/25 and included diagnoses of vitamin D deficiency, and gastro esophageal reflux disease. R15's MDS dated [DATE] documented a BIMS score of 15, indicating cognition is intact.On 01/07/26 at 8:29 AM, R15 stated he does not like cold food, that is the one thing he really dislikes. R15 stated the food here is cold and the other day the pancakes were so cold the butter would not melt. R15 stated it has gotten better the last two to three weeks, now the food is only cold about half the time.The facility document titled, Week at a Glance dated day 18 documents: tuna casserole, buttered carrots, bread/margarine, Gelatin with whipped topping, and beverage.On 01/07/26 at 7:20 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 01/07/26 at 12:46 PM, a test tray was acquired from the kitchen and the temperature of the food was measured. The tuna noodle casserole was 98 degrees Fahrenheit and the carrots were 103 degrees Fahrenheit.Resident Council meeting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145664 If continuation sheet Page 6 of 7 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 01/09/2026 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete minutes dated 10/29/25 documented under Complaints, Concerns, and Compliments for Dietary Wasn't a fan of the goulash, meal of the month didn't get the potatoes they asked for or the cobblers. Resident Council minutes dated 11/06/25 documented under Complaints, Concerns, and Compliments for Dietary chili was too spicy; don't want the three bean salad anymore. Resident Council meeting minutes dated 12/04/25 documented under Complaints, Concerns, and Compliments for Dietary Drink station has been set up late; requests something besides scrambled eggs lately.On 01/07/26 at 1:26 PM, V5 (Activities Director/Acting Dietary Manager) stated she has been filling in as the dietary manager for the last couple of weeks. V5 stated she does not know if they have done a food council meeting, V13 (previous Dietary Manager) should have done one or two, but she does not have any minutes from any meetings. V5 stated on 01/05/26, they substituted peas for the green beans and bread for the biscuit. V5 stated, the food should be hot whether the residents eat in their room or the dining room. V5 stated the food should be hotter than 103 degrees Fahrenheit and should be hot enough for the margarine to melt at least somewhat. V5 stated she still does the resident council meetings. Regarding resident complaints of food quality and temperatures, V5 stated she doesn't remember residents talking about the food temperatures or quality in the last couple meetings, but V5 stated she will take more detailed minutes in the future.On 01/07/26 at 2:58 PM, V1(Administrator) stated she would expect the food to be hot when the residents receive it no matter where they eat. V1 stated she was not for sure an exact temperature the food should be, but the residents should feel it is hot.The undated facility policy titled, Handling, Serving, and Transporting Foods documents: foods should be handled, served, and transported at the proper holding temperatures. Foods should be presented attractively, under sanitary conditions, and according to the facility menu. Event ID: Facility ID: 145664 If continuation sheet Page 7 of 7