Inspection·February 10, 2026

F 0600 Level of Harm - Actual harm Residents Affected - Few longer wanted to be roomed with the resident (R2) anymore. This report documented no injures observed post incident.2. A Report to IDPH Regional Office marked as Final documents a Date of Incident/Accident as 12/15/2025 with at time of 3:25 AM and names R4 and R2 as the residents involved. Under Description of Occurrence is documented Alleged Resident to Resident Physical Altercation. No injuries were noted, and the report indicates Residents Separated, Police called and an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (R2) was found to have hit (R4) in back of her head, resident confused at time not understanding what he (R2) had done. (R4) was not injured and stated it did not hurt her just stunned her and she (R4) is not afraid. (R2) has followed up with psychiatrist and has had a medication change. The report documents it was completed by V1 (Administrator) on 12/17/25.R4's admission Record documented an admission date of 11/5/24 and included diagnoses of schizoaffective disorder, anxiety disorder, dementia, and depressive disorder. R4's MDS dated [DATE] documented a BIMS score of 12, indicating R4 was moderately cognitively impaired.Additional facility investigation documentation labeled #152 Res/Res Altercation dated 12/15/2025 at 3:30 AM documents the incident location was the dining room and V14 (LPN) prepared the report. The incident description documents CNA (Certified Nursing Assistant) staff stated that agitated resident hit this resident on the top of the head with facility signage that was removed from the wall. Resident description documents Resident (R4) didn't state much about the incident but said ‘it was a shock more than anything, he does crazy things.' This nurse asked resident if she was in any pain to which she stated no. Under Injuries observed at time of incident documents injury location as top of scalp. Mental status is documented as alert and oriented to person, situation, place and time. The injuries report post incident documents No Injuries Observed Post Incident. Under Statements, V14 (LPN) documented I did not personally see this incident occur but after talking with this resident (R4), she seemed more shaken up than anything. Residents vitals and neuro assessments were all within normal limits. No visible injuries were noted to residents face or scalp. V15's (CNA) statement documents (V16/CNA) got me from (room number) to come to dining room to help with an agitated resident that was combative. Resident was sitting on piano bench and began hitting me, swinging with fists and a board off the wall. He hit me in right ribs and breast. He grabbed a heavy Christmas decoration and threw it at me. He got up chasing mr on foot at me, I got the w/c (wheelchair) and got him to sit. V16's (CNA) statement documents Client in dining room, became combative with staff by standing up and swinging upper body and arms with closed hands resulting between contact between staff and patient. 1:1 given client redirected, no injuries noted. On the way back from nurses desk another client approached the same area resulting in an altercation between said aggressive patient and other client. Top of patient's head smacked at contact made 1:1 give, nurse notified. No injuries noted.3. A Report to IDPH (Illinois Department of Public Health) Regional Office marked as Initial & Final documents a Date of Incident/Accident as 02/03/2026 with no time documented and names R1 and R2 as the residents involved. Under Description of Occurrence is documented Alleged resident to resident altercation. No injuries were noted and the report indicates an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (Name of R1's) daughter reported to the Administrator that on December 16, 2025 that resident (name of R2) grabbed her father's blanket and hit his back. The daughter reported this to Admin weeks after the incident occurred. The daughter spoke to the nurse on duty at the time of the incident and stated that (name of R2) was bothering her and her father (R1) and asked if he (R2) could be moved. At the time of the incident resident's daughter did not mention any hitting. By the time the incident was reported (name of R2) had been sent to inpatient psychiatric care. (Name of R2) has since returned to the facility with no further incidents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 2 of 12 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 02/10/2026 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 0600 Level of Harm - Actual harm Residents Affected - Few Residents and staff interviewed with no concerns identified. The report documents it was completed by V1 (Administrator) on 02/03/2026.R1's admission Record documented an admission date of 3/25/25 and included diagnoses of chronic obstructive pulmonary disease, panlobular emphysema, and dysphasia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. On 2/4/26 at 10:29 AM, V3 (Licensed Practical Nurse/LPN) said she was working on 12/16/25. V3 said she was down the hall with the medication cart administering medications to other residents when V9 approached her and told her R2 was yelling at V9 (Family Member). V3 said she told V9 she would take care of it and went to the dining room. V3 said when she got to the dining room R2 was sitting in his wheelchair about 3 tables away from R1 and was yelling at V9. V3 said she assisted R2 to the other side of the dining room away from R1. V3 said V9 did not report any physical incident to her at the time. V3 said V9 had only told V3 that R2 was being verbally abusive to V9. V3 said about a month after this incident, V1 came to V3 asking when V9 had reported to V3 on the date of this incident. V3 said she did not tell V9 to report what had happened on 12/16/25 to V1.On 2/4/26 at 3:20 PM, R1 was alert and oriented to self, time, and place. R1 said he was not sure of the exact date of the incident with R2. R1 said he was sitting in the dining room after the evening meal talking to V9 (Family Member) when R2 came up behind R1 and rammed R2's wheelchair into R1's wheelchair and R2 started punching R1 in the back. R1 said he told R2 to stop and get away from R1. R1 said another male resident sitting in the dining room yelled at R2 to stop. R1 said he thought the other resident yelling scared R2 and caused R2 to stop and roll away from R1. R1 said he was not sure of the other male resident's name. R1 said V9 immediately went to get a nurse, so R1 assumed the facility was aware of the incident. R1 said a nurse came to the dining room and assisted R2 back to R2's room.On 2/4/26 at 3:39 PM, V9 said she had been told by various staff R2 could become physically aggressive. V9 said on 12/16/25, V9 and R1 were sitting in the dining room when R2 came up behind R1 and hit R1's wheelchair with R2's wheelchair. V9 said R1 told R2 to stop when R2 started punching R1 in the back and started pulling on R1's blanket. V9 said R7 was sitting at a table on the far side of the dining room and used a stern voice to tell R2 to stop. V9 said R2 stopped punching R1 and R2 rolled his wheelchair back away from R1. V9 said after the incident, V9 went to get V3 (LPN) and informed V3 of what had happened. V9 said V3 came to the dining room and R2 was still close to R1 sitting in his wheelchair. V9 said V3 assisted R2 back to R2's room. V9 said V3 told V9 to report what happened to V1 (Administrator) and V9 sent V1 an email describing the events. V9 said after she sent V1 the email on 12/16/25, V9 returned to the facility the next day and did not see R2. V9 said she thought R2 was no longer in the building due to the email V9 had sent to V1 and thought it was taken care of. V9 then said on 1/6/26, she visited the facility and saw R2 had returned to the facility. V9 said she spoke with V2 (Director of Nursing/DON) on 1/6/26 regarding her concerns with R2 being back in the facility after R1 and R2's physical altercation and the need for R1 and R2 to be kept apart. V9 said later that day on 1/6/26, V1 (Administrator) called V9 and yelled at V9 for about 20 minutes saying V1 only had 24 hours to report the incident and asking why V9 didn't report this to V1. V9 said she told V1 she had sent V1 an email on the day the incident had happened. V9 said V1 said she had not received any email from V9 about this incident so V9 told V1 she would forward the previously sent email.On 2/5/26 at 10:12 AM, V7 (Certified Nursing Assistant/CNA) said he could not recall a specific date with any incident between R1 and R2. V7 said he did recall an incident when R2 grabbed R1's wheelchair and R2 had to be redirected away from R1. V7 said R2 had a lot of conflict with a lot of residents. V7 said he had seen R2 raise his fist like he was going to hit another resident, but staff had intervened prior to R2 making contact. V7 said he had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 3 of 12 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 02/10/2026 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 0600 Level of Harm - Actual harm Residents Affected - Few witnessed the event between R1 and R2 on 12/16/25 but had come to the dining room after V9 spoke with V3. V7 said he did not recall what V9 said at that time. V7 said later on V9 had asked staff to keep R2 away from R1 because R2 had hit R1 in the past.On 2/5/26 at 10:23 AM, V8 (CNA) said she did not witness the incident between R1 and R2. V8 said in the past she had seen R2 get physically aggressive with other residents and it was common for (R2) to get aggressive.On 2/5/26 at 1:42 PM, V1 (Administrator) said she was not aware of the incident occurring on 12/16/25 between R1 and R2 until 1/6/26 when V9 came to speak with V1. V1 said she did not report the incident at that time because V1 thought it was unfounded. V1 said she reported the 12/16/25 incident on 2/3/26 after V9 sent a letter to corporate.R7, who was determined to be present in the dining room at the time of the 12/16/26 incident between R1 and R2, was unable to be interviewed due to being discharged prior to this investigation and did not answer the phone or return a phone call.An email communication dated 1/6/26 at 3:53 PM from V9 to V1 documented in part .Here's my original email. (CC'ing (V2/DON) since I talked to her about it today.) It never registered that you didn't receive my email since everything in this email was resolved the next day and hasn't been an issue since. I just assumed you took care of it! . This email chain also contained the original email from V9 to V1 dated 12/16/25 at 9:55 PM documenting in part . you probably will get a report on this in the morning from the nursing staff but the nurse tonight (V3's name) asked me to report directly to you. The first two incidents are related: (R1) was attacked or harassed by (name of R2) twice today. The first instance happened earlier in the day when I wasn't there. (R1) said that (name of V7) intervened. The second happened at dinnertime, when I was there. First, (name of R2) rolled up to the table, invading his (R1's) personal space. When (R1) didn't move (he was actively eating his dinner) (name of R2) started pushing his chair and I asked (name of R2) to move away from (R1). (Name of R2) them (sic) hit him (R1) in the back and started yelling at him. (Name of R2) pushed him (R1), slapped/hit him, yelled at him, and yanked his blanket. (Name of R7) yelled at (Name of R2) very loudly and I went to get a nurse or a CNA to help. (Name of V3) responded. For the last month or so, I have been actively trying to keep (R1) as far away from (Name of R2) as possible: ensuring CNAs do not put them at the same table and making sure they are as far away from each other in the dining room as possible, as I have been told by multiple nurses and CNAs that (name of R2) is combative, aggressive, and dangerous. One told me one day that it was inevitable that someone was going to get hurt with (name of R2) in the building. I want to make sure that (name of R2) never touches (R1) ever again. If he (R2) threatens or touches (R1) in an aggressive way ever again, I will file a report against him (R2).The facility presented a letter dated 1/31/26 from V9 documenting in part . I am writing to formally address two major issues that require immediate action. 1. Resident-to-Resident Assault (Unreported and Mishandled). On December 16, 2025 (R1) was assaulted by another resident during dinnertime. I witnessed the incident. The resident approached (R1), invaded (R1's) space, pushed (R1's) wheelchair, hit (R1) yelled at (R1), and pulled (R1's) blanket. Another resident intervened verbally, and I immediately sought staff assistance. (V3) responded promptly, and I was instructed to email the Site Administrator, (V1), with a full account, which I did that same evening. I received no response, but when the aggressor was absent from the facility the following days, I reasonably assumed the incident had been addressed. On January 6, 2026, I learned from (V1) that the resident had been temporarily away for treatment related to aggression and had returned with what was descried as a clean slate. Upon seeing this resident back in the facility, I alerted department heads to keep (R2) away from (R1). I was repeatedly told to speak with (V1). I subsequently forwarded the original email, complete with timestamp, proving the report was made the night of the assault. To my knowledge, no formal report has been filed by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 4 of 12 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 02/10/2026 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility, and no meaningful safeguards have been implemented.On 2/6/26 at 2:45 PM, V1 (Administrator) said the resident to resident abuse allegation investigations between R2 and R3 and R2 and R4 were substantiated because they were found to have happened. V1 said the intervention put in place for R3 was R2 was moved out of R3's room. V1 said the intervention put in place for R4 was R2 was referred to psychiatry for a medication change.The facility's revised 10/24/22 Abuse Prevention and Reporting-Illinois policy documented in part . This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services be staff or mistreatment. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Identifying occurrences and patterns of potential mistreatment. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Filing accurate and timely reports. Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other that by accidental means. Abuse is a willful infliction of injury. with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Event ID: Facility ID: 145978 If continuation sheet Page 5 of 12 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 02/10/2026 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to timely report a resident to resident abuse allegation for 1 (R1) of 7 residents reviewed for abuse in the sample of 7.Findings include:R1's admission Record documented an admission date of 3/25/25 and included diagnoses of chronic obstructive pulmonary disease, panlobular emphysema, and dysphasia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. R2's admission Record documented an admission date of 11/10/25 and included diagnoses of anxiety disorder, depression, and dementia. R2's MDS dated [DATE] documented a BIMS score of 6, indicating R2 was severely cognitively impaired.A Report to IDPH (Illinois Department of Public Health) Regional Office marked as Initial & Final documents a Date of Incident/Accident as 02/03/2026 with no time documented and names R1 and R2 as the residents involved. Under Description of Occurrence is documented Alleged resident to resident altercation. No injuries were noted and the report indicates an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (Name of R1's) daughter reported to the Administrator that on December 16, 2025 that resident (name of R2) grabbed her father's blanket and hit his back. The daughter reported this to Admin weeks after the incident occurred. The daughter spoke to the nurse on duty at the time of the incident and stated that (name of R2) was bothering her and her father (R1) and asked if he (R2) could be moved. At the time of the incident resident's daughter did not mention any hitting. By the time the incident was reported (name of R2) had been sent to inpatient psychiatric care. (Name of R2) has since returned to the facility with no further incidents. Residents and staff interviewed with no concerns identified. The report documents it was completed by V1 (Administrator) on 02/03/2026.On 2/4/26 at 10:29 AM, V3 said she was working on 12/16/25. V3 said she was down the hall with the medication cart administering medications to other residents when V9 approached her and told her R2 was yelling at V9. V3 said she told V9 she would take care of it and went to the dining room. V3 said when she go to the dining room R2 was sitting in his wheelchair about 3 tables away from R1 and was yelling at V9. V3 said she assisted R2 to the other side of the dining room from R1. V3 said V9 did not report any physical incident to her at the time. V3 said V9 had only told V3 R2 was being verbally abusive to V9. V3 said about a month after this incident V1 came to V3 asking when V9 had reported to V3 on the date of this incident. V3 said she did not tell V9 to report what had happened on 12/16/25 to V1.On 2/4/26 at 3:20 PM, R1 was alert and oriented to self, time, and place. R1 said he was not sure of the exact date of the incident with R2. R1 said he was sitting in the dining room after the evening meal talking to V9 (Family Member) when R2 came up behind R1 and rammed R2's wheelchair into R1's wheelchair and R2 started punching R1 in the back. R1 said he told R2 to stop and get away from R1. R1 said another male resident sitting in the dining room yelled at R2 to stop. R1 said he thought the other resident yelling scared R2 and caused R2 to stop and roll away from R1. R1 said he was not sure of the other male resident's name. R1 said V9 immediately went to get a nurse, so R1 assumed the facility was aware of the incident. R1 said a nurse came to the dining room and assisted R2 back to R2's room.On 2/4/26 at 3:39 PM, V9 said she had been told by various staff R2 could become physically aggressive. V9 said on 12/16/25, V9 and R1 were sitting in the dining room. V9 said R2 came up behind R1 and hit R1's wheelchair with R2's wheelchair. V9 said R1 told R2 to stop when R2 started punching R1 in the back and started pulling on R1's blanket. V9 said R7 was sitting at a table on the far side of the dining room and used a stern voice to tell R2 to stop. V9 said R2 stopped punching R1 and R2 rolled his wheelchair back away from R1. V9 said after the incident V9 went to get V3 (Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 6 of 12 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 02/10/2026 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Practical Nurse/ LPN) and informed V3 of what had happened. V9 said V3 came to the dining room and R2 was still close to R1 sitting in his wheelchair. V9 said V3 assisted R2 back to R2's room. V9 said V3 told V9 to report what happened to V1 (Administrator) and V9 sent V1 an email describing the events. V9 said after she sent V1 the email on 12/16/25, V9 returned to the facility the next day and did not see R2. V9 said she thought R2 was no longer in the building due to the email V9 had sent to V1 and thought it was taken care of. V9 said on 1/6/26 she returned to the facility and saw R2 had returned to the facility. V9 said she had spoken with V2 (Director of Nursing/ DON) on 1/6/26 with her concerns with R2 being back in the facility after R1 and R2's physical altercation and the need for R1 and R2 to be kept apart. V9 said later that day on 1/6/26 V1 called V9 and yelled at V9 for about 20 minutes saying V1 only had 24 hours to report it and asking why I didn't report this to V1. V9 said she told V1 V9 had sent V1 an email on the day the incident had happened. V9 said V1 told V9 V1 had not received any email from V9 about this incident. V9 said she told V1 V9 would forward the previously sent email.On 2/5/26 at 1:42 PM, V1 said she was not aware of the incident occurring on 12/16/25 between R1 and R2 until 1/6/26 when V9 came to speak with V1. V1 said she did not report the incident at that time because V1 thought it was unfounded. V1 said she reported the 12/16/25 incident on 2/3/26 after V9 sent a letter to corporate.An email communication dated 1/6/26 at 3:53 PM from V9 to V1 documented in part .Here's my original email. (CC'ing (V2/DON) since I talked to her about it today.) It never registered that you didn't receive my email since everything in this email was resolved the next day and hasn't been an issue since. I just assumed you took care of it! . This email chain also contained the original email from V9 to V1 dated 12/16/25 at 9:55 PM documenting in part . you probably will get a report on this in the morning from the nursing staff but the nurse tonight (V3's name) asked me to report directly to you. The first two incidents are related: (R1) was attacked or harassed by (name of R2) twice today. The first instance happened earlier in the day when I wasn't there. (R1) said that (name of V7) intervened. The second happened at dinnertime, when I was there. First, (name of R2) rolled up to the table, invading his (R1's) personal space. When (R1) didn't move (he was actively eating his dinner) (name of R2) started pushing his chair and I asked (name of R2) to move away from (R1). (Name of R2) them (sic) hit him (R1) in the back and started yelling at him. (Name of R2) pushed him (R1), slapped/hit him, yelled at him, and yanked his blanket. (Name of R7) yelled at (Name of R2) very loudly and I went to get a nurse or a CNA to help. (Name of V3) responded. For the last month or so, I have been actively trying to keep (R1) as far away from (Name of R2) as possible: ensuring CNAs do not put them at the same table and making sure they are as far away from each other in the dining room as possible, as I have been told by multiple nurses and CNAs that (name of R2) is combative, aggressive, and dangerous. One told me one day that it was inevitable that someone was going to get hurt with (name of R2) in the building. I want to make sure that (name of R2) never touches (R1) ever again. If he (R2) threatens or touches (R1) in an aggressive way ever again, I will file a report against him (R2).The facility presented a letter dated 1/31/26 from V9 documenting in part . I am writing to formally address two major issues that require immediate action. 1. Resident-to-Resident Assault (Unreported and Mishandled). On December 16, 2025 (R1) was assaulted by another resident during dinnertime. I witnessed the incident. The resident approached (R1), invaded (R1's) space, pushed (R1's) wheelchair, hit (R1) yelled at (R1), and pulled (R1's) blanket. Another resident intervened verbally, and I immediately sought staff assistance. (V3) responded promptly, and I was instructed to email the Site Administrator, (V1), with a full account, which I did that same evening. I received no response, but when the aggressor was absent from the facility the following days, I reasonably assumed the incident had been addressed. On January 6, 2026, I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 7 of 12 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 02/10/2026 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete learned from (V1) that the resident had been temporarily away for treatment related to aggression and had returned with what was descried as a clean slate. Upon seeing this resident back in the facility, I alerted department heads to keep (R2) away from (R1). I was repeatedly told to speak with (V1). I subsequently forwarded the original email, complete with timestamp, proving the report was made the night of the assault. To my knowledge, no formal report has been filed by the facility, and no meaningful safeguards have been implemented.The facility's revised 10/24/22 Abuse Prevention and Reporting-Illinois policy documented in part .External Reporting. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. If there is a suspicion that a crime has been committed. and does not involve serious bodily injury, then a report to local law enforcement and Department of Public Health as soon as possible but within 24 hours of within 24 hours of when the suspicion was formed. The initial report to Department of Public Health shall include the following information, if known at the time of the report:. Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom the property was misappropriated. Type of abuse reported. Date, time, location and circumstances of the alleged incident. Five-day Finial Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The final investigation report shall contain the following: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom the property was misappropriated. The original allegation. A summary of facts determined during the process of the investigation, review of medical record and interviews of witnesses. Conclusion of the investigation based on facts. Event ID: Facility ID: 145978 If continuation sheet Page 8 of 12 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 02/10/2026 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 0610 Respond appropriately to all alleged violations. 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 timely initiate and complete a thorough investigation of a resident to resident abuse allegation for 1 (R1) of 7 residents reviewed for abuse in the sample of 7.Findings include:R1's admission Record documented an admission date of 3/25/25 and included diagnoses of chronic obstructive pulmonary disease, panlobular emphysema, and dysphasia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. R2's admission Record documented an admission date of 11/10/25 and included diagnoses of anxiety disorder, depression, and dementia. R2's MDS dated [DATE] documented a BIMS score of 6, indicating R2 was severely cognitively impaired.On 2/4/26 at 3:20 PM, R1 was alert and oriented to self, time, and place. R1 said he was not sure of the exact date of the incident with R2. R1 said he was sitting in the dining room after the evening meal talking to V9 (Family Member/Power of Attorney-POA) when R2 came up behind R1 and rammed R2's wheelchair into R1's wheelchair and R2 started punching R1 in the back. R1 said he told R2 to stop and get away from R1. R1 said another male resident sitting in the dining room yelled at R2 to stop. R1 said he thought the other resident yelling scared R2 and caused R2 to stop and roll away from R1. R1 said he was not sure of the other male resident's name. R1 said V9 immediately went to get a nurse, so R1 assumed the facility was aware of the incident. R1 said a nurse came to the dining room and assisted R2 back to R2's room.On 2/4/26 at 3:39 PM, V9 said she had been told by various staff R2 could become physically aggressive. V9 said on 12/16/25, V9 and R1 were sitting in the dining room. V9 said R2 came up behind R1 and hit R1's wheelchair with R2's wheelchair. V9 said R1 told R2 to stop when R2 started punching R1 in the back and started pulling on R1's blanket. V9 said R7 was sitting at a table on the far side of the dining room and used a stern voice to tell R2 to stop. V9 said R2 stopped punching R1 and R2 rolled his wheelchair back away from R1. V9 said after the incident, V9 went to get V3 (Licensed Practical Nurse/LPN) and informed V3 of what had happened. V9 said V3 came to the dining room and R2 was still close to R1 sitting in his wheelchair. V9 said V3 assisted R2 back to R2's room. V9 said V3 told V9 to report what happened to V1 (Administrator) and V9 sent V1 an email later that evening describing the events. V9 said after she sent V1 the email on 12/16/25, V9 returned to the facility the next day and did not see R2. V9 said she thought R2 was no longer in the building due to the email V9 had sent to V1 and thought it was taken care of. V9 then said on 1/6/26, she visited the facility and saw R2 had returned to the facility. V9 said she had spoken with V2 (Director of Nursing/DON) on 1/6/26 regarding her concerns with R2 being back in the facility after R1 and R2's physical altercation and the need for R1 and R2 to be kept apart. V9 said later that day on 1/6/26, V1 called V9 and yelled at V9 for about 20 minutes saying V1 only had 24 hours to report the incident and asking why V9 didn't report this to V1. V9 said she told V1 she had sent V1 an email on the day the incident had happened. V9 said V1 said she had not received any email from V9 about this incident so V9 told V1 she would forward the previously sent email.On 2/4/26 at 10:29 AM, V3 (Licensed Practical Nurse/LPN) said she was working on 12/16/25. V3 said she was down the hall with the medication cart administering medications to other residents when V9 approached her and told her R2 was yelling at V9 (Family Member). V3 said she told V9 she would take care of it and went to the dining room. V3 said when she got to the dining room R2 was sitting in his wheelchair about 3 tables away from R1 and was yelling at V9. V3 said she assisted R2 to the other side of the dining room away from R1. V3 said V9 did not report any physical incident to her at the time. V3 said V9 had only told V3 that R2 was being verbally abusive to V9. V3 said about a month after this incident, V1 came to V3 asking when V9 had reported to V3 on the date of this incident. V3 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 9 of 12 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 02/10/2026 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she did not tell V9 to report what had happened on 12/16/25 to V1.On 2/5/26 at 10:12 AM, V7 (Certified Nursing Assistant/CNA) said he could not recall a specific date with any incident between R1 and R2. V7 said he did recall an incident when R2 grabbed R1's wheelchair and R2 had to be redirected away from R1. V7 said R2 had a lot of conflict with a lot of residents. V7 said he had seen R2 raise his fist like he was going to hit another resident, but staff had intervened prior to R2 making contact. V7 said he had not witnessed the event between R1 and R2 on 12/16/25 but had come to the dining room after V9 had spoken with V3. V7 said he did not recall what V9 said at that time. V7 said later on, V9 had asked staff to keep R2 away from R1 because R2 had hit R1 in the past.On 2/5/26 at 10:23 AM, V8 (CNA) said she did not witness the incident between R1 and R2. V8 said in the past she had seen R2 get physically aggressive with other residents and it was common for (R2) to get aggressive.An email communication dated 1/6/26 at 3:53 PM from V9 to V1 documented in part .Here's my original email. (CC'ing (V2/DON) since I talked to her about it today.) It never registered that you didn't receive my email since everything in this email was resolved the next day and hasn't been an issue since. I just assumed you took care of it! . This email chain also contained the original email from V9 to V1 dated 12/16/25 at 9:55 PM documenting in part . you probably will get a report on this in the morning from the nursing staff but the nurse tonight (V3's name) asked me to report directly to you. The first two incidents are related: (R1) was attacked or harassed by (name of R2) twice today. The first instance happened earlier in the day when I wasn't there. (R1) said that (name of V7) intervened. The second happened at dinnertime, when I was there. First, (name of R2) rolled up to the table, invading his (R1's) personal space. When (R1) didn't move (he was actively eating his dinner) (name of R2) started pushing his chair and I asked (name of R2) to move away from (R1). (Name of R2) them (sic) hit him (R1) in the back and started yelling at him. (Name of R2) pushed him (R1), slapped/hit him, yelled at him, and yanked his blanket. (Name of R7) yelled at (Name of R2) very loudly and I went to get a nurse or a CNA to help. (Name of V3) responded. For the last month or so, I have been actively trying to keep (R1) as far away from (Name of R2) as possible: ensuring CNAs do not put them at the same table and making sure they are as far away from each other in the dining room as possible, as I have been told by multiple nurses and CNAs that (name of R2) is combative, aggressive, and dangerous. One told me one day that it was inevitable that someone was going to get hurt with (name of R2) in the building. I want to make sure that (name of R2) never touches (R1) ever again. If he (R2) threatens or touches (R1) in an aggressive way ever again, I will file a report against him (R2).The facility presented a letter dated 1/31/26 from V9 documenting in part . I am writing to formally address two major issues that require immediate action. 1. Resident-to-Resident Assault (Unreported and Mishandled). On December 16, 2025 (R1) was assaulted by another resident during dinnertime. I witnessed the incident. The resident approached (R1), invaded (R1's) space, pushed (R1's) wheelchair, hit (R1) yelled at (R1), and pulled (R1's) blanket. Another resident intervened verbally, and I immediately sought staff assistance. (V3) responded promptly, and I was instructed to email the Site Administrator, (V1), with a full account, which I did that same evening. I received no response, but when the aggressor was absent from the facility the following days, I reasonable assumed the incident had been addressed. On January 6, 2026, I learned from (V1) that the resident had been temporarily away for treatment related to aggression and had returned with what was descried as a clean slate. Upon seeing this resident back in the facility, I alerted department heads to keep (R2) away from (R1). I was repeatedly told to speak with (V1). I subsequently forwarded the original email, complete with timestamp, proving the report was made the night of the assault. To my knowledge, no formal report has been filed by the facility, and no meaningful safeguards have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 10 of 12 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 02/10/2026 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few implemented.A Report to IDPH (Illinois Department of Public Health) Regional Office marked as Initial & Final documents a Date of Incident/Accident as 02/03/2026 with no time documented and names R1 and R2 as the residents involved. Under Description of Occurrence is documented Alleged resident to resident altercation. No injuries were noted and the report indicates an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (Name of R1's) daughter reported to the Administrator that on December 16, 2025 that resident (name of R2) grabbed her father's blanket and hit his back. The daughter reported this to Admin weeks after the incident occurred. The daughter spoke to the nurse on duty at the time of the incident and stated that (name of R2) was bothering her and her father (R1) and asked if he (R2) could be moved. At the time of the incident resident's daughter did not mention any hitting. By the time the incident was reported (name of R2) had been sent to inpatient psychiatric care. (Name of R2) has since returned to the facility with no further incidents. Residents and staff interviewed with no concerns identified. The report documents it was completed by V1 (Administrator) on 02/03/2026.On 2/5/26 at 1:42 PM, V1 said she was not made aware of the 12/16/25 incident between R1 and R2 until 1/6/26. V1 said she had not started an investigation at that time because V1 thought the incident was unfounded. V1 said she started an investigation on 2/3/26 when V9 sent a letter to corporate. V1 said she had sent the initial report and final report on the same day, 2/3/26. V1 was asked for the investigation materials such as resident and employee statements and V1 responded she had not interviewed all the staff working at the time of the incident yet or the residents involved. V1 was asked if she had spoken to R1, and V1 responded no, she had not. V1 was asked why she had not spoken to R1, and V1 responded I didn't speak to (R1) because (V9) won't let you speak to (R1) alone and answers questions for (R1). V1 was asked how she had sent a final report claiming no concerns were identified when V1 did not speak to R1 and had not spoken to all staff involved, and V1 responded I don't know.The facility's revised 10/24/22 Abuse Prevention and Reporting-Illinois policy documented in part . Internal Reporting Requirements and Identification of Allegations:. All residetns, visitors, volunteers, family members are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator or the person acting as administrator in the administrator's absence. Reports should be documented and a record kept of the documentation. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Internal Investigation. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment, or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. Investigation Procedures: The appointed investigator will, at minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. External Reporting. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145978 If continuation sheet Page 11 of 12 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 02/10/2026 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident property has been reported and is being investigated. If there is a suspicion that a crime has been committed. and does not involve serious bodily injury, then a report to local law enforcement and Department of Public Health as soon as possible but within 24 hours of within 24 hours of when the suspicion was formed. The initial report to Department of Public Health shall include the following information, if known at the time of the report:. Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom the property was misappropriated. Type of abuse reported. Date, time, location and circumstances of the alleged incident. Five-day Finial Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The final investigation report shall contain the following:. Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom the property was misappropriated. The original allegation. A summary of facts determined during the process of the investigation, review of medical record and interviews of witnesses. Conclusion of the investigation based on facts. Event ID: Facility ID: 145978 If continuation sheet Page 12 of 12