Health inspection·December 6, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review the facility failed to allow an independent smoker the right to choose when to smoke for 1 (R32) of 4 residents reviewed for smoking in a sample of 38. Residents Affected - Few Findings include: R32's face sheet documented an admission date of 5/4/23. R32's 11/1/23 through 11/30/23 Physician Order Sheet (POS) documented diagnoses including ischemic stroke, hypertension, bipolar affective disorder. R32's 5/17/23 care plan documented R32 is independent with Activities of Daily Living (ADLs) and benefits from supervision when showering for safety. R32's 11/4/23 Fall Risk Assessment documented a score of 5, indicating R32 was not at high risk for falls. R32's 11/4/23 Elopement Evaluation documented a score of 1, indicating R32 was not at risk of leaving the facility unattended. R32's 10/6/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R32 was cognitively intact. On 11/28/23 at 10:42 AM, R32 said he was capable of independently going out to smoke by himself but could only smoke 4 times a day at the designated smoking times. R32 said all the smokers in the facility had to be supervised by staff while smoking. On 11/29/23 at 3:34 PM, R32 was observed in the designated smoking area wearing a smoking apron with staff present. R32's first cigarette was lit by staff. R32 smoked the cigarette and extinguished the cigarette safely and independently. R32 lit his second cigarette, smoked the cigarette, and extinguished the cigarette safely and independently. On 11/30/23 at 1:14 PM, R32 was observed in the designated smoking area wearing a smoking apron with staff present. R32 lit his cigarette, smoked the cigarette, and extinguished the cigarette safely and independently. On 12/1/23 at 12:18 PM, V3 (Registered Nurse/RN) said all residents who smoke must wear a smoking apron and be supervised by staff while smoking. V3 said if any resident asks to go smoke when it is not a designated smoking time, they will be told no. On 11/30/23 at 4:12 PM, V1 (Administrator) was asked why R32 was not able to smoke when R32 wanted due to R32 being independent with Activities of Daily Living (ADLs). V1 said it was the corporate facility policy all residents had to be supervised while smoking during the designated smoking times. R32's 11/30/23 Resident Smoking Assessment documented in part . to abide by the smoking policy, Page 1 of 26 145759 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0561 Level of Harm - Minimal harm or potential for actual harm understands that a change in condition may necessitate an assessment, impact the status of participating in the smoking procedures and result in discontinuance or modification of smoking procedures. Resident agrees to smoke only in attendance of staff, approved family member or volunteer . R32 was designated as being able to smoke independently documenting in part . Independently: Resident exhibits physical ability to smoke independently as evidenced by the evaluation of motor and cognitive skills . Residents Affected - Few R32's 11/30/23 Smoking Safety Risk Assessment documented a total score of 0, indicating . May independently be able to handle smoking material (score 0-4) . The facility's undated Information/ Schedule for Resident Smoking policy documented in part . Below are our scheduled smoking times and designated staff to accompany resident. Times: 9:00 AM CNA, 1:00 PM Housekeeper, 3:30 PM Kitchen, 7:30 PM Nurse/ CNA. At these times, the resident can be taken out to the smoking area for 10 minutes (max 2 cigarettes) . Smoke Apron must be worn by resident . Do NOT take their whole pack out with them . 145759 Page 2 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident/resident representative with required notice of transfer/discharge for 2 of 2 residents (R2, R33) reviewed for hospitalizations in the sample of 38. The findings include: 1. R33's document labeled new admission information note that R33 was admitted to the facility on [DATE]. R33's Physician's orders dated 12/1/23-12/31/23 with diagnoses to include, left middle cerebral CVA (Cerebral vascular accident), right sided hemiparesis, aphasia. R33's Nurses Notes dated 11/12/23 documents R33 was taken by ambulance and transported to an out of state hospital. Document labeled Nursing Home to Hospital Transfer Form dated 11/12/23 note that R33 was sent to a local hospital emergency room. The reason for transfer is noted as Pulled out G-tube. 2. R2's document labeled new admission information note that R2 was admitted to the facility on [DATE]. R2's Physician's orders dated 11//1/23-11/30/23 document diagnoses to include dementia, depression, Alzheimer's, glaucoma. R2's Nurse progress note dated 10/22/23 document that on 10/22/23, R2 was sent to a local hospital per families request for not acting right. On 11/29/23 at 11:00am, V9 (Licensed Practical Nurse/LPN) said that the nurses call the resident representative or inform the resident when they are sending them to the hospital. V9 said they do not mail anything on the transfer. On 11/29/23 at 1:58pm, V20 (Regional Quality Assurance Nurse) said it is the nurse's responsibility to inform the resident/resident representative about the reason for transfer. V20 said they do not mail anything that she is aware of. On 12/5/23 at 1:00pm, V12 (Business Office Manager) said she does not mail any transfer information to resident's representative. V12 said that the nurse takes care of calling them about the reason for transfer. 145759 Page 3 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed notify resident/resident representative in writing of the bed hold policy for 2 of 2 residents (R2, R33) reviewed for hospitalizations in the sample of 38. The findings include: 1. R33's document labeled new admission information note that R33 was admitted to the facility on [DATE]. R33's Physician's orders dated 12/1/23-12/31/23 with diagnoses to include, left middle cerebral CVA (Cerebral vascular accident), right sided hemiparesis, aphasia. R33's Nurses Notes dated 11/12/23 documents R33 was taken by ambulance and transported to an out of state hospital. Document labeled Nursing Home to Hospital Transfer Form dated 11/12/23 note that R33 was sent to a local hospital emergency room. The reason for transfer is noted as Pulled out G-tube. 2. R2's document labeled new admission information note that R2 was admitted to the facility on [DATE]. R2's Physician's orders dated 11//1/23-11/30/23 document diagnoses to include dementia, depression, Alzheimer's, glaucoma. R2's Nurse progress note dated 10/22/23 document that on 10/22/23, R2 was sent to a local hospital per families request for not acting right. On 11/29/23 at 1:58pm, V20 (Regional Quality Assurance Nurse) said that prior to transfer to the hospital, the nurse goes over the bed hold policy with the resident or resident representative via telephone and writes a verbal ok. V20 said they do not mail them to her knowledge. V20 said that V12 (Business Office Manager) keeps a list for the ombudsman and sends them monthly. On 12/5/23 at 1:00pm, V12 (Business Office Manager) said she does not mail or provide the bed hold policy to the resident/resident representative. V12 said the nurses go over it with the resident/resident representative at the time of transfer. V12 said the room rate is not listed on their bed hold policy. Document labeled Bed Hold Guarantee Policy revised 8/1/17 notes the facility strives to ensure that each Medicaid Resident, who is discharged to an acute care setting or takes a therapeutic leave, has a bed reserved for his/her return. Beds shall be held for 10 days for hospitalization and therapeutic leave for Medicaid recipients and indefinitely for private pay residents who elect to pay the charges. The document does not specify what the room rate is. Document labeled Notice of Bed Hold Policy revised 9/2018 notes that if you are a Medicaid resident and you are admitted to the hospital or take a therapeutic leave, Illinois Medicaid does not pay to hold your bed. You are guaranteed a bed in this facility upon return if: .As a Medicaid resident you or the responsible party has agreed to pay the Public Aid rate for days in excess of the 10 days or as a private pay resident have insured a hold on your bed through reimbursement at the current private pay rate. 145759 Page 4 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 accurately assess residents to ensure the necessary level of assistance was provided with eating for 4 of 4 (R2, R5, R28, and R30) residents reviewed for meal assistance in a sample of 38. Residents Affected - Some The Findings Include: 1. R30's Minimum Data Set (MDS) documents a most recent admission date of 11/25/22. The November 2023 Physician Orders includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Hypertension, malignant neoplasm of eye, and dementia. Current Diet order is listed as regular diet. On 12/1/23 at 10:30 AM, V1 (Administrator) stated that R30 does not have current supplements ordered due to poor intake of those supplements. V1 stated that several different types had been trialed. R30's report of monthly weight and vitals for the 2023 year lists the following weights: June 2023 is 135 pounds, July 2023 is 131 pounds, August 2023 is 125 pounds, September 2023 is 123 pounds, October 2023 is 119 pounds, and November 2023 is 115 pounds. R30's care plan with a goal date of 2/24 lists a goal that resident weight will be a proper Body Mass Index (BMI). Interventions with a start date of 3/15/23 is listed for the following: serve diet as ordered and tolerated, see orders/tray card for current diet, set up tray per resident preference, Ensure proper/comfortable positioning at table, record intake for each meal, and offer substitutes for foods not eaten, note any reporting chewing/swallowing difficulties or changes in habits or intake and notify nurse for follow up with physician, allow use of clothing protector per resident/family preference, encourage the resident to participate to the fullest extent possible with each interaction, praise all efforts for eating/nutritional care. An intervention with the start date 3/15/23 is to use lids on coffee cups to prevent spills. R30's Skilled activities of daily living (ADL) reports that are filled out by the CNA's (Certified Nurse Assistants) for June and July for eating are coded daily as an 'S' which is described on the form to be: Set Up/Clean Up by helper but resident completes the ADL on own. The ADL assist report for June and July is coded as a '1' for all meals that is defined as '1' being supervision (oversight, encouragement or cueing). August ADL assist report documents R30 is coded as a '1' and '2.' A '2' is defined as being limited assistance (resident highly involved in activity and staff provide non-weight bearing assistance). The August ADL report lists R30 as an 'S' or a 'V' (verbal cueing/supervision/touching, helper may touch/steady/contact guard). The September skilled ADL report lists R30 as an 'S' all month except one meal she refused. The September ADL assist report documents R30 as being a '2' for eating. The October skilled ADL sheet documents that R30 is coded as an 'S' for eating and no skilled ADL assist report was provided. November 2023 skilled ADL report was coded as an 'S' for R30, and no skilled assist report was provided. R30's Minimum Data Set (MDS) dated [DATE] is a quarterly assessment and codes eating as R30 requiring set up or clean up assistance, set up or clean up provided, resident completes activity. The annual MDS with a 12/1/23 acceptance date is coded the same as the 8/30/23 quarterly. These documents also show that R30 has a BIMS (Brief Interview for Mental Status) score of 4, which indicates severe cognitive impairment. 145759 Page 5 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/29/23 at 11:50pm, R30 was in her room with her regular meal lunch tray and drinks on the bedside table. The tray contained pulled pork, macaroni and cheese, butternut squash, and a fruit cup (strawberries and bananas in juice/syrup). R30 was lying in bed with eyes closed. Observations of R30 conducted at approximately 15-minute intervals revealed R30 not attempting to eat, tray still untouched at bedside. No staff were observed going in the room to encourage her to eat or offer assistance. Housekeeping was noted entering in room at approximately 12:45 PM cleaning up soda that R30 had spilled on the floor. R30 was awake and sitting up with bedside table & tray in front of her at this time but had still not taken any bites of food. At 12:52 PM, R30 started eating her fruit cup, which contained cut up strawberries in a juice/syrup. She was eating this with her fingers despite having rolled up silverware in front of her. After finishing this, R30 did not attempt to eat any of the other food items on her tray. At approximately 12:58pm, V4 and V8 (both Certified Nursing Assistants/CNA) came to room. When asked at this time if R30 requires assistance with eating, V4 stated no she didn't, that she can feed herself. When asked about R30 eating the strawberries in juice/syrup with her fingers despite having silverware and pointing out the fact she did not attempt to eat any other meal items, V4 stated, yes R30 has been declining. On 11/30/23 at 11:55PM, R30 was observed up to the dining table with her lunch meal being served at this time. From 11:55am to 12:20pm, R30 sat with meal in front of her, not eating, with no staff prompting or encouraging her to eat the taco salad meal. At 12:20pm, without attempting to encourage or feed her the regular meal, R30 was brought a peanut butter and jelly sandwich (which had been requested by staff for her tablemate (R5), but R30 still sat without eating the sandwich. After 35 minutes of not eating lunch, at 12:29pm, V7 (Licensed Practical Nurse/LPN) began verbally prompting R30 to eat the sandwich, and she responded by taking bites of the sandwich until she finished it. On 12/01/23 at 11:30 AM, R30 was observed sleeping laying across her bed across, with her feet hanging over the side of the bed towards the floor and her head against the wall. At 12:15 PM, R30's lunch tray was delivered to her room. At this time, the tray was placed in her room on the bedside table while the resident remained asleep. At 12:47 PM, housekeeping was removing the untouched tray from R30's room. The cover was still on the food, the silverware was still wrapped in the napkin, and the drinks still had the covers on them. Intermittent observations of R30 were completed throughout the lunch service from 11:30AM -12:47PM and R30 remained in this position with an untouched tray without staff intervention or assistance. On 12/01/23 at 12:47 PM, V1 (Administrator) came to R30's room as housekeeping was removing R30's tray from the room and acknowledged that the tray had not been touched, the silverware remained wrapped, the cover was still on the plate as well as the lids on the drinks. R30 was still sleeping at this time. 2. R2's new admission information sheet has an admit date of 2/1/18. R2's November 2023 physician orders include the following diagnosis: dementia, depression, and chronic obstructive pulmonary disease. The diet order is listed as pureed with thickened liquids. R2's care plan has a goal date of November of 2023 with a goal that resident will feed self every meal through the next 90 days. The interventions listed with a start date of 12/17/21 include serve diet as ordered and tolerated, see orders/tray card for current diet. Set up tray per resident preference, ensure proper/comfortable positioning at table, record intake for each meal, offer substitutes for foods not eaten, notify nurse for follow up with physician and follow guidelines for comfort focused treatment, allow use of clothing protector per resident/family preference, encourage the resident to participate to the fullest extent possible with each interaction, provide ample time to eat 145759 Page 6 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Level of Harm - Minimal harm or potential for actual harm and encourage resident to eat 75%-100% of meals, praise all efforts at the eating/nutritional care, medications as ordered, (brand name supplement) as ordered. An intervention with a start date of 5/28/23 is to provide (brand name supplement) three times a day. An intervention of 6/29/23 is to mix (brand name supplement) and milk per resident preference and an intervention on 11/30/23 is to assist resident as needed while eating. Residents Affected - Some R2's skilled ADL's report for June of 2023 document eating as 'D' for dependent at breakfast and supper and 'S' for set up at lunch time. The ADL assist report for June of 2023 documents R2 as a '1' for all meals all month long indicating she is only requiring supervision-oversight, encouragement or cueing. R2's July 2023 skilled ADL report lists the resident as 'D' for meals. The July 2023 ADL Assist report documents a '2' for all meals indicating that limited assistance/resident is highly involved in activity. R2's ADL assist report for August 2023 documents the resident as a '2' and '3' (extensive assistance/resident is involved in activity). R2's August 2023 ADL report for eating is coded as 'D' for dependent. R2's September 2023 ADL assist report is coded as '2' AND '4' (total dependence/full staff performance every time during this ADL). R20's Skilled ADL report is coded as a 'D' for September of 2023. R2's Skilled ADL report for October of 2023 is coded as a 'D.' R2's November 2023 skilled ADL report documents eating as a 'D.' R2's most recent annual MDS dated [DATE] has her coded as a '5' indicating that she requires set up/clean up and resident completes activity. This same MDS documents a BIMS score of 3, indicating she has severe cognitive impairment. On 11/29/23 at approximately 11:55pm, R2's pureed lunch meal of pulled pork, macaroni and cheese, butternut squash and fruit cup were sitting in front of her at the dining room table. R2 had a spoon available but was intermittently dipping her finger in her pureed food items, then sucking the food off her finger. At 12:25pm, V4 (CNA) was asked if R2 required assistance. She stated no and said R2 tends to get frustrated if they try to help her. No staff were observed to assist or encourage R2 with eating until 12:40pm. At this time, V8 (CNA) sat down beside R2 and started feeding R2 with the spoon. R2 then proceeded to eat with no issues of frustration noted. On 11/30/23 at approximately 11:55pm, R2 was in the dining room and served her pureed lunch meal of taco salad, rice & green beans. R2 had a spoon available but was intermittently dipping her finger in her pureed food items and sucking the food off her finger. At 12:08PM, V7 (Licensed Practical Nurse/LPN) began feeding R2 and she responded well to being fed, however threw up at 12:10PM. After cleaning her up, V7 resumed assisting R2 to eat. R2 ate less than 25% of her lunch meal. 3. R5's new admission information sheet documents an admission date of 7/21/12. R5's November 2023 physician orders listed the following diagnosis: depression, anxiety, panic disorder with borderline psychosis, and dementia with psychosis. The current diet order is listed as a regular diet. R5's most recent quarterly MDS dated [DATE] has her coded as a partial/moderate assistance that the helper does less than half the effort for eating. This same MDS documents R5 having a BIMS of 4, indicating that she has severe cognitive impairment. R5's June ADL assist report documents that she is a '1' for eating assistance. R5's skilled ADL report for June of 2023 documents as an 'S' and 'M' indicating a maximal assistance at the evening meal. The July 2023 ADL report documents R5 as an 'S' and 'P' (partial assist/helper does less than half the effort). The July 2023 ADL assist report documents R5 as a supervision at meals. R5's August 2023 ADL assist report documents eating at a '2.' The August 2023 eating report documents R5 needed 145759 Page 7 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Level of Harm - Minimal harm or potential for actual harm 'P', 'D' and 'V' (verbal curing/supervision/touching) at meals for the month. The September 2023 ADL assist report documents that R5 required a '2' or a '3' for eating assistance. The September 2023 ADL report documents that R5 required a 'D', 'P' and 'S' for assistance for the month at meals. The October 2023 skilled ADL report documents R5 required an 'S' for meal assistance the entire month. The November 2023 skilled ADL report has R5 receiving 'P' for all meals. Residents Affected - Some R5's care plan with a goal date of 1/24 documents a problem of Potential risk for altered nutritional status and/or weight loss related to leaving 25% of meal uneaten at times. The goal is to maintain weight +/- 3 pounds for the next 90 days. The interventions for this problem are to provide the diet as ordered, honor food preferences, offer snacks, resident consent to use clothing protector and provide ample time to eat. On 11/29/23 at approximately 11:55pm, R5 was in the dining room at her table with her regular lunch meal of pulled pork, macaroni and cheese, butternut squash, and fruit cup in front of her. She was observed intermittently picking at the food with her fingers but not taking large bites or using her silverware. She was heard mumbling something unintelligible after putting the small bites in her mouth and pushing herself back from the table. This went on for about 45 minutes with her not eating and not being encouraged or offered assistance. At 12:40pm, R5 stated more clearly I don't like it. Surveyor asked R5 if she did not like her lunch food today and she again said, I don't like it, it's cold. Surveyor stated she can ask for something different, and she responded, I don't want nothin. At this time, a staff member came out and told R5 she would bring her a bologna sandwich. R5 said she didn't want anything, but at 12:55pm when the sandwich was brought out, R5 proceeded to eat some of the sandwich. On 11/30/23 at approximately 11:55pm, R5 was in the dining room at her table with her regular lunch meal of taco salad, rice and vegetable served. She sat with food in front of her not eating for 25 minutes. Without encouraging or offering assistance to eat the regular meal, at 12:20 PM, staff asked R5 if she wanted something different and brought R5 a bologna sandwich. R5 still did not eat and pushed herself away from the table. At 12:29pm, V7 (LPN) began prompting/encouraging R5 to eat her sandwich. She ate approximately ¼ of the sandwich. 4. R28's new admission information record documents an admission date of 1/13/23. R28's physician orders include the following diagnosis: dementia and anxiety. The current diet order is a regular mechanical soft with (brand name supplement) twice daily. R28's quarterly MDS dated [DATE] indicate that R28 requires eating set up/cleanup and resident completes the activity and documents a BIMS of 1 indicating that she is severely cognitively impaired. R28's care plan has a written in statement titled Nutrition with a date of 8/29/23 that resident may eat food with fingers at times. R28's ADL assist for June 2023 documents that she requires supervision for meals. The June 2023 skilled ADL report documents that R28 requires 'S' for breakfast and lunch and 'M' for evening meal. July 2023 skilled ADL report for eating is coded as 'S' for breakfast and lunch and 'P' for dinner. August 2023 ADL assist report documents that R28 is a variety of '1', '2', and '3' for meal assistance. The skilled ADL assist sheet for August of 2023 documents for eating that R28 requires 'P' for all meals. R28's September 2023 ADL assist sheet foe eating is coded as requiring either a '2' limited assistance or a '4' total dependence throughout the month. The September 2023 skilled ADL report documents R28 needed 'M' maximal assist or 'P' partial assist for meals throughout the month. The 145759 Page 8 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some October 2023 skilled ADL report documents that R28 required 'P' partial assist and 'M' maximal assist throughout the month for eating assistance. The November 2023 skilled ADL report documents that R28 requires 'S' set up/clean up assistance or 'P' partial assist throughout the month for meals. On 11/29/23 at approximately 11:55pm, R28 was observed sitting in the dining room at her table with the regular lunch meal of pulled pork, macaroni and cheese, butternut squash, and fruit cup in front of her. She was observed intermittently using her fingers to pick up small bits of food items, despite having silverware in front of her. From 11:55pm to 12:40pm, R28 was not encouraged or assisted to eat. She was not prompted to use her silverware and was not asked if she liked the meal or wanted something different. When her tray was picked up at the end of meal service her plate was still full of food. On 11/30/23 at approximately 11:55pm, R28 was observed sitting in the dining room at her table with the regular lunch meal of taco salad, rice, and green beans in front of her. She was observed using her fingers to pick up small bits of food items, despite having silverware in front of her. From 11:55pm to 12:40PM, R28 was not encouraged to use her silverware throughout the duration of the lunch meal. She ate a plain soft tortilla and small bits of the other food items, but her plate was still very full at the end of the meal. On 12/1/23 at 10:30 AM, V15 (Regional MDS Coordinator) stated that the MDS's are coded based on the CNA daily ADL report and ADL assist report. V15 stated that she is not in the building daily, as she is a regional MDS coordinator. V15 further stated that prior to taking on a regional position she was the floating MDS coordinator for this facility, so the facility has not had a full-time person in the MDS position for some time. V15 stated that she questions what can be done if large number of residents need assistance with eating because they do not have enough CNAs to do that and they are looking at reducing the nursing hours. 145759 Page 9 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure results of a urine culture and sensitivity were received timely and physician notification of those results were communicated to ensure necessary treatment for a urinary tract infection for 1 (R29) of 3 residents reviewed for urinary tract infections out of a sample of 38. Residents Affected - Few Findings include: R29's face sheet documented an admission date of 6/1/22. R29's 12/1/23 through 12/31/23 Physician Orders Sheet (POS) documented diagnoses including neurogenic bladder, Benign Prostatic Hypertrophy (BPH), fracture of head/ neck of right femur, subsequent encounter for closed fracture with routine healing, atrial fibrillation, chronic obstructive pulmonary disease, and anemia. R29's 11/8/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. R29's 12/1/23 through 12/31/23 POS documented a 9/29/23 order to change foley catheter monthly and as needed and a 9/29/23 order to flush foley catheter twice daily as needed if tubing becomes blocked. R29's 11/5/23 at 1:00 PM Nurses Notes documented in part . UA (urinalysis) obtained (after) flushing. Notify (Medical Doctor) of results. Still (with) pain all over . R29's report on urinalysis done on 11/5/23 documented a trace of occult blood, positive for nitrite, 2+ leukocyte esterase, 16-20 white blood cells, 3-5 red blood cells, and 1+ bacteria. The reference range for these results are occult blood negative, nitrite negative, leukocyte esterase negative, white blood cell none seen to 3-5 seen, red blood cells none seen to 3-5 seen, bacteria negative. R29's Medical Record contain the 11/5/23 urinalysis but did not document the 11/5/23 culture and sensitivity or any documentation notifying the physician of the 11/5/23 culture and sensitivity. R29's 11/5/23 at 5:30 PM Nurses Notes documented in part . Lab results sent to (Medical Doctor with) orders to begin Doxycycline 100 (milligrams 1 tab twice a day for 1 week) Family aware. Resident confused (and) restless. Woke up didn't know where he was . On 11/28/23 at 10:32 AM, R29 was lying in bed with catheter collection bag hanging from bedframe. R29 catheter tubing and collection bag contained dark yellow urine with a large amount of mucous/ sediment. On 11/27/23, 11/28/23, and 11/30/23, R29's 11/5/23 urine culture and sensitivity were requested from V1 (Administrator) due to the results not being present in R29's medical record. On 11/30/23 at 3:38 PM, V17 (Infection Preventionist/ Licensed Practical Nurse) presented R29's urine culture and sensitivity report document a collection date of 11/5/23, a physician acknowledgment date of 11/8/23, and a fax date of 11/30/23. R29's urine culture and sensitivity physician acknowledgment were pre-printed on the results received from the lab. R29's urine culture and sensitivity report documented the organism was resistant to tetracycline (Doxycycline is in the family of tetracycline). V17 said the facility had just received R29's urine culture on 11/30/23 after she had called the lab to request the urine culture and sensitivity report on 11/30/23. V17 said she was unsure if anyone had notified R29's physician of the urine culture and sensitivity documenting the organism was resistant to the antibiotic ordered. 145759 Page 10 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R29's Nurses Notes did not document any communication with R29's physician pertaining to R29's 11/5/23 urine culture and sensitivity report. R29's 11/1/23 through 11/30/23 Medication Administration sheet documented R29 had received doxycycline 100 milligrams twice a day for a week from 11/5/23 through 11/12/23 and 11/22/23 through 11/30/23. On 11/30/23 at 3:52 PM, V17 said she had notified R29's physician on 11/30/23 of the 11/5/23 urine culture and had received orders to repeat the urinalysis with culture and sensitivity if indicated. On 12/1/23 at 11:24 AM, V6 (Physician) said he expected to be notified if a urine culture and sensitivity was received and documented resistance to the antibiotic being given. R29's report on urinalysis done on 11/30/23 documented 2+ occult blood, positive nitrite, 1+ leukocyte esterase, too many to count white blood cells, too many to count red blood cells, and 3+ bacteria. On 12/1/23 at 1:36 PM, V6 (Physician) said if R29 had been changed to an antibiotic that the 11/5/23 urine culture and sensitivity had been sensitive to it is possible R29's 11/30/23 urinalysis would have improved. On 12/1/23 at 12:00 PM, V7 (LPN) said a few months ago the lab the facility used stopped automatically sending lab results to the facility. V7 said nursing staff had to call the lab and follow up on lab results and ask them to be faxed to the facility. V7 said sometimes she had to call the lab two to three times requesting the labs be faxed to the facility. V7 said any labs that needed to be followed up on would be written on the calendar so the nurse working that day would know to call for the lab to be faxed to the facility. V7 said she was unsure if anyone had called to follow up on R29's 11/5/23 urine culture and sensitivity. V7 said if she received a urine culture and sensitivity, and it documented the antibiotics being administered were resistant she would notify the resident's physician for a possible change in antibiotic. The facility's revised 12/7/17 Notification for Change in Resident Condition or Status policy documented in part . The facility and/ or facility staff shall promptly notify appropriate individuals (i.e., . Physician .) of changes in the resident's medical/ mental condition and/ or status . The nurse supervisor/ charge nurse will notify the resident's attending physician or on-call physician when there has been: . m. Abnormal lab findings . 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in condition occurring in the resident's medical/ mental condition or status . 145759 Page 11 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide incontinence care in a timely manner for 1 of 1 resident (R9) reviewed for bowel and bladder in the sample of 38. The findings include: R9's face sheet document that R9 was admitted to the facility on [DATE]. R9's Physician's order's dated 12/1/23-12/31/23 list some of R9's diagnoses as physical debilitation, dementia, DJD (degenerative joint disease), anxiety disorder, dysphagia. MDS (Minimum Data Set) dated 9/13/23 note in Section C note a BIMS (Brief Interview of Mental Status) of 01 which indicates severe cognitive impairment. Section GG of the same MDS note for toileting hygiene and chair/bed to chair transfers R9 is dependent-helper does all the effort-Resident does none of the effort to complete the act. This same MDS also documents R9 is always incontinent. R9's care plan note a problem area with a start date of 1/1/23 of alteration in bladder/bowel elimination: Resident is incontinent of bladder and bowel. Some listed approaches/interventions are, pad appropriately for dignity and comfort, turn and reposition every 2 hours, assist prn. All with a start date of 1/1/23. The same care plan notes a problem area of potential for impaired skin integrity related to decreased mobility. Some listed approaches/interventions are maintain clean, dry, wrinkle free linens. On 11/28/23 beginning at 8:30 am, R9 was noted to be sitting in a reclining chair in front of the television in the front area of the facility. The reclining chair was in a reclining position with her feet elevated. During intervals of approximate 15-30 minutes in length R9 was noted in the same place in the same reclining position until 3:45pm. At approximately 3:45pm, V8 (Certified Nursing Assistant/CNA) was asked to lay R9 down for a skin observation. V8 and V11(CNA) put R9 in bed, R9's gown was observed to be wet up her back, the incontinent pad underneath R9 was also soaked. R9's incontinence brief was completely saturated with urine and had a brown color. A strong odor was also observed. R9's coccyx and buttocks were reddened, with no open areas noted. After providing incontinence care, V11 went to R9's roommates bedside table and removed protective barrier ointment and V8 told V11 not to use that and to go get a new tube of the ointment. On 11/28/23 at 3:50pm, neither V8 nor V11 answered when asked if R9 had been changed all day. On 12/05/23 at 1:11 PM, V10 (family member) said she thinks they usually do not change her until they put her back in bed in the afternoon. On 12/5/23 at 2:00pm, V1 (Administrator) said it would be her expectation that residents be checked at least every 1-2 hours to see if they are wet. On 12/5/23 at 2:10pm, V17 (Registered Nurse) said she would expect that residents be checked at least every 2 hours and be laid down after breakfast and lunch. 145759 Page 12 of 26 145759 12/06/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide assistance with eating for 1 (R30) of 4 residents reviewed for nutrition out of a sample of 38. This failure resulted in R30 having a significant weight loss of 14.8% in 6 months. Residents Affected - Few The Findings Include: R30's Minimum Data Set (MDS) documents a most recent admission date of 11/25/22. The November 2023 Physician Orders includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Hypertension, malignant neoplasm of eye, and dementia. Current Diet order is listed as regular diet. R30's care plan with a goal date of 2/24 lists a goal that resident weight will be a proper Body Mass Index (BMI). Interventions with a start date of 3/15/23 is listed for the following: serve diet as ordered and tolerated, see orders/tray card for current diet, set up tray per resident preference, Ensure proper/comfortable positioning at table, record intake for each meal, and offer substitutes for foods not eaten, note any reporting chewing/swallowing difficulties or changes in habits or intake and notify nurse for follow up with physician, allow use of clothing protector per resident/family preference, encourage the resident to participate to the fullest extent possible with each interaction, praise all efforts for eating/nutritional care. An intervention with the start date 3/15/23 is to use lids on coffee cups to prevent spills. R30's report of monthly weight and vitals for the 2023 year lists the following weights: June 2023 is 135 pounds, July 2023 is 131 pounds, August 2023 is 125 pounds, September 2023 is 123 pounds, October 2023 is 119 pounds, and November 2023 is 115 pounds. R30 has had a significant weight loss of 14.8% over the last 6 months. On 12/1/23 at 10:30 AM, V1 (Administrator) stated that R30 does not have current supplements ordered due to poor intake of those supplements. V1 stated that several different types had been trialed. R30's Skilled activities of daily living (ADL) reports that are filled out by the CNAs (Certified Nursing Assistants) for June and July for eating are coded daily as an 'S' which is described on the form to be: Set Up/Clean Up by helper but resident completes the ADL on own. The ADL assist report for June and July is coded as a '1' for all meals that is defined as '1' being supervision (oversight, encouragement or cueing). August ADL assist report documents R30 is coded as a '1' and '2.' A '2' is defined as being limited assistance (resident highly involved in activity and staff provide non-weight bearing assistance). The August ADL report lists R30 as an 'S' or a 'V' (verbal cueing/supervision/touching, helper may touch/steady/contact guard). The September skilled ADL report lists R30 as an 'S' all month except one meal she refused. The September ADL assist report documents R30 as being a '2' for eating. The October skilled ADL sheet documents that R30 is coded as an 'S' for eating and no skilled ADL assist report was provided. November 2023 skilled ADL report was coded as an 'S' for R30, and no skilled assist report was provided. R30's Minimum Data Set (MDS) dated [DATE] is a quarterly assessment and codes eating as R30 requiring set up or clean up assistance, set up or clean up provided, resident completes activity. The annual MDS with a 12/1/23 acceptance date is coded the same as the 8/30/23 quarterly. These documents also show that R30 has a BIMS (Brief Interview for Mental Status) score of 4, which indicates severe cognitive impairment. 145759 Page 13 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0692 Level of Harm - Actual harm Residents Affected - Few On 12/1/23 at 10:30 AM, V15 (Regional MDS Coordinator) stated that the MDS's are coded based on the CNA daily ADL report and ADL assist report. V15 stated that she is not in the building daily, as she is a regional MDS coordinator. V15 further stated that prior to taking on a regional position she was the floating MDS coordinator for this facility, so the facility has not had a full-time person in the MDS position for some time. V15 stated that she questions what can be done if many residents need assistance with eating because they do not have enough CNAs to do that and they are looking at reducing the nursing hours. On 11/29/23 at 11:50pm, R30 was in her room with lunch tray and drinks on the bedside table. R30's tray contained the regular diet of pulled pork, macaroni and cheese, butternut squash, and fruit cup (strawberries in juice/syrup and bananas). R30 was lying in bed with eyes closed. Observations of R30 conducted at approximately 15-minute intervals revealed R30 not attempting to eat, tray still untouched at bedside. No staff were observed going in the room to encourage her to eat or offer assistance. Housekeeping was noted entering in room at approximately 12:45PM cleaning up soda that R30 had spilled on the floor. R30 was awake and sitting up with bedside table & tray in front of her at this time but had still not taken any bites of food. At 12:52 PM, R30 started eating her fruit cup with her fingers, which contained cut up strawberries in a juice/syrup, despite having rolled up silverware in front of her. After finishing this, R30 did not attempt to eat any of the other food items on her tray. At approximately 12:58pm, V4 and V8 (CNAs) came to room. When asked at this time if R30 requires assistance with eating, V4 stated no she didn't. When asked about R30 eating the strawberries in juice/syrup with her fingers despite having silverware and pointing out the fact she did not attempt to eat any other meal items. V4 stated, yes R30 has been declining. R30 was not offered any alternative food items before her tray was picked up with only the fruit cup eaten. On 11/30/23 at 11:55PM, R30 was observed up to dining table with lunch meal of taco salad, rice, and vegetable being served at this time. From 11:55am to 12:20pm, R30 sat with meal in front of her, not eating, with no staff prompting or encouraging her to eat the taco salad meal. At 12:20pm, R30 was brought a peanut butter and jelly sandwich (which had been requested by staff for her tablemate (R5), but R30 still sat without eating it. At 12:29pm, V7 (Licensed Practical Nurse/LPN) began verbally prompting R30 to eat the sandwich, and she responded by taking bites of the sandwich until she finished it. On 12/01/23 at 11:30 AM, R30 was observed sleeping laying across her bed across, with her feet hanging over the side of the bed towards the floor and her head against the wall. On 12/01/23 at 12:15 PM, R30's lunch tray was delivered to her room. At this time, the tray was placed in her room on the bedside table while the resident remained asleep. At 12:47 PM, housekeeping was removing the untouched tray from R30's room. The cover was still on the food, the silverware was still wrapped in the napkin, and the drinks still had the covers on them. Intermittent observations of R30 were completed throughout the lunch service from 11:30AM -12:47PM and R30 remained in this position with an untouched tray without staff intervention or assistance. On 12/01/23 at 12:47 PM, V1 (Administrator) came to R30's room as housekeeping was removing R30's tray from the room and acknowledged that the tray had not been touched, the silverware remained wrapped, the cover was still on the plate as well as the lids on the drinks. R30 was still sleeping at this time. R30's nutritional assessment signed off on 11/17/23 by V16 (Regional Dietitian) documents the following: weight of 115.7 pounds is below acceptable BMI (Body Mass Index) range of (21.92)-underweight 145759 Page 14 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0692 Level of Harm - Actual harm Residents Affected - Few or age with significant weight loss noted for 6 months (15.55%). Resident diet/supplement prescription is noted above and resident feeds self. Oral intake is reported as approximately 25-50% of most meals per the November intake log. Varied oral intake may alter weights. R30's food and fluid intake sheet for November 2023 shows a varied intake of 0-100%, with the resident usually showing an intake of 25-50%. On 12/5/23 at 12:56 PM, V16 (Regional Dietitian) stated that when she is in the facility, she observes mealtimes, reviews charts, and speaks with residents. V16 stated that she had not witnessed the issues survey staff have observed this week with R30 not eating. V16 stated that what she had seen was that R30 was able to feed herself. V16 said that CNAs fill out the ADL sheets and that is how the care plan and MDS are filled out to determined how residents are to be assisted. V16 stated she trialed all the different supplements for R30 and said that she had not been made aware that R30 needed assistance and was not eating on her own anymore. V16 stated she was just told R30 had poor intake. V16 said she would expect staff to tell her if there were any issues with residents needing more assistance, then see if adding that as an intervention would improve intake and stabilize R30's weight loss. 145759 Page 15 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to provide adequate staff to meet resident needs. This has the potential to affect all 36 residents in the facility. Residents Affected - Many Findings include: 1. R30's Minimum Data Set (MDS) documents a most recent admission date of 11/25/22. R30's November 2023 Physician Orders includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Hypertension, malignant neoplasm of eye, and dementia. Current Diet order is listed as regular diet. R30's most recent Minimum Data Set (MDS) dated is a quarterly assessment and document R30 has a BIMS (Brief Interview for Mental Status) of 4 that indicates she is cognitively impaired. On 11/29/23 during the noon time meal service several residents who required assistance with eating were in the dining room. During this time 2 Certified Nursing Assistants (CNA) were working the floor and two office staff who were CNAs were present in the dining room to assist residents. On 11/29/23 at 11:50 AM, R30 was in her room with her (regular meal) lunch tray and drinks on the bedside table. R30 was lying in bed with eyes closed. Observations at approximately 15-minute intervals revealed R30 not attempting to eat, tray still at bedside. No staff observed going in room to encourage her to eat or assist. Housekeeper noted in room at approximately 12:45pm cleaning up soda R30 had spilled on the floor. R30 was awake and sitting up with bedside table & tray in front of her at this time, had still not taken any bites of food. At 12:52 PM R30 started eating her fruit cup, which contained cut up strawberries in a juice/syrup. She was eating this with her fingers despite having rolled up silverware in front of her. After finishing this, she did not attempt to eat any other food items. At approximately 12:58pm, V4 (CNA) and V8 (CNA) came to room. Asked if R30 requires assistance and V4 stated no she didn't. When asked about her eating juicy strawberries with her fingers despite having silverware, and pointing out the fact she did not attempt to eat any other meal items, V4 stated, yes R30 has been declining. V4 was asked why no one had been in R30's room to encourage R30 to eat. V4 said I don't know how they expect 2 CNAs to assist all these people needing assistance with eating. On 12/01/23 at 12:15 PM, R30's lunch tray was delivered to her room. At this time, the tray was placed in her room on the bedside table while the resident remained asleep. At 12:47 PM, housekeeping was removing the untouched tray from R30's room. The cover was still on the food, the silverware was still wrapped in the napkin, and the drinks still had the covers on them. Intermittent observations of R30 were completed throughout the lunch service from 11:30AM -12:47PM and R30 remained in this position with an untouched tray without staff intervention or assistance. On 12/01/23 at 12:47 PM, V1 (Administrator) came to R30's room as housekeeping was removing R30's tray from the room and acknowledged that the tray had not been touched, the silverware remained wrapped, the cover was still on the plate as well as the lids on the drinks. R30 was still sleeping at this time. 2. On 11/28/23 at 10:51 AM, R187 said the other day he waited for 45 minutes for a staff member to assist him urinate. R187 said during the night there was only two staff for the entire facility and call light times were too long to meet his needs. R187's face sheet documented an admission date of 11/10/23. R187's MDS documented a BIMS Indicating R187 was cognitively intact. 145759 Page 16 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 11/28/23, V10 (Family member) said she feels there is not enough staff at the facility. V10 said that sometimes there is only 2 staff in the facility. V10 also said that they are frequently told they must wait or need 2 people for help. V10 said that sometimes they must wait longer than 15 minutes for assistance with any needs. On 12/1/23 at 12:18 PM, V3 (Registered Nurse/RN) said most the time on day shift there are 2 licensed nurses and 2 CNAs. V3 said the night shift will sometimes have 1 licensed nurse and 1 CNA. V3 said 4 nursing staff on day shift and 2 nursing staff on night shift cannot meet all the resident needs. On 12/1/23 at 12:32 PM, V4 (CNA/Certified Nurse Assistant) said when there are only 2 CNAs on day shift, they could not get all the resident needs met. On 12/5/23 at 1:30pm, V4 said that the past weekend was terrible. V4 said they worked with only 2 CNAs all weekend and that last night (12/5/23) there was only 1 CNA from 2am to 6am. On 12/1/23 at 12:35 PM, V5 (CNA) said she usually worked from 6:00 AM to 6:00 PM. V5 said when there is only 2 CNAs working on day shift, they could not get all the resident needs met. V5 said due to night shift low staffing day shift would try to assist as many residents as possible to bed for the night prior to 6:00 PM. The facility Daily Nursing Staff documented on 11/3/23 and 11/17/23 the night shift had 1 RN and 1 CNA, on 11/3/23, 11/5/23, 11/6/23, 11/11/23, 11/12/23, 11/13/23, and 11/17/23 the day shift had 2 licensed nurses and 2 CNA. The Long-Term Care Facility Application for Medicare and Medicaid (form CMS 671) dated 11/28/23 documents that there are 36 residents residing at the facility. 145759 Page 17 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

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 provide the services of a Director of Nursing on a full-time basis. This has the potential to affect all 36 residents living in the facility. Residents Affected - Many Findings include: 1. On 12/5/23 at 9:58 AM, V1 (Administrator) said the facility had not had a full time Director of Nursing (DON) since December 26, 2022. V1 said she had interviewed 2 or 3 applicants for DON, but no one had accepted the position. V1 said the facility had advertised for the position but they had not had anyone interested. The facility working schedules documented the last day the facility had a full time DON was 12/26/22. The facility's undated Facility Assessment Tool documented the facility should have nursing personnel with administrative duties (DON) 5 days per week. The Long-Term Care Facility Application for Medicare and Medicaid (form CMS 671) dated 11/28/23 documents that there are 36 residents residing at the facility. 145759 Page 18 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to provide physician ordered therapeutic diets for 2 (R21 and R29) of 4 residents reviewed for nutrition in a sample of 38. Residents Affected - Few Findings include: 1. R29's face sheet documented an admission date of 6/1/22. R29's 12/1/23 through 12/31/23 Physician Orders Sheet (POS) documented diagnoses including fracture of head/neck of right femur, subsequent encounter for closed fracture with routine healing, atrial fibrillation, chronic obstructive pulmonary disease, anemia. R29's 11/8/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. R29's 12/1/23 through 12/31/23 POS documented a 9/14/23 diet order for mechanical soft with extra sauces and gravies, double protein every meal, super cereal at breakfast, nutritional drink once daily. R29's meal card documented R29 is to receive double protein at meals. On 11/30/23 at 8:03 AM, R29's morning meal tray was observed being delivered to R29 containing mechanical soft sausage, eggs, super cereal, toast, coffee, and nutritional juice drink. R29's meal tray contained a single portion of mechanical soft sausage and eggs; no double protein was observed. On 11/29/23 at 2:35 PM, R29 said he didn't think he received double protein on his meal trays. R29 said he thought he received a normal number of proteins on his meal trays. On 12/5/23 at 12:57 PM, V16 (Regional Dietitian) said she would expect R29 to have received a double portion of the mechanical sausage or the eggs on 11/30/23. V16 said the double protein was ordered to add extra calories for R29 for weight gain and wound healing. On 12/1/23 at 1:20 PM, V2 (Dietary Manager) said she expected kitchen staff to serve R29 meals as ordered. V2 said R29's 11/30/23 morning meal tray should have contained double portions of both the mechanical sausage and a double portion of eggs. 2. R21's face sheet documented an admission date of 10/15/20. R21's 11/1/23 through 11/30/23 Physician Orders Sheet (POS) documented diagnoses including left hip nailing, dementia, depression, anemia, vitamin D deficiency. R21's 11/1/23 through 11/30/23 POS documented a 9/20/23 diet order for finger foods only with thin liquids. R21's 10/6/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. R29's meal card documented R29 is supposed to receive finger foods. On 11/29/23 at 12:00pm, R21 was in the dining room eating her lunch. R21 was observed picking up her food items with her fingers. R29 did not have silverware available. At 12:25pm, V4 (Certified Nursing Assistant/ CNA) stated R29 is on finger foods. At 12:30pm, V2 (Dietary Manager) stated that there are different menu items for those on finger foods. V2 provided the menu for the finger foods which documented Pulled Pork on Bun, Carrots, drained and a banana. R29 had the drained carrots and banana but did not receive the pulled pork on bun. R29 was served and ate the pulled pork, macaroni and cheese with her fingers. 145759 Page 19 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/5/23 at 12:57 PM, V16 (Regional Dietitian) said she expected the facility to provide residents with finger food orders with the appropriate foods as listed on the diet spreadsheet. V16 said finger food orders are used for residents who prefer to eat with their hands to increase oral intake. The facility's Week 4 Wednesday diet spreadsheet documented residents with a diet order for finger foods should have received pulled pork on bun, carrots drained, and a banana. The facility's revised 10/2020 Therapeutic & Mechanically Altered Diets policy documented in part . A therapeutic diet is a diet ordered to manage problematic health conditions . A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake . 1. A physician's order is written for all diets including therapeutic and mechanically altered diets 3. The Food Service Manager and/ or dietitian write an extension of the regular diets using the same foods when possible . 6. Portion sizes are evident for each item on the menu extensions . 8. The facility prepares and serves all therapeutic and mechanically altered diets as planned . 145759 Page 20 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review the facility failed to obtain food preferences and offer substitute options to residents at mealtime. This has the potential to affect all 36 residents residing in the facility. The Findings Include: 1. R1's new admission information sheet documents an admission date of 6/17/22. R1 was alert to person and place during the interview on 12/1/23 at 12:30 PM when she stated that she is never asked about meal preferences or options other than the main selection. R1 stated that she is blind, so she would not be able to read the board if they did fill it out. R1 stated that she just gets what they serve her at meals, and that is what she eats. R4's food preference questionnaire is dated 6/17/23. 2. R4's new admission information sheet documents an admission date of 1/11/19. R4 was alert to person and place during the interview on 12/1/23 at 12:30 PM when she stated that she is never asked what her food preferences are, nor do they offer or tell the residents what the substitute options are for the meals. R4's food preference questionnaire that is dated 1/11/19 documents that that she 'likes most everything' under favorite foods, along with documenting what drinks she prefers with meals. 3. R6's new admission information sheet documents an admission date of 7/26/12. R6 was alert to person and place during the interview on 12/1/23 at 12:30 PM when she stated that she is never offered the substitute option for the meal, nor is it posted on the meal board in the dining room. R6 stated that she just eats what she likes off the plate that is placed in front of her and doesn't bother to ask for anything else. R6 stated that this week she did not eat the macaroni/pulled pork on 11/29/23, the taco salad on 11/30/23 nor the fish on 12/1/23, which were the main entree of each meal. R6 stated that no one asked or offered her any substitute options when she didn't eat them. R6 stated that no one reviews the menu prior to the meal with the residents. R6's food preference questionnaire is dated 12/1/23. The previous food preference questionnaire in R6's medical record was dated August 2019. On 12/1/23 at 1:30 PM, V2 (Dietary Manager) stated that the residents are to have an updated food preference questionnaire annually. V2 at this time checked R6's medical record and stated that it was time to update it due to not being updated since 2019. R6's diet card provided from the kitchen on 12/1/23 was blank under the likes and dislikes and V2 at this time also stated that was inaccurate because she knows that R6 doesn't like some foods and that she would update all of this right now. 4. R12's new admission information sheet documents an admission date of 1/3/17. R12 was alert to person and place during the interview on 12/1/23 at 12:30 PM when she stated that the staff do not go over the menus with residents prior to the meal to get options to select from in case they do not like the main entree. R12 also stated that they do not post the substitutes on the menu board for the meals. R12 does not remember being asked about what foods she likes and dislikes. R12's chart had a food preference On 12/05/23 at 11:31 AM, V9 (Certified Nursing Assistant) stated that they normally just give a bologna or peanut butter and jelly sandwich when they notice the resident is not eating or if they ask 145759 Page 21 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0806 for something else, but if they would ask the kitchen staff, they could probably heat something up. Level of Harm - Minimal harm or potential for actual harm On 12/05/23 at 1:19 PM, V16 (Regional Registered Dietitian) stated that someone should be speaking with residents prior to the meal to determine if they need a substitute choice for the meal. V16 stated that this could be any department including certified nurse assistants, activities, or the kitchen. The kitchen should have a hot protein and vegetable choice for alternate selections. V16 also stated at this time that the food preference questionnaire is filled out on admission and as needed if there are any food complaints or concerns with dietary needs. Residents Affected - Many No alternate selections were observed to be written on the meal board in the dining room for the lunch meals on 11/28/23-12/1/23 or 12/5/23. Residents who did not eat the meals at lunch time were offered bologna or peanut butter sandwiches during these days. No hot selections were observed as being offered as substitutes. On 12/5/23 at 11:30 AM, V2 stated that she isn't sure what the alternate selections are for today and acknowledges it is not written on the meal board but said something is in the oven. On 12/5/23 at 1:30 PM, V19 (Director of Operations) stated that there is not a policy on filling out the food preference questionnaire. The Long-Term Care Facility Application for Medicare and Medicaid (form CMS 671) dated 11/28/23 documents that there are 36 residents residing at the facility. A policy for Meal Alternatives with a revision date of 04/17 documents that it is the policy to provide appropriate alternates to those residents who dislike or do not eat the main entree and vegetable to help ensure adequate nutritional intake. The Procedure of the policy is as follows: 1. The general menus are posted within the facility. 2. An appropriate entree and vegetable alternate is prepared and readily available at meals. The alternate may be provided to the resident who dislikes the main entree and vegetable and may also be offered to a resident who eats less than 50% of their entree and vegetable at the meal. Other dining options may be available as well, such as, but not limited to, an always available menu, buffet, or restaurant style menu. 3. If the resident refuses the original entree/or the alternate; the nurse shall be informed. Refusal to eat or poor intake should be documented in the resident's medical record. 145759 Page 22 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents who require antibiotics are prescribed the appropriate antibiotics to treat infections for 1 (R29) of 3 residents reviewed for urinary tract infections in a sample of 38. Residents Affected - Few Findings include: 1. R29's face sheet documented an admission date of 6/1/22. R29's 12/1/23 through 12/31/23 Physician Orders Sheet (POS) documented diagnoses including neurogenic bladder, Benign Prostatic Hypertrophy (BPH), fracture of head/ neck of right femur, subsequent encounter for closed fracture with routine healing, atrial fibrillation, chronic obstructive pulmonary disease, anemia. R29's 11/8/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. R29's 11/5/23 at 1:00 PM Nurses Notes documented in part . UA (urinalysis) obtained (after) flushing. Notify (Medical Doctor) of results. Still (with) pain all over . R29's 11/5/23 urinalysis documented a trace of occult blood, positive for nitrite, 2+ leukocyte esterase, 16-20 white blood cells, 3-5 red blood cells, and 1+ bacteria. The reference range for these results are occult blood negative, nitrite negative, leukocyte esterase negative, white blood cell none seen to 3-5 seen, red blood cells none seen to 3-5 seen, bacteria negative. R29's 11/5/23 at 5:30 PM Nurses Notes documented in part . Lab results sent to (Medical Doctor with) orders to begin Doxycycline 100 (milligrams 1 tab twice for 1 week) Family aware. Resident confused (and) restless. Woke up didn't know where he was . On 11/28/23 at 10:32 AM, R29 was lying in bed with catheter collection bag hanging from bedframe. R29 catheter tubing and collection bag contained dark yellow urine with a large amount of mucous/ sediment. On 11/30/23 at 3:38 PM, V17 (Infection Preventionist/Licensed Practical Nurse) presented R29's urine culture and sensitivity with a collection date of 11/5/23, a physician acknowledgment date of 11/8/23, and a fax date of 11/30/23. R29's urine culture and sensitivity documented the organism was resistant to tetracycline (Doxycycline is in the family of tetracycline). V17 said the facility had just received R29's urine culture on 11/30/23 after she had called the lab to request the urine culture and sensitivity. V17 said she was unsure if anyone had notified R29's physician of the urine culture and sensitivity documenting the organism was resistant to the antibiotic ordered. V17 said she expected staff to notify a resident's physician when a resident was being treated with an antibiotic that the organism was resistant to for possible antibiotic changes. R29's Nurses Notes did not document any communication with R29's physician pertaining to R29's 11/5/23 urine culture and sensitivity. R29's 11/1/23 through 11/30/23 Medication Administration sheet documented R29 had received Doxycycline 100 milligrams twice a day for a week from 11/5/23 through 11/12/23 and 11/22/23 through 11/30/23. On 11/30/23 at 3:52 PM, V17 said she had notified R29's physician of the 11/5/23 urine culture and had received orders to repeat the urinalysis with culture and sensitivity if indicated. 145759 Page 23 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0881 Level of Harm - Minimal harm or potential for actual harm On 12/1/23 at 11:24 AM, V6 (Physician) said he expected to be notified if a urine culture and sensitivity was received and documented resistance to the antibiotic being given. R23's 11/30/23 urinalysis documented 2+ occult blood, positive nitrite, 1+ leukocyte esterase, too many to count white blood cells, too many to count red blood cells, and 3+ bacteria. Residents Affected - Few On 12/1/23 at 1:36 PM, V6 (Physician) said if R29 had been changed to an antibiotic that the 11/5/23 urine culture and sensitivity had been sensitive to it is possible R29's 11/30/23 urinalysis would have improved. The facility policy titled Antibiotic Stewardship Program (review date 6/7/17) under the section Core Elements of Antibiotic Stewardship documents Reporting: Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, or other relevant staff. The Leadership Commitment Statement of the same policy documents in part .Antibiotic Stewardship is the act of using antibiotics appropriately-that is, using them only when truly needed and using the right antibiotic for each infection. 145759 Page 24 of 26 145759 12/06/2023 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow the Immunization of Residents policy and failed to provide the Pneumococcal Immunization for 1 (R29) of 5 residents reviewed for immunizations in a sample of 38. Residents Affected - Few Findings include: 1. R29's face sheet documented an admission date of 6/1/22. R29's Physician Orders Sheet (POS) documents diagnoses including fracture of head/ neck of right femur, subsequent encounter for closed fracture with routine healing, atrial fibrillation, chronic obstructive pulmonary disease, anemia. R29's 11/8/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. R29's Immunization Record documented R29 had not received any pneumococcal vaccines prior to or since admission to the facility. R29's 11/30/23 Social Services Progress Notes documented .Spoke with (R29's Power of Attorney/ POA) about pneumonia vaccine and stated (R29's POA) wants to talk with doctor and will let us know (R29's POA) decision . The facility was not able to produce any other documentation on educating or offering R29 a pneumococcal vaccine prior to 11/30/23. On 12/5/23 at 8:54 AM, V1 (Administrator) said the facility did not have any other documentation for R29 pertaining to pneumococcal vaccinations. V1 said R29 had documentation from his admission from the hospital documenting no pneumococcal vaccination. On 12/5/23 at 11:48 AM, V17 (Infection Preventionist/ Licensed Practical Nurse) said she was responsible to review resident Immunization Records to ensure pneumococcal vaccinations are given. V17 said on 11/30/23 R29's POA had declined R29 receiving the pneumococcal vaccine until R29's POA spoke with R29's physician. V17 said she did not know why R29 had not had any pneumococcal vaccinations. The facility's revised 5/19/23 Immunization of Residents policy documented in part . will offer immunization and vaccinations that aid in the prevention of infection disease unless medically contraindicated or otherwise ordered by the resident's physician or the facility's medical director . Procedure: 1. Explain to the resident, resident's guardian or the resident's Durable Power of Attorney for Health Care, at the time of admission and at the start of the recognized mass immunization period, the importance of vaccination against common illnesses such as pneumonia and influenza. 2. Obtain written order for the vaccination . 3. Obtain permission/ consent from the resident, resident's guardian, or the resident's Durable Power of Attorney for Health Care to administer the ordered vaccine . 4. Verify the date of last vaccination. Obtain proof of previous Pneumococcal . vaccination for residents when able. Assess all newly admitted resident's pneumococcal . vaccination status upon admission and record last known immunization on the resident's Immunization Record . 5. Offer the PCV13, PCV15, PCV20 or PPSV 23 as indicated utilizing the Pneumonia Vaccine Timing Guidelines . Offer the Pneumococcal vaccine within 30 days of admission . 145759 Page 25 of 26 145759 12/06/2023 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 Based on observation and interview the facility failed to maintain an effective pest control program. This has the potential to affect all 36 residents in the facility. Residents Affected - Many Findings include: On 11/28/23 at 10:05 AM, on the initial tour of the kitchen, two live cockroaches were seen under the three-part sink. V2 (Dietary Manager) verified there were two cockroaches under the three-part sink and said she would tell V18 (Maintenance Director). On 12/1/23 at 1:19 PM, a piece of brownish colored food was observed lying on the floor in front of the stove with three live cockroaches around it and one live cockroach on the floor beside the stove. On 12/5/23 at 11:05 AM, V18 said the pest control company came to the facility monthly. V18 said when the pest control company came to the facility, they would compile a report of any infestations they found. V18 said the pest control company had not reported any infestations of cockroaches. V18 said if any concerns were reported of cockroaches, he would call corporate, and they would schedule the pest control company to come to the facility for an extra visit. V18 said on 11/28/23 when V2 had reported the cockroaches in the kitchen he had not called corporate because it was only one report. V18 said he would only call corporate if there were multiple reports of cockroaches. V18 said he had not had to call corporate for an extra pest control company visit in longer than a year. On 12/1/23 at 12:18 PM, V3 (Registered Nurse/RN) said she frequently saw cockroaches in the facility in the dining room, nurse's station, and bathrooms. V3 said she would report to V18 any time she saw cockroaches in the facility. On 12/5/23 at 11:48 AM, V17 (Infection Preventionist/ Licensed Practical Nurse) said she expected V18 to follow the facility policy if cockroaches were discovered in the kitchen. The facility's undated Insect and Pest Control Policy documented in part . A preventative treatment, both interior and exterior, shall be applied at least monthly. Treatments well be applied more often if required . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 4. Any employee observing insects or rodents shall inform their supervisor giving the exact location and type of infestation . 6. The maintenance person shall contact the contracted pest control company for eradication . The Long-Term Care Facility Application for Medicare and Medicaid (form CMS 671) dated 11/28/23 documents that there are 36 residents residing at the facility. 145759 Page 26 of 26