Inspection·September 16, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility Resident Council Meeting minutes dated 4/28/22 document Nursing: Requested more help. Have to turn on call lights well before they need help because of length of time it takes to answer call lights. Sometimes have to do for themselves. Resident Council Memorandum dated 4/28/22 documents under Department Response: We have just hired a DON (Director of Nurses) and have been sending out tons of help wanted ads for the department. Also hired a night shift aide. The Resident Council Meeting minutes dated 5/25/22 document under new/business/concerns: .call lights . with no department response documented on the resident council memorandum. The facility resident council dated 6/27/22 documents call lights taking a while . The Resident Council Meeting minutes dated 8/25/22 documents, .Doing well other than respond (sic) to call lights. There is no documentation of department responses for the 6/27/22 and 8/25/22 meeting. On 9/16/22 at 1:36 PM, V13 (Regional Director of Operations) stated she was not able to locate any department responses or Quality Assurance reviews related to the resident concerns of call lights not being answered in the resident council meetings. The facility Resident Rights dated 11/18 documents under Your rights to dignity and respect Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 2 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0553 Level of Harm - Minimal harm or potential for actual harm Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on interview and record review, the facility failed to involve a resident's representative in care planning for one resident of 27 residents (R17) reviewed for care plans in the sample of 27. Residents Affected - Few Findings include: On 09/13/22 at 02:55 PM, V8, R17's Power of Attorney (POA) stated in the past year she has received no invitations to participate in R17's care planning meetings, either by phone or in person. R17's Face Sheet listed V8 as R17's POA. R17's Care Plan documented that it was reviewed and updated on 07/11/22. There was no documentation on the care plan to indicate V8 was involved in its development. On 09/15/22 at 12:11 PM, V2, Minimum Data Set Coordinator/Care Plan Coordinator/Licensed Practical Nurse, stated she has not sent out any care plan invitations in the past year. V2 stated this is due to her having to perform other duties such as working on the floor and helping to cover Director of Nurses (DON) duties since the facility is without a DON. A Comprehensive Care Planning Policy with a revision date of 07/20/22 documented, The resident/guardian/representative of upcoming care conferences(shall be notified of the care plan meeting) and (staff should)accommodate(their) schedule as appropriate . Notify the resident/guardian/representative when significant changes are made to (the care plan) and (the representative should be )afforded the opportunity to sign after significant changes are made to the CCP (Comprehensive Care Plan). Documentation of the notification of the resident/guardian/responsible party of significant changes to the CCP can be accomplished via signature on the IDT (Interdisciplinary Team) Progress Note, on the New Care Plan page, on Care Plan Summary/Participation Record or documentation in the Nurse ' s Notes or Social Services notes if updates (are) given per phone, (the representative)refused to sign, or attempts to contact (the representative) have been unsuccessful. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 3 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to ensure residents were safe from abuse for 1 of 4 residents (R25) reviewed for abuse in a sample of 27. Residents Affected - Few The findings include: R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses in part of invert lumbar disc with myelopathy lumbar region, spinal stenosis cervical region, crushing injury multiple sites, agoraphobia with pan disorder, injury of unspecified blood vessel at neck level, difficulty in walking, post-traumatic stress disorder, personal history of traumatic brain injury, low back pain, post-traumatic. R25's September Physician's Order Sheet (POS) documents he is prescribed Olanzapine 15 mg (milligram) tablet take 1 tablet by mouth once daily; Sertraline 50 mg tablet take 1 ½ tablets (75 mg) by mouth once daily. R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident-to-resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 (Family) notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to Seroquel. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her. V1 confirmed she had not done an abuse investigation for R12 and R25. When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. During the course of this survey the facility could not provide any reproducible evidence that the altercation between R12 and R25 had been investigated. The facility's Abuse Prevention Program policy dated 05/2017 includes - This facility affirms the right of our residents to be free from abuse .This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 4 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete its control to prevent occurrences of mistreatment, neglect, or abuse of our residents .This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual .Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Event ID: Facility ID: 145692 If continuation sheet Page 5 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm 2. R20's profile face sheet documents an original admission date of 7/13/18. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. Residents Affected - Few On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for dialysis and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for dialysis and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated no, nothing. On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health IDPH) involving misappropriation of items or potential theft of money for R20 nor was the physician, family or police notified. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor, so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June regarding R20's missing razor and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. On 9/15/22 at 1:00 PM, V4 (Business Office Manager) stated that she had heard that R20 was missing a razor, but it has never been found to her knowledge. On 9/15/22 at 1:45PM, review of IDPH data base of reported incidents of abuse allegations, documents no reports involving R20's missing money or razor. The facility's Abuse Prevention Program policy dated 05/2017 documents in part- This facility affirms the right of our residents to be free from abuse .This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents .This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 6 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few services to the individual .IV. Internal Reporting Requirements and Identification of Allegations .Supervisors shall immediately inform the administrator or his/her designated representative .of all reports of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator of designee shall initiate an investigation .VI. Internal Investigation of Allegations and Response, 1. Appointing an investigator. Once the administrator or designee receives an allegation of mistreatment, neglect or abuse .and misappropriation of resident property, the administrator will appoint a person to take charge of the investigation .5. Final Investigation Report .the investigator or designee with report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident .the administrator or designee with review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is responsible for informing the resident or their representative of the result of the investigation and of any corrective action taken . VII. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to a least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion 4. Informing Law Enforcement Authorities .If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours . Based on interview and record review the facility failed to implement their abuse policy by failing to notify the Illinois Department of Public Health, notify the local police, and initiate abuse investigations for allegations of abuse for 3 of 4 residents (R25, R12 and R20) residents reviewed for abuse in the sample of 27. The findings include: 1. R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses in part of invert lumbar disc with myelopathy lumbar region, spinal stenosis cervical region, crushing injury multiple sites, agoraphobia with pan disorder, injury of unspecified blood vessel at neck level, difficulty in walking, post-traumatic stress disorder, personal history of traumatic brain injury, low back pain, post-traumatic. R25's September Physician's Order Sheet (POS) documents he is prescribed Olanzapine 15 mg (milligram) tablet take 1 tablet by mouth once daily; Sertraline 50 mg tablet take 1 1/2 tablets (75 mg) by mouth once daily. R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident-to-resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 7 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 (Family) notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to Seroquel. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her and confirmed she had not done an abuse investigation for R12 and R25 nor reported it to the department . When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. When asked who is responsible for doing the abuse investigations for the facility, V1 stated she was the one who did them, but just did not remember this one. During the course of this survey the facility could not provide any reproducible evidence that the altercation between R12 and R25 had been investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 8 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. Based on interview and record review the facility failed to notify the local police on an allegations of misappropriation of resident property for 1 of 3 (R20) reviewed for abuse allegations in a sample of 27. The Findings Include: R20's profile face sheet documents an original admission date of 7/13/18. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for dialysis and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for dialysis and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated 'no, nothing.' On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health involving misappropriation of items or potential theft of money for R20 nor was the physician, family or police notified. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor, so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. The Facility Abuse and Prevention Program Policy dated 5/2017 documents in part, VII. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 9 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0608 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to a least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion 4. Informing Law Enforcement Authorities .If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours . Event ID: Facility ID: 145692 If continuation sheet Page 10 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. R20's profile face sheet documents an original admission date of 7/13/18. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for dialysis and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for dialysis and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated 'no, nothing.' On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health involving misappropriation of items or potential theft of money for R20. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor, so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. On 9/15/22 at 1:45PM, review of IDPH data base of reported incidents of abuse allegations, documents no reports involving R20's missing money or razor. The facility's Abuse Prevention Program policy dated 05/2017 documents in part- .VII. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to a least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 11 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on interview and record review the facility failed to report allegation of abuse to the Department of Public Health for 3 of 4 residents (R25, R12, R20) reviewed for abuse in a sample of 27. The findings include: R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident-to-resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to Seroquel. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her and confirmed she had not done an abuse investigation for R12 and R25 nor reported it to the Department. When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. When asked who is responsible for doing the abuse investigations for the facility, V1 stated she was the one who did them, but just did not remember this one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 12 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm R20's profile face sheet documents an original admission date of 7/13/18. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. Residents Affected - Few On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for dialysis and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for dialysis and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated 'no, nothing.' On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health involving misappropriation of items or potential theft of money for R20. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. On 9/15/22 at 1:00 PM, V4 (Business Office Manager) stated that she had heard the razor was missing but it has never been found to her knowledge. On 9/15/22 at 1:45PM, review of IDPH data base of reported incidents of abuse allegations, documents no reports involving R20's missing money or razor. The facility's Abuse Prevention Program policy dated 05/2017 includes - .IV. Upon learning of the report, the administrator of designee shall initiate an investigation .VII. 1. External Reporting of Potential Abuse - Initial Reporting of Allegation: The facility must ensure that all alleged violations involving .neglect or abuse .misappropriation of resident property .are reported immediately to .other officials in accordance with State law through established procedures .the report must be made to .the Illinois Department of Public Health .not later than 24 hours after forming the suspicion. A written report must be sent to the Department of Public Health. The written report should contain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 13 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the following information, if known at the time of the report; Name, age, diagnosis and mental status of the resident allegedly abused or neglected; Type of abuse reported (physical, sexual, theft, neglect, verbal or mental abuse); Date, time, location and circumstances of the alleged incident; Any obvious injuries or complaints of injury; and, Steps the facility has taken to protect the resident. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted. Based on interview and record review the facility failed to initiate, thoroughly investigate, and maintain documentation of a thorough investigation for an allegations of abuse for 3 of 4 residents (R25, R12,R20) reviewed for abuse in a sample of 27. The Findings Include: R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses in part of invert lumbar disc with myelopathy lumbar region, spinal stenosis cervical region, crushing injury multiple sites, agoraphobia with pan disorder, injury of unspecified blood vessel at neck level, difficulty in walking, post-traumatic stress disorder, personal history of traumatic brain injury, low back pain, post-traumatic . R25's September Physician's Order Sheet (POS) documents he is prescribed Olanzapine 15 mg (milligram) tablet take 1 tablet by mouth once daily; Sertraline 50 mg tablet take 1 1/2 tablets (75 mg) by mouth once daily. R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident to resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to Seroquel. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her and confirmed she had not done an abuse investigation for R12 and R25. When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. When asked who is responsible for doing the abuse investigations for the facility, V1 stated she was the one who did them, but just did not remember this one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 14 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure comprehensive assessments were completed timely for 1 of 27 (R281) residents reviewed for assessments in the sample of 27. Findings Include: R281's facility undated New admission Information documents R281 was admitted to the facility on [DATE]. R281's Physician's Order sheet dated 9/2/22 documents diagnoses that include acute kidney failure and prostate cancer. On 9/15/22 at 1:02 PM, V2 (LPN/MDS Coordinator) stated R281 did not have a current MDS (Minimum Data Set) assessment completed. V2 stated it should have been done but has not. On 9/16/22 at 10:14 AM, V2 (LPN/MDS Coordinator) stated R281 should have had a five-day MDS assessment completed on 9/9/22 and a 14 day MDS assessment completed on 9/14/22. V2 stated the assessments were not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 15 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure quarterly assessments were completed timely for 2 of 27 (R1 and R3) residents reviewed for timely quarterly assessments reviewed for in a sample of 27. Residents Affected - Few The Findings Include: 1. R1's facility undated New admission Information documents R1 was admitted to the facility on [DATE]. On 9/16/22 at 10:14 AM, V2 (LPN/MDS Coordinator) confirmed that the most recent MDS (Minimum Data Set) completed for R1 was on 4/20/22. 2. R3's facility undated New admission Information documents that R3 was admitted to the facility on [DATE]. On 9/16/22 at 10:14 AM, V2 confirmed the most recent MDS completed for R3 was done on 4/29/22 On 9/15/22 at 1:02 PM, V2 (LPN/MDS Coordinator) stated R1 and R3 did not have a current up to date quarterly MDS assessments completed. V2 stated it should have been done but has not because she has been busy working to fill floor nursing shifts and helping V1 (Administrator) with nursing issues due to not having a current Director of Nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 16 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0661 Level of Harm - Minimal harm or potential for actual harm Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on record review and interview the facility failed to ensure that a recapitulation of stay was completed for 1 of 2 residents (R30) reviewed for discharge in a sample of 27. Residents Affected - Few The Findings Include: R30's profile face sheet documents an admission date of 12/22/21. R30's nursing progress notes documents on 6/23/22 that resident was discharged home with family. Review of R30's closed record had no copy of a discharge summary, or a recapitulation of stay found in the document. On 9/15/22 at 10:15AM, V3 (Social Services) reviewed the closed record and confirmed that there was no indication other than a nursing progress note stated that resident was discharged home. V3 went on to state that they should be doing a discharge summary or recapitulation of stay with all departments documenting when a resident is discharged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 17 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to check the placement of a gastrostomy feeding (G) tube prior to administering medication for one resident of one resident (R228 ) reviewed tube feeding in the sample of 27. Findings include: On 09/13/22 at 2:08pm, V7, Registered Nurse, was observed administering Mylanta 30cc (cubic centimeters) to R228. V7 unhooked the G tube from the feeding pump, flushed the tube with 60 cc of water via syringe, pushed the Mylanta in with the syringe, and followed with another 60cc of water. V7 then hooked the tubing back up to the pump and the feeding began infusing again. The surveyor asked V7 if facility policy called for checking the placement of the G tube prior to administering the medication, to which V7 replied, I checked it earlier today. I guess I could have rechecked it before I gave the medication. R228's September 2022 Physicians Order Sheet documented an order for Mylanta 30cc daily via G tube, flush tube with 60cc of tap water before and after the medication. An Administration of Medication via a Feeding Tube Policy dated 11/06/18 documented, Policy: It is the policy of(the facility) that when feeding is provided via (G) tube, the resident may receive ingestible medication via the feeding tube when the oral route cannot be used and an order for such exists .Stop the feeding and disconnect tubing if you are interrupting a continuous pump feeding. Check for tube placement by checking the (gastric content) residual. If no residual is aspirated, verify placement by placing (a)stethoscope over the stomach and instilling approximately 30 cc of air. Auscultate for air installation, proceed if heard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 18 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 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 designate a Director of Nursing for the facility. This failure has the potential to affect all 34 residents residing in the facility. Residents Affected - Many Findings Include: On 09/13/22 at 10:20 AM, V1 (Administrator) acknowledges the facility does not have a Registered Nurse (RN) working in the Director of Nursing (DON) role for the facility. V1 states that V2 (Minimum Data Set / Care Plan Coordinator) who has a Licensed Practical Nursing license works to fill the DON duties at this time. V1 states the facility has sought to hire a DON, but been unsuccessful, but that they have an interview schedule for 9/14/22. On 9/15/22 at 1:30 PM, V2 stated that they have not had a DON for a couple months but is unsure of her last date on the schedule. V2 stated that she is trying to help V1 with those DON duties but that she is a Licensed Practical Nurse (LPN) so she is limited. V1 (Administrator) was unable to verify prior to exit the last date of employment of DON due to having to quarantine after testing positive for COVID. The resident census and conditions list provided by the facility on 9/15/22 documents 34 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 19 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0791 Provide or obtain dental services for each resident. 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 ensure timely dental care was provided for 1 of 1 (R11) resident reviewed for dental services in the sample of 27. Residents Affected - Few Findings Include: R11's undated face sheet documents R11 was admitted to the facility on [DATE]. R11's MDS (Minimum Data Set) dated 8/31/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R11 is cognitively intact. R11's nurse's notes dated 8/9/22 at 3:15 PM documents, Resident (R11) c/o (complains of) R (right) tooth pain. Notified transportation to check on a dentist appt (appointment) for resident. R11's progress notes were reviewed 8/1/22 through 9/15/22 with no further documentation related to tooth pain and/or a dental appointment being scheduled. On 9/14/22 at 1:07 PM, R11 stated she is needing a dental appointment but doesn't have the money to go to the dentist. R11 stated her teeth hurt her occasionally. R11 showed this surveyor her mouth and observed teeth broken off at the gum line with no full teeth observed. On 09/15/22 at 3:02 PM, V10 (Transportation/Medical Records) stated she was not aware R11 was having dental pain. V10 stated she had not scheduled an appointment with a dentist for R11. V10 stated she would call R11's son and get a dental appointment scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 20 of 21 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed, according to its policy, to notify a resident's representative of positive COVID tests of a resident and a staff member. This has the ability to affect all 34 residents living at the facility. Residents Affected - Many Findings include: On 09/13/22 at 7:55am, V1, Administrator, stated the facility currently had one resident, R1, who was in isolation due to testing positive for COVID on 09/12/22. On 09/13/22 at 2:55pm, V8 stated she is the Power of Attorney (POA) for R17. V8 stated within the past year, the facility has not been notifying her of positive cases of COVID within the resident population nor the staff members. On 09/14/22 at 3:10pm, the door to R1's room had a red sign on it which read, Isolation: See nurse before entering. R1, who was alert and oriented to person, place, and time, confirmed he has been in isolation for testing positive for COVID on 09/12/22. On 09/15/22 at 12:48PM, V1 Administrator, was interviewed by phone. V1 stated she was not at the facility as on 09/14/22 she tested positive for COVID. V1 stated she is currently the only staff member out with COVID. V1 stated she was not sure if staff had notified residents and their representatives of a COVID positive staff member and resident. V1 stated these notifications are to be recorded in the Nursing Progress Notes. V1 stated she was not sure if the facility was still required to notify residents and their representatives of COVID cases. R17's Face Sheet listed V8 as R17's POA. R17's Nursing Progress Notes for September 2022 had no documentation to substantiate V8 was contacted about R1 nor V1 having tested positive for COVID. A COVID 19 Control Measures Policy with a revision date of 2/21/22 documented, Written notification should be initiated and completed by 5pm the following day to each resident of the facility, residents family/representatives, and to all staff members upon the identification of a single confirmed Covid infection of a resident or staff member. A Resident Census and Conditions form dated 09/13/22 documented a total of 34 residents living at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 21 of 21