Health inspection·October 28, 2022

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 Based on interview, and record review the facility failed to perform resident assessments in a timely manner for 2 of 6 residents (R4, R8) reviewed for assessments in a sample of 26. Residents Affected - Few The Findings Include: R4's New admission Information sheet documents admission to this facility on 06/17/22. R4's most recent MDS, section A2300 - admission assessment observation date reflects 06/24/22. R4's quarterly MDS is 33 days overdue. R8's New admission Information sheet documents admission to this facility on 03/16/21. R8's most recent MDS, section A2300 - admission assessment observation date reflects 06/25/22. R8's quarterly MDS is 32 days overdue. On 10/27/22 at 1:44 PM, V7 (Registered Nurse - RN/MDS - Minimum Data Set) confirmed he is responsible for completing the MDS assessments and inputting the data into their computer system. When asked to confirm when the most recent MDS was completed for R4 and R8, V7 stated R4 had her annual assessment on 06/24/22, and R8 had her quarterly assessment on 06/25/22. V7 provided the calendar/planner book where he handwrote R4 due to be re-assessed on 09/24/22 and R8 due to be reassessed on 09/25/22, stating he was about 3 weeks behind. V7 continued to state he started these assessments on paper but had not completed them and was unable to locate them. The facility policy titled, Comprehensive Assessment/MDS dated 10/01/19 includes - It is the policy of (facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goals, life history, and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practical physical, mental, and psychosocial well-being . 5. The MDS shall be re-evaluated according to the following schedule. A) Quarterly within 92 days of previous ARD (Assessment Reference Date)/MDS . Page 1 of 7 145759 145759 10/28/2022 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0692 Provide enough food/fluids to maintain a resident's health. 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 provide a physician ordered dietary supplement for 1 (R23) of 3 residents reviewed for nutrition in a sample of 26. Residents Affected - Few Findings include: R23's face sheet documented an admission date of 8/1/22. R23's undated Resident MDS (Minimum Date Set)/ Diagnosis Information sheet documented diagnoses including pneumonia, C. difficile associated diarrhea with colitis, hypertension, dementia, anemia chronic, hypokalemia. R23's 8/8/22 MDS documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. R23's October 2022 Physician Order Sheet (POS) documented an 8/18/22 order for (nutritional supplement) three times a day. R23's Care Plan documents in part .Potential risk for altered nutritional status and/ or weight loss . Provide diet as ordered. See POS for current diet order- (nutritional supplement) as ordered, Start 08/01/2022 . R23's Report of Monthly Weight and Vitals form documented a weight of 153lbs August 2022, 148lbs September 2022, 147lbs October 2022. R23's meal card did not document any nutritional supplements ordered. R23's Nutritional assessment dated [DATE] documented in part . Summary of Risk Factors . Below acceptable wt (weight) range, Poor intake/ potential less than 75%, Dementia, BMI (Body Mass Index) less than 23 . Dietitian Nutritional Assessment . will recommend to add . (nutritional supplement) BID (~580 calories and 18 g [grams] protein daily) . On 10/25/22 at 12:05 PM and on 10/26/22 at 11:43 AM, R23 was sitting in the dining room eating the noon time meal. R23 was given a mechanically altered meal tray, but no nutritional supplement was provided. On 10/26/22 at 12:12 PM, V4 (Certified Nurse's Assistant (CNA)/ Activities Director/ Social Services) said when facility staff are passing meal trays to residents the meal card will have any nutritional supplements ordered written on it. V4 said if a resident's meal card documents a nutritional supplement, and none is on the resident's meal tray the staff should return to the kitchen to retrieve the nutritional supplement. On 10/26/22 at 12:14 PM, V15 (Cook) said when the meal trays are being prepared any nutritional supplement will be written on the resident's meal card. V15 said there was only one resident in the facility who received the specific nutritional supplement R23 was ordered, and the resident named was not R23. V15 said R23's meal card did not have any nutritional supplements documented on it. On 10/27/22 at 10:46 AM, V16 (Dietician) said R23 was reviewed by a dietician on 8/17/22. V16 said R23 was recommended to have a dietary supplement two times daily because R23 was underweight for R23's age, had poor intake, and had a pressure injury. V16 said a Dietician would give a recommendation but the resident's Primary Care Provider (PCP) would order dietary supplements if they agreed the 145759 Page 2 of 7 145759 10/28/2022 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0692 Level of Harm - Minimal harm or potential for actual harm resident needed them. V16 said she expected facility staff to give residents dietary supplements as ordered. V16 said R23 did have some weight loss but it was not significant weight loss. V16 said if R23 was receiving the dietary supplement there would be a boost in R23's caloric and protein intake. V16 said if R23 was refusing the dietary supplement she expected the facility to notify V16 to reevaluate R23 for a different nutritional supplement. Residents Affected - Few The facility's 10/2014 Resident Weight Monitoring policy documented in part . 9. The Dietitian shall review and document . any recommended nutritional interventions . 10. Nursing contacts the physician to convey recommendations from the . Dietitian, and obtains any new orders . 145759 Page 3 of 7 145759 10/28/2022 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly check placement of a gastrostomy tube prior to administering medication and feeding for 1 of 1 resident (R13) reviewed for gastrostomy tube placement in a sample of 26. Findings include: R13's face sheet documented R13 was admitted to the facility on [DATE]. R13's Resident MDS (Minimum Date Set)/ Diagnosis Information documented diagnoses including: neuroacanthocytosis, epilepsy without mention of intracut epilepsy, dysphagia status post G-tube (gastrostomy tube) placement. R13's Physician Order Sheet (POS) documented in part .Check G-tube placement before feedings/Meds (Medications) . R13's 7/12/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R13 was cognitively intact. On 10/27/22 at 11:09 AM, V11 (Licensed Practical Nurse/LPN) checked R13's G-tube placement by injecting 30cc of air and auscultating over the stomach prior to giving medication and feeding. V11 did not attempt to check residual for placement of R13's G-tube. On 10/28/22 at 8:29 AM, V18 (Registered Nurse/RN) said G-tube placement should be checked aspiration of residual. V18 said if the G-tube is not in the stomach and auscultation of air is used to verify placement air bubbling will still be heard. V18 said if there is any question the G-tube is not in the stomach the resident should have an X-ray completed to verify placement. V18 said if the G-tube is not placed correctly in the stomach and medications and/ or feedings is given the resident could develop an infection in the abdominal cavity and/ or peritonitis. The facility's 11/6/18 Administration of Medication Via a Feeding Tube policy documented in part . 13. Check for tube placement by checking residual . 145759 Page 4 of 7 145759 10/28/2022 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the kitchen in a clean, sanitary and pest free condition. The facility also failed to maintain sanitizer solutions at a safe level to be used on food contact surfaces. This failure has the potential to affect all 34 residents living in the facility. The Findings Include: During the initial tour of the kitchen on 10/25/22 at 9:30 AM the following items were observed: 1. A cockroach was observed crawling up the wall by the kitchen handwash sink and crawling across the sink. 2. A gallon size water pitcher with red liquid with no lid was on the ground next the stove. V1 (Dietary Manager) stated that she believed this was de-[NAME]. 3. Food debris was on the floor under the refrigeration unit. 4. The area under the three-compartment sink needed swept with accumulation of food debris and dirt underneath it. 5. Items were on the floor behind the ice machine. 6. Items were on the floor under the counters and shelving units. 7. The quaternary sanitizer bucket test strip showed that the solution had 400ppm (parts per million) of sanitizer level in it. At this time of the initial tour V10 stated that the quaternary sanitizer bucket would be disposed of and new solution made due to the solution being too strong. V10 stated that the recommendation is the solution should be 200ppm. When asked what the ratio of water and sanitizer is to make the manufacturer recommended 200ppm solution V1 stated that she does not know. V10 at this time stated that they do not have a policy or instructions on how prepare the mixture. V10 thinks it is about 1 pump per sanitizer to water in the bucket. When asked how much water to add to the 'pump' of solution she stated that she did not know. On follow up visits to the kitchen on 10/25/22 at 11:00 AM, cockroaches were observed to be seen crawling up the wall behind the stove, on the floor in front of the stove and more by the steam table. V1 stated at this time that the exterminator had been in this month to do pest control maintenance. When asked if the exterminator was here specifically for cockroaches or if he knew they were experiencing issues she said that they had just seen a couple at that time. V10 went on to state that there are bait stations set up in the kitchen in various places. Also, during the follow up visit to the kitchen the sanitizer level for the quaternary solution was asked to be checked again. The test strip V10 used to check the level of quaternary sanitizer registered at 400 ppm. V10 again stated that they have not received any training on the mixing of the 145759 Page 5 of 7 145759 10/28/2022 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sanitizer and water to ensure that the proper level is attained to effectively and safely sanitize the kitchen equipment. V10 stated that they do have the dispenser that automatically mixes it, but they just don't use that one. The kitchen staff just use the hand pump jug of quaternary sanitizer and add water to that. V10 stated that the sanitizer log is filled out for the month of October, and it shows that the level is 200ppm daily when checked. V10 stated at this time they would fix the level of sanitizer again to ensure it was at the appropriate level. V10 stated that she is aware that too high of a level can leave a buildup level of sanitizer on the food contact surfaces that could be unsafe. Six-month review of pest control service records documents each month from June 2022 through October 2022 that under the recommendations area/device: an accumulation of food product from damaged goods noted. Please remove food product to prevent attraction by pests. Food debris on the floor under shelves and equipment. The Resident Census and Conditions of Residents Form dated 10/25/22 documents that 34 residents reside in the facility. 145759 Page 6 of 7 145759 10/28/2022 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain a pest free environment. This has the potential to affect all 34 residents in the facility. Residents Affected - Many The Findings Include: During the initial tour of the kitchen on 10/25/22 at 9:30 AM the following were observed: a cockroach was observed crawling up the wall by the kitchen hand wash sink and crawling across the sink. A gallon size water pitcher with red liquid with no lid was on the ground next the stove that V10 (Dietary Manager) stated that she believed this was de-[NAME]. Food debris was on the floor under the refrigeration unit. The area under the three-compartment sink needed swept with accumulation of food debris and dirt underneath it. Items were on the floor behind the ice machine and items were on the floor under the counters and shelving units. On follow up visits to the kitchen on 10/25/22 at 11:00 AM, cockroaches were observed to be seen crawling up the wall behind the stove, on the floor in front of the stove, and more by the steam table. V10 stated at this time that the exterminator had been in this month to do pest control maintenance. When asked if the exterminator was here specifically for cockroaches or if he knew they were experiencing issues she said that they had just seen a couple at that time. V10 went on to state that there are bait stations set up in the kitchen in various places. Six-month review of pest control service records documents each month from June 2022 through October 2022 that under the recommendation's area/device: an accumulation of food product from damaged goods noted. Please remove food product to prevent attraction by pests. Food debris on the floor under shelves and equipment. The facility's non dated insect and pest control policy states, ' A preventative treatment, both interior and exterior shall be applied at least monthly. Treatments will be applied more often if required. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.' The Resident Census and Conditions of Residents Form dated 10/25/22 documents that 34 residents reside in the facility. 145759 Page 7 of 7