Inspection·October 27, 2023

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide sufficient dietary staff. This has the potential to affect all 21 residents that reside in the facility. Findings include: On 10/26/23 at 11:45 AM V1 (Administrator) stated, V12 (Previous Dietary Manager) quit on 09/11/23 and they hired V3 (Dietary Manager) on 10/12/23. V1 said that on 09/08/23, 10/02/23, 10/03/23, 10/04/23, V13 (Registered Dietician) helped in the kitchen. V1 said that on 09/25/23 through 09/27/23, and 09/29/23, V14 (Dietary Manager from another facility) helped in the kitchen. On 10/11/23 through 10/13/23, V15 (Dietary Manager from another facility) helped in the kitchen, and on 09/10/23 through 09/13/23, 09/21/23, 09/28/23, and 09/30/23 through 10/08/23 there was no one scheduled for dietary. V1 said that on 09/15/23, 09/16/23, 09/18/23, 09/19/23, 09/20/23, 09/22/23, 09/24/23 through 09/27/23, 09/29/23 and 10/08/23 there was one person scheduled for dietary services. V1 stated, V1 and V2 (Business office manager/Social Service Director), V4 (Minimum Data Set Coordinator), V16 (cook), V17 (dietary aide), V18 (previous Activities Director) helped in the kitchen. On 10/25/23 at 1:42 PM V6 (Certified Nurse Aide) stated, she did help in the kitchen during the timeframe the kitchen did not have any staff. She did not cook but she helped with drinks and the dietary cards. On 10/25/23 at 1:47 PM V2 (Business Office Manager/Social Services Director) stated, she was hired on October 2, 2023. V2 stated her first week of work she worked in the kitchen. V2 said she did not have any true kitchen experience but she sure learned a lot about mechanical soft diets and how to make puree foods. On 10/25/23 at 12:55 PM V5 (Registered Nurse) stated, V9 (dietary) started as needed to help in the kitchen but she did not have any dietary experience. V5 said they did not have any staff in the kitchen. V5 stated she knows V1 (Administrator), V2 (BOM/SSD), V6 (CNA) and other worked in the kitchen. On 10/25/23 at 2:55 PM V10 (Speech Therapy) stated, there was a period that they did not have dietary staff, staff from other positions did step into rolls that were not their jobs. On 10/25/23 at 1:30 PM V4 (Minimum Data Set Coordinator/MDS) stated, he did assist in the kitchen when they had no dietary staff. V4 said he followed the menu to the best of his/their ability. V4 said some of the dietary staff quit, and some were terminated due to no call/no shows. The facility document titled, work schedule for the week of [DATE] - 16 Dept (Department) Dietary documents: no staff scheduled for 09/10/23 - 09/13/23 and only V18 (dietary) scheduled from 5 - 1 (5:00 AM - 1:00 PM) on 09/15/23 and only V17 (dietary aide) scheduled 6 - 6 (6:00 AM - 6:00 PM) on 09/16/23. The facility document titled, work schedule for the week of [DATE] - 23 Dept (Department) Dietary documents, only V16 (Cook) working 5 - 6 (5:00 AM - 6:00 PM) on 09/18/23 - 09/20/23 and no staff scheduled on 09/22/23 and only V17 (dietary aide) working 6 - 6 (6:00 AM - 6:00 PM) on 09/23/23. There is no documentation of a dietary schedule for 09/30/23 - 10/08/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 2 of 3 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 145978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Harrisburg 1000 West Sloan Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many V1 (Administrator) stated, V16 (cook) quit on 09/19/23 and V17 (dietary aide) quit on 09/25/23. V1 said the schedule of 09/24/23 - 09/30/23 is not what was worked, only the 09/24/23 was worked by the facilities dietary staff. V1 said there was no schedule for 09/30/23 - 10/08/23 because they did not have any dietary staff to put on it. V1 stated she worked in the kitchen most of those days. The facility assessment dated [DATE] documents: Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Staff type: Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents. Potential data sources include staffing records, organization chart, and Payroll-Based Journal reports. Considering the following type of staff and other professionals/practitioners, list (or refer to or provide a link to) your staffing data, directories, organization chart, or other lists that show the type of staff needed to care for your resident population. Administration (e.g., Administrator, Administrative Assistant, Staff Development, QAPI, Infection Control and Prevention, Environmental Services, Social Services, Discharge Planning, Business Office, Finance, Human Resources, Compliance and Ethics), Nursing Services (e.g., DON, RN, LPN or LVN, CNA or NAR, medication aide or technician, MDS nurse), Food and Nutrition Services (e.g., Director, support staff, registered dietician). Staffing plan: 3.2. Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Food and nutrition services staff: with 3 documented. The facility's document titled, Nurses Midnight census dated 10/25/23 documents 21 residents reside at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 3 of 3