Inspection·April 3, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents (R1) reviewed for care plans in a sample of 5. Findings include: R1's admission record dated 04/02/25, documents an admission date of 01/28/25 with diagnoses in part of unspecified dementia, depression, hypertension, polyneuropathy, idiopathic urticaria, and hyperlipidemia. R1's MDS (Minimum Data Set) dated 02/07/25 documents in Section C a BIMS (brief interview for mental status) score of 7 which indicates severely impaired cognition. Section D - Mood documents no mood indicators present. Section E- Behaviors documents no behavioral indicators. Section GG- Functional Abilities documents toileting as partial/moderate assistance, Shower/bathe as substantial/maximal assistance, personal hygiene as partial/moderate assistance. Sit to stand as substantial/maximal assistance. Section V Care Area Assessment Summary Documents Cognitive loss/Dementia as Care Area triggered, ADL (Activities of Daily Living)/rehabilitation potential care area triggered, Urinary incontinence and indwelling catheter as a care area triggered. Nutritional status as a care area triggered, Pressure ulcers as a care area triggered. R1's current Care Plan documents a Focus area of R1 (I) am a Full Code. Attempt resuscitation, CPR (Cardiopulmonary Resuscitations), including intubation and mechanical ventilation with a date initiated of 02/07/25. A focus area of R1 (I) was recently admitted to facility. Has a need to adjust to situation and life changes. Interest includes music, dogs, and going outside with a date initiated 01/30/25. A focus area of R1 (I) have expressed a desire to remain for permanent placement with a date initiated of 02/07/25 and revision date of 03/18/25. Another focus area of R1 (I) have had an actual fall with (specify: no injury, minor injury, serious injury) poor balance with a date initiated of 03/10/25. No other focus areas noted on care plan. On 04/01/25 at 11:45AM, V3 (MDS/Care Plan Coordinator) stated she has not had the time to finish and complete R1's comprehensive care plan. V3 stated she should have had focus areas addressed on the care plan regarding cognition, ADL functions, Urinary Incontinence, Nutrition, and Pressure ulcer risk everything that triggered in Section V of the admission MDS dated [DATE]. V3 stated that she has been working the floor often and doing other duties and has not had time to work on completing R1's care plan. V3 stated that she did have a care plan meeting with R1 and his power of attorney (POA) on 02/27/25. V3 said that her and V5 (Social Service Director) were the ones who had the meeting with the R1 and his POA. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145692 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 04/03/2025 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)