Inspection·November 7, 2023

F 0656 On 11/01/2023, at 12:30 PM, there was no Comprehensive Care Plan for R20 available for review. Level of Harm - Minimal harm or potential for actual harm On 11/01/2023, at 1:30 PM, V4 (MDS Coordinator/LPN) stated that the facility's computer system has been down, and she has not been able to complete the care plan. Residents Affected - Few On 11/02/2023, at 8:45 AM, V4 was observed writing out R20's Comprehensive Care Plan and was given to surveyor for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 2 of 6 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 11/07/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to implement new and applicable interventions to prevent further falls for 1 of 3 residents (R9) reviewed for falls in a sample of 25. Findings include: R9's Face Sheet documents an admission date of 01/06/21. R9's Physician Order Sheet dated 11/01/23 documents diagnoses including: [NAME] korsakoff syndrome, hypertension, anxiety, dementia with behaviors, and a left hip fracture. R9's Minimum Data Set (MDS) dated [DATE] documents a Brief interview for Mental Status (BIMS) of 11 indicating R9's cognition is moderately impaired. Section GG documents R9's Functional Abilities as: Partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for chair/bed - to - chair transfers, toilet transfers and sit to stand. R9's care plan dated 01/03/23 under the category titled, Falls documents an intervention dated 11/24/22 of first toileted after meals, 11/29/22 remove food from room when finished, on 12/24/22 an intervention of: encourage and assist placement of proper non-skid footwear, on 12/27/22 the intervention of: toilet every 2 hours is documented, on 03/29/23 the fall intervention documented is: skilled therapy eval (evaluation) & tx (treatment). The same care plan for R9 dated 01/03/23 under the category titled, ADL (Activities of Daily Living) Function Rehab. (Rehabilitation) documents: a fall on 01/30/23 due to transferring self to bed with an intervention of re-education, rehab, and therapy PT/OT (Physical therapy/Occupational therapy) and a fall on 02/09/23 due to transferring self to bathroom with an intervention of toileting program. The facility document dated, May 2023 titled, Fall Analysis Log documents a fall by R9 on 05/10/23 at 9:21 AM with a root cause of: self-transfer without asking for asst (assistance) with an intervention listed as: visual aid in place for assistance with transfers and a fall by R9 on 05/18/23 at 19:20 (7:20 PM) with the root cause documented as: resident room took self to bathroom, pulling up pants, fell lost balance not asking for assistance with no new intervention documented. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 05/18/23; follow up for the fall with the intervention documented as: noncompliance to staff assist (assistance) R/T (related to) transfers and ambulation. The facility document dated, July 2023 titled, Fall Analysis Log documents a fall by R9 on 07/24/23 at 05:25 (5:25 AM) with the place of fall listed as shower room, injury type listed as left knee abrasion, and the root cause listed as: cognition, unwillingness to wait for assistance with the intervention in place listed as: alarm mat on floor and the new intervention listed as: never leave alone in bathroom unattended. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 07/28/23; follow up to the fall on 07/24/23 with the intervention documented as: never leave in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 3 of 6 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 11/07/2023 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 0689 bathroom unattended, the root cause listed as unwilling to wait. Level of Harm - Minimal harm or potential for actual harm The facility document dated, October 2023 titled, Fall Analysis Log documents a fall by R9 on 10/01/23 at 16:00 (4:00 PM) with the place of fall listed as: residents room and the injury type listed as: redness to right side of rib cage with the root cause listed as: transferring self to wc (wheelchair) to get socks/balance with the intervention in place listed as: alarm mat on floor (d/c) (discontinued) and the new intervention documented as: frequently used items in reach/CNA (Certified Nurse Aide) apply socks in AM. Residents Affected - Few R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 10/03/23; follow up to the fall on 10/01/23 with the root cause listed as balance and the intervention documented as: frequently used items in reach/CNA (Certified Nurse Aide) applies socks when getting dressed in the AM. The facility document dated, October 2023 titled, Fall Analysis Log documents a fall by R9 on 10/07/23 at 20:00 (8:00 PM) with the place of fall listed as: residents room and the injury type listed as: leg pain right femoral neck fracture, hospital listed as: ER (Emergency Room), root cause is listed as: balance with the intervention in place documented as: frequently used items in reach, and the new intervention documented as: follow up to ortho (orthopedic) due to fracture to see about tx (treatment) plan. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 10/09/23; follow up to the fall on 10/07/23 with the root cause listed as balance and the intervention documented as: follow up with ortho regarding the compression Fx (fracture) to the (R) (right) hip to see about tx (treatment) plan. On 11/02/23 at 1:20 PM R9 stated, when he fell in the bathroom, he can't say how long he waited but it seemed like a really long time. He tries to wait but sometimes it seems like a really long time or sometimes he gets impatient now because his hip still hurts, and he wants to get the weight off of it. On 11/02/23 at 2:10 PM V2 (Director of Nursing/DON) stated, there should not be the same interventions used more than once, she does see where placing nonskid footwear on R9's feet was an intervention used on 12/24/22 and again on 10/03/23 and CNAs should put socks, or socks and shoes, on the residents when they are assisting them to get dressed in the morning. Sending a resident to the orthopedic doctor is not a good intervention, it does not help prevent any falls. The toileting program is usually toilet every two hours, but most residents need to use the toilet after they eat and that intervention was used on 11/24/22 and 12/27/22 respectively, then on 02/09/23 the intervention of a toileting program was used. R9's cognition level is not the same as it used to be after he has had some falls. R9 is now an assist of two people. After the hip fracture he does have some pain and does not like to wait even more than before. V2 stated with the continued falls apparently R9's interventions are not working. The facility document titled, Fall Prevention dated 11/10/18 documents: policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 4 of 6 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 11/07/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to attempt GDR (gradual dose reduction) of psychotropic medications and failed to adequately monitor the medications effectiveness for 2 of 4 residents (R22, R18) reviewed for psychotropic medications in a sample of 25 1. Per R22's Face sheet, R22 was admitted to this facility on 9/27/2021 with diagnosis of Parkinson's Psychosis, Schizophrenia and Anxiety among others. R22's current physician's order sheet (11/1/23-11/30/23) documents R22 is ordered the anti-psychotic medication known as Haldol Decanoate 50mg (milligrams) injection every month and Haldol 5 mg tablets by mouth four times per day. Both medications are prescribed for the diagnosis of Parkinson's Psychosis and Schizophrenia. Pharmacy recommendations for R22, dated 12/14/2022, 5/4/2023 and 10/4/2023 all document requests for R22's doctor to evaluate R22's need for a gradual dose reduction attempts for Haldol Decanoate 50mg injection every month and Haldol 5mg tablet by mouth four times per day. The recommendation dated 12/14/2022, under physician's response documents I decline the recommendations and do not wish to implement any changes due to: Did not prescribe. To start seeing new provider for psych. The recommendations dated 5/4/2023 and 10/4/2023 are not signed and are left blank under physician's response. There were no Behavioral Tracking Sheets available for R22 for review upon request. On 11/2/2023 at 2:00pm, V1 (Administrator) and V4 (Care Plan Coordinator) said the facility has failed to monitor and track R22's targeted behaviors/symptoms being treated by the anti-psychotic medication Haldol (monthly injection and daily oral tablets) for the past year. V1 said they would immediately put appropriate monitoring in place. V1 said she could not find when a gradual dose reduction for R22's Haldol was attempted, but it has not been attempted over the past year. V1 said R22 was last seen by her new mental health provider on 5/9/2023, but a gradual dose reduction of R22's medications was not attempted and an order to continue with current medications was prescribed. R18's Face Sheet documents an admission date to the facility of 6/12/2018 with diagnoses of anxiety, depression, panic attacks, and PTSD (Post Traumatic Stress Disorder). R18's Minimum Data Set (MDS) dated [DATE] documents in Section C, Brief Interview for Mental Status (BIMS) score is 14, indicating R18 is cognitively intact. R18's Physician's Orders dated 11/01/2023 - 11/30/2023 documents Xanax 0.5mg (milligrams) daily (Anxiety/PTSD), Xanax 0.25mg at noon (Anxiety), Zoloft 150mg daily (Depression), Buspirone 7.5mg twice daily (Anxiety). On 11/01/2023, at 2:00 PM, V1 (Administrator) stated that R18 is not due for a gradual dose reduction for her Xanax and Buspirone per the facility's pharmacy gradual dose reduction tracking report dated 10/04/2023. The facility's pharmacy gradual dose reduction (GDR) tracking report dated 10/04/2023 documents R18's Xanax last GDR was 7/03/2021 and next GDR is dated for 10/04/2024; R18's Buspirone start date of 9/18/2021. The facility provided no documentation of any GDR attempt for Buspirone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 5 of 6 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 11/07/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R18's Behavior Tracking reviewed for the last six months with only months May, June, October, & November 2023 available for review. The facility provided no documentation for months July, August, and September 2023 for behavior tracking for R18. The Pharmacy Policy titled Gradual Dose Reduction/Tapering in a Nursing Facility (revision date 05/2009) documents under frequency of GDR/tapering, within the first year in which a resident is admitted on a psychopharmacological medication or after the facility has initiated a psychopharmacological medication, taper twice in two separate quarters with at least one month between attempts; After the first year, once per year. The facility's Psychotropic Medication Policy dated 6/17/2022, documents under Procedure: 8. The Behavioral Tracking sheet of the facility will be implemented to ensure behaviors are being monitored. 9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. 10. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145692 If continuation sheet Page 6 of 6