Inspection·January 31, 2024

F 0686 Level of Harm - Actual harm Residents Affected - Few V8. The same assessment under wound review documents Y (yes) to the question of Does the resident currently have an unresolved pressure ulcers? (If yes, please see weekly wound measurement) Under Skin Treatment Review: Indicate all used in the last 7 days float heels is marked as being used. V8's nurse progress note dated 12/4/23 at 10:00pm, documents a Body Assessment was completed, and R1 has reddened pressure areas on back, spine, sacrum, et (and) bilateral heels. Right heel has a 0.5 x 1 cm (centimeter) scabs intact. R1's nursing summary dated 1/16/24 and signed by V8 notes for skin care, pressure relief mattress and heel protectors and notes heels are soft. R1's Braden Scale for Predicting Pressure Ulcer Risk documented by V9 (LPN/Licensed Practical Nurse) dated 12/11/23, 12/18/23, 12/25/23 and 1/1/24, all document a score of 15, which indicates R1 is at high risk of developing pressure ulcers. The wound review section for all of the above dates has a line drawn through the column which asks, Does the resident currently have any unresolved pressure ulcers? R1's Physician's Orders dated 12/4/23 to 12/31/23 documents R1 is a moderate skin risk and documents an order of weekly skin assessment with note on Monday shift 2-10. R1's Physician's orders dated 1/1/24-1/31/24 document an order dated 12/4/23 for weekly skin assessment with note on Monday 2-10 shift and a new order dated 1/29/24 for daily skin checks on 6-2 shift. R1's Skilled Progress notes from 12/4/23 to 1/22/24 indicate there was no documentation of wound location, measurements, drainage or treatment. A Skilled Progress note dated 1/23/24 at 1:30pm by V9 documents N.O. (new order) received from wound physician to apply betadine to bilateral heels bid (twice a day), son notified. A Skilled Progress Note dated 1/30/24 at 9:00am by V7 (RN/Registered Nurse) documents pressure areas to bilateral heels remain but appear to be improving. Tx (treatment) to bilateral heels performed. There was no documentation noted from 1/23/24 to 1/30/24 of wound location, measurements, drainage or treatment. R1's TARS (Treatment Administration Record) dated 12/4/23-12/31/23 document weekly skin assessments on Monday 2-10 shift. Initials indicating assessment were completed were documented on the following dates: 12/4/23, 12/11/23, 12/18/23, 12/19/23, and 12/25/23. The back of the TAR documents a skin assessment on 12/19/23 and notes skin assessment performed post shower and no new areas observed and signed by V7. There were no other skin assessments documented on the back of the TAR or in the nurse progress notes. There was no documentation noted under location, stage, diameter, depth/shape/type, color or drainage. R1's TARS dated 1/1/24-1/31/24 were reviewed and document skin assessments were initialed as being completed on the following dates: 1/1/24, 1/8/24, 1/15/24, 1/22/24, and 1/23/24. The skin assessment on the back of the TAR on 1/1/24, 1/8/24, 1/15/24, and 1/22/24 all document no new skin issues under progress/comments. On 1/23/24 under progress/ comments it documents Skin assessment performed post shower. Pressure areas remain to bilateral heels. No new areas observed. There was no documentation noted under location, stage, diameter, depth/shape/type, color or drainage. R1's Initial Wound Evaluation and Management Summary dated 1/25/24 by V12 (Wound Physician) documents R1 has an unstageable DTI of the right heel, undetermined thickness. Etiology is noted as pressure with a duration of > (greater than) 6 days. The wound measurement to the right heel is noted as 2.5 x 3 x not measurable cm (centimeters), exudate: none and skin: intact with purple/maroon discoloration. The same evaluation also documents an unstageable DTI of the left heel, undetermined thickness, with a documented etiology of pressure with a duration of > 6 days. The wound measurement of the left hell is noted as 0.9 x 0.9 x not measurable cm, exudate: none, skin: intact with purple/maroon discoloration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 2 of 5 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 01/31/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few On 1/26/23 at 8:30am, R1's skin check, completed by V9 (LPN), was observed. There were no wounds observed to R1's back or spine. R1's coccyx is lightly reddened. R1's left heel has an approximately 1-centimeter (cm) x 1 cm black area, then a 4 cm x 3 cm boggy area around bottom of heel and is darker pink in color. R1's right heel has 4 cm x 3 cm black area with a small area of yellow tissue in the middle. There was no drainage noted from either wound. The surrounding tissue on both wounds is light red. On 1/26/24 at 8:40am, R1 was observed lying in bed without heel protectors on. V10 (CNA/Certified Nurse Assistant) then applied heel protectors. On 1/26/24 at 9:00am, V1 (Administrator) said she did not have any wound notes or wound assessments on R1 prior to 1/25/24. On 1/26/24 at 12:51pm, V8 (LPN) said she admitted R1 to the facility. V8 said R1 did not have an open area on her left heel but did have a scabbed area on her right heel. V8 said R1's heels were boggy. V8 said R1 had heel protectors on at first, then she wasn't wearing them. V8 said she did not contact the physician regarding the open areas on R1's body when she admitted her. V8 said she did not look at R1's heels and did not measure them after she admitted her. V8 said she did sign off as doing a skin assessment but did not do an assessment or look at her heels. V8 said she would consider heels to be a part of a skin assessment. On 1/26/24 at 12:31pm, V7 (RN/Registered Nurse) said she was shown R1's wounds by Physical Therapy. V7 said R1 usually gets her showers on the evening shift, and she usually does not do the skin checks on her since they are done on 2-10 shift. V7 said she did report the wounds to V9 (Licensed Practical Nurse/ LPN) and he was supposed to get ahold of the V12 (Wound Physician). V7 said she knew R1 was admitted to the facility with a wound as she did read her admission assessment. V7 said she did not call the physician since she assumed V9 called him. On 1/26/24 at 9:05am, V9 (Licensed Practical Nurse/LPN) said he guesses they just dropped the ball on R1's wound care. V9 said he asked staff if they saw an ulcer on R1's feet because some were charting it and some were not. V9 said he became aware of the ulcers on her heels on 1/23/24 and he called physician and V12 (Wound Physician). V9 said the wound physician came to see R1 on 1/25/24. On 1/26/24 at 9:30am, V9 said they just missed the wounds and he just found out about them. V9 said the wounds were not charted on due to staff thinking he knew about them, and he didn't or he would have notified the physician and got orders for wound care. On 1/26/24 at 10:14am, V5 (LPN) said she was aware of the open areas on R1's heels. V5 said she did keep R1's heels floated. V5 said she was aware on 1/18/24 as her and V9 spoke about it, and she did not call the physician. V5 said she figured someone else had called him. V5 said she just did a check mark on R1's skin assessment and did not do a note or an assessment. V5 said she did pass it on about her heels and guesses she didn't know where it went from there. V5 said she thinks it was on 1/18/24. V5 said she would expect a resident's heels to be a part of a skin assessment. On 1/26/24 at 11:30am, V6 (Regional Quality Assurance) said she would expect heels to be a part of a skin assessment and it to be documented on the back of the TAR (Treatment Administration Record) or in the nurses note. The facility policy titled Pressure Sore Prevention Guidelines (Revised 4/06) document The nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 3 of 5 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 01/31/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few will complete a skin assessment on all residents upon admission then weekly for four weeks .The following guidelines will be implemented for any resident assessed at a Moderate Risk or High Risk, Some Interventions listed for high risk include turn and reposition every 2 hours, special mattress, positioning devices prn (as needed), daily skin checks. The same document notes turn and reposition every 2 hours, weekly skin checks, care plan entry. The same document states Any resident scoring a high or moderate risk for skin breakdown will be noted on the treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. A facility policy titled Decubitus Care/Pressure Areas (revised 5/07) documents it is the facility policy to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. The document lists the procedure as 1. Upon notification of skin breakdown, a newly acquired skin condition report will be completed and forwarded to the Director of nursing. 2. The pressure area will be assessed and documented on the Treatment Administration Record. 3. Complete all areas of the TAR-Document the size, stage, site, depth, drainage, color, odor and treatment (upon obtaining from the physician), Document the status of the pressure ulcer, Document the color, 4. Notify the physician for treatment orders, 5. Documentation of the pressure area must occur upon identification and at least once a week on the TAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 4 of 5 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 01/31/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, observation, and record review the facility failed to provide Registered Nurse services at least 8 hours a day, 7 days a week and failed to provide a full time Director of Nursing (DON). This failure has the potential to affect all 20 residents residing in the facility. Findings include: On 1/25/24 at 10:40am, V1 (Administrator) said she thinks they are doing better with RN/Registered Nurse Coverage. V1 said they now have an RN that comes in when needed. V1 said they do not currently have a DON/Director of Nurses and have not had one in about a month or so. On 1/25/24 at 12:30pm, V5 (LPN/Licensed Practical Nurse) said they do not have a DON/Director of Nurses. The facilities January 2024 licensed nursing schedule documented no Registered Nurse (RN) coverage on 1/5/24, 1/6/24, 1/12/24, 1/13/24, 1/19/24, 1/20/24, 1/25/24, and 1/26/24. On 1/25/24 at 11:00am, V1 verified there was no RN coverage in the facility on the above listed dates. On 1/25/24 and 1/26/24, there were no RN's observed working in the facility during the survey. Facility Document labeled Nurses Midnight Census dated 1/25/24 note there are 21 residents, with 1 resident in the hospital for a total of 20 residents residing in the facility. The facility's undated Facility Assessment Tool documented the facility required 1 full time RN to serve as DON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 5 of 5