Inspection·January 10, 2025

F 0689 was observed. Level of Harm - Minimal harm or potential for actual harm On 1/9/25 at 9:30 AM V10 Maintenance stated the room with the broken window was supposed to be locked. I was not asked to repair it. I will have to order a window. Residents Affected - Few On 1/9/25 at 9:15 AM V1 Administrator stated, I thought the room was locked. The Policy Safety and Supervision of Residents dated 12/2007 documents our facility strives to make the environment as free from accident hazards as possible. When accident hazards. The QA&A Safety Committee shall evaluate and analyze the cause of the hazard, and develop strategies to mitigate or remove the hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record reveiw, and observation the facility failed to ensure staff readily had access to and donned appropriate personal protective equipment prior to entering COVID positive resident rooms, failed to ensure isolation signage was placed to identify type of isolation required for resident rooms on isolation for COVID, and failed to document COVID testing. These failures affect 3 of 3 residents (R1, R2, R3) reviewed for infection control with the potential to affect all 59 residents residing in the facility. Residents Affected - Many Findings Include: 1. R1's MDS (Minimum Data Set) dated 11/14/24 documents R1 is moderately cognitively impaired. R1's Nurses Note dated 1/7/24 documents (R1) tested positive during routine COVID test. (R1) is currently afebrile and asymptomatic. R1's Nurses Note dated 1/7/24 documents Contact Isolation precautions started related to COVID positive. COVID Positive residents should also be on droplet precautions. On 1/9/25 at 8:45 AM, R1 is lying in bed with the door open. R1 was not interviewable, because she would not answer questions. There was no isolation signage on the door or wall near her room. R1 did have an isolaion cart outside of her room. The isolation cart did not contain any N95 masks or eye protection. 2. R2's MDS dated [DATE] documents she is severely cognitively impaired. R2's Nurses Note dated 1/7/25 documents R2 tested positive for COVID during routine COVID testing. R2 is currently afebrile and asymptomatic. Contact isolation was started. COVID positive residents should also be on droplet precautions. On 1/9/25 8:50 AM, R2 is sitting up in bed being helped with her breakfast.She did not answer questions, V4 CNA (Certified Nursing Assistant) was in R2's room helping R2 eat her breakfast. V4 had on a surgical mask, a gown which she said was too small, and gloves. V4 did not have on a face shield or goggles. V4 stated I should be wearing N95 mask and face shield. There wasn't any isolation signage on R2's door or wall near her room. On 1/9/25 at 8:51 AM, V5 Unit Aide stated, we are suppose to wear N95 mask, gown and gloves. I don't know. I haven't seen any N95 or goggles. On 1/9/25 at 8:56 AM, V7 Housekeeper stated, we are suppose to wear N95 mask, gown, gloves and goggles, but we don't have goggles or face shields. On1/9/25 at 9:00 AM, V11 Medical Records and Supplies stated we have all PPE (Personal Protective Equipment). V11 went to two locked areas. The first locked room was inside the Physical Therapy room gloves and gowns were found there. The second locked room was on a closed hall, and N95 masks and face shields were found in this room. V11 stated, The Houskeeping supervisor stocks the hall carts every morning. On 1/9/25 at 9:10 AM, V9 Housekeeping Supervisor stated, I restock carts with a stethoscope, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many disinfectant wipes, hand sanitizer,gowns, gloves, N95/regular masks, alcohol swabs, thermometer, I check it every morning and supply it. V9 did not mention stocking the isolation carts with goggles or face shields. 3. R3's MDS dated [DATE] documents R3 is cognitively intact. On 1/9/25 8:53 AM, I'm doing okay the staff wear gown and a mask. Some wear blue some wear white. I don't have COVID. R3's curtain is not pulled. An air purifier is not present in the room. R3's Nurses Note dated 1/8/25 documents remains on contact isolation R/T (related to) roommate being Covid positive. R3 remains asymptomatic. Will continue to monitor. R3's Electronic Health Record did not document that she had been tested for COVID. On 1/9/25 at 9:15 AM, V1 Administrator stated, I don't know why they were roomed together. I don't know why there is no isolation signage on the doors. On 1/9/25 at 1:15 PM, V2 DON I believe V1 was trying to interpret the policy. I cannot speak to exactly why they were roomed together, but she was exposed to her roommate. I am off with COVID, and I just don't know what's going on. On 1/9/25 at 2:15 PM, V12 Unit Aide stated they should just be on isolation. On 1/9/25 at 2:22 PM V13 LPN, (Licensed Practical Nurse) stated they should be on droplet and contact isolation. V13 stated V13 did ask for signs, but V13 didn't receive any. On 1/9/25 at 2:25 PM V14 CNA, stated they should be on COVID Precautions. The Facility's Daily Census Sheets dated 1/9/25 documents a total of 59 residents living in the facility. Undated Facility Policy Source Control Pandemic Coronavirus documents for those HCP ( health care provider) who enters the room of a patient with suspected or confirmed (COVID) infection. The HCP should wear a respirator with a N95 filter, gown, gloves, and eye protection. The Undated Facility Policy Testing documents if cohorting only residents with the same respiratory pathogens should be housed in the same room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observation, interview and record review, the facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full time in the facility. This has the potential to affect all 59 residents living in the facility. Findings include: On 1/9/25 at 9:15 AM V1 Administrator stated, we dont have an ICP and are trying to hire one now. On 1/9/25, the facility was observed as having residents who had tested positive for COVID residing in the facility. On 1/9/25 at 1:15 PM, V2 Director of Nursing (DON) stated I believe V1 Administrator was trying to interpret the facility policy. I am off with COVID infection and I just don't know what's going on. The Facility's Daily Census Sheets dated 1/9/25 documents a total of 59 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 5 of 5