Inspection·December 24, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.The facility's Code Pink- Missing Resident/Elopement, reviewed date of 11/15/2018, documented the following: Guidelines: 1) All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2) Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should: Attempt to prevent the departure without use of force. Obtain assistance from other staff members in the immediate vicinity, if necessary. Instruct another staff member to inform the Charge Nurse or Director of Nursing services of the resident's attempt to leave the premises. Be courteous in preventing the departure and returning the resident to the facility Notify the attending physician of the resident's attempt to leave the facility Contact legal representative/responsibility party and inform him/her of the incident. Make appropriate notations in the resident's medical record. Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated. Event ID: Facility ID: 146043 If continuation sheet Page 2 of 26 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 12/24/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Wound Nurse Practitioner (NP) orders were followed and implemented in a timely manner, failed to ensure low air loss mattress was maintained in well working order, and failed to ensure wound dressings were changed per NP orders for 1 of 3 residents (R2) in a sample of 9. This failure resulted in R2 having worsening of wounds which became infected leading to R2 being hospitalized several times, requiring surgical debridement and Intravenous (IV) antibiotics due to infections of Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli.This failure resulted in R2's wounds worsening and becoming infected. R2 was hospitalized several times, during which R2's wounds required surgical debridement and Intravenous (IV) antibiotics due to multiple infections with Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli.The Immediate Jeopardy began on 08/21/25 when the facility failed to ensure Wound Nurse Practitioner (NP) orders were followed and implemented in a timely manner, failed to ensure low air loss mattress was maintained in proper working order, and wound dressings were changed per NP orders. V1, Administrator, and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 12/05/25 at 8:30 AM. Abatement number one on 12/05/25 was accepted. The Immediate Jeopardy was removed on 12/05/25, but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service trainings.Finding Include:R2's Face Sheet, print date of 12/04/25, document R2's admission date was 05/15/2023 and that R2's diagnoses include a pressure ulcer of right buttock, stage 3, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), and chronic combined systolic and diastolic (congestive) heart failure. Note the State Survey Agency survey event PGW811 exit 7/17/2025 cites an Immediate Jeopardy on current resident, R2 for failing to timely identify, assess and monitor, and provide treatment to prevent the worsening of pressure ulcers.R2's Minimum Data Set (MDS), dated [DATE], section M documents R2 did not have any pressure ulcers/injuries at that time.R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting. R2's Care Plan, admission date of 08/18/25, documented Potential for skin breakdown r/t (related to) incontinence, Hx (history) weeping L/E's (lower extremities), ace wraps for edema, morbid obesity, OAB (overactive bladder), resident is at increased risk for unavoidable skin breakdown r/t autoimmune disease pyoderma gangrenosumStage 3 R (right) buttockStage 3 R posterior thighStage 3 L (left) buttockStage 3 L posterior thighStage 3 L proximal buttockR lateral calf skin tearGoal: R2's will have wounds show improvement through next review and Interventions included but are not limited to Low Air Loss Bariatric Mattress for pressure reduction Per wound clinic/V13, Nurse Practitioner (date initiated 10/15/25), monitor for redness or discoloration to skin, keep skin dry and well lubricated, and weekly skin checks.R2's Hospital Visit records dated 08/13/25, document Assessment and Plan: Active Problems: Decubitus ulcer of right buttock, stage 3 and Infected decubitus ulcer, stage III. 1. Infected decubitus ulcer stage 3/ulcer right buttock stage 3- consult to wound nurse, cultures wound. It further documented R2 was admitted with multiple diagnoses which give rise to active medical issues or baseline comorbidities. Given the complexity of the situation, pending testing, follow-up labs, and ongoing medical interventions it is anticipated the patient will require admission as an impatient spending at least two midnight(s) in the hospital.R2's Wound Care report, dated 08/21/25, documented the following History of Present Illness Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 3 of 26 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 12/24/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (HPI). R2 has pressure ulcers to her buttocks; hematoma/trauma to her right lateral calf; abrasion to her left knee; and avulsion of nail to her left 5th toe. It also documented R2 had developed pressure ulcers to the bilateral buttocks and thighs and on 08/13/25 she was admitted into the hospital due to worsening infection of the wounds. She received IV vancomycin and had a wound culture done during her hospitalization which was positive for Methicillin-resistant Staphylococcus aureus (MRSA- is a type of staph bacteria resistant to several common antibiotics making infections harder to treat.). Wound #2 pressure ulcer was located on her right buttock and posterior thigh. Initial wound measurements were 20 centimeters (cm) length x 12cm width x 0.2cm depth. Post debridement measurements were 20cm x 12cm x 8cm depth. Wound #6 Left buttock was a chronic pressure injury/pressure ulcer. Initial wound measurements were 16cm x 8cm x 0.3cm. Post debridement measurements were 16cm x 8cm x 8cm. Wound orders: for Wound #2 (right buttock and posterior thigh) were given as followed: Apply a thick layer of Silvadene over the wounds, cover with abdominal (ABD) pad, secure with tape. Change daily and as needed if soiled or dislodged. Wound #6 (left buttock) pack the depth of the wound with silver alginate rope. Apply Silvadene over the rest of the open wound, cover with ABD pad, secure with tape, change daily and as needed if soiled or dislodged. Additional orders: Off-loading/Pressure relief Specialty Bed/Mattress for Pressure Reduction- Low air loss mattress, and limit time in the chair, encourage patient to lay in bed on her low air loss mattress to relieve pressure from wounds. Return in one week.R1's August 2025 Treatment Administration Record (TAR) was reviewed and documents the above wound order did not start until 08/26/25 and the wrong treatment for the right buttocks and right posterior thigh were put in place, a wrong treatment was completed and was then corrected on 08/27/25. This TAR does not document a skin check was completed on 08/26/25. R1's Wound Care Report, dated 08/26/25, documented R1's wounds measured as follows: Wound #2- Right buttock and posterior thigh 23cm x 14cm x 0.3cm after debridement and Wound #6- Left buttock 11.5cm x 9cm x 3.7cm after debridement. Dressing orders did not change. Additional orders: Specialty bed/mattress for pressure reduction- Low air loss mattress. Other order: Heel float boots to bilateral feet-similar to (soft support) boots. Not cushioned bootie type. R2's Physician's Orders, dated 08/26/25 at 10:45 AM, documented Right Buttock and R posterior thigh- Cleanse areas with (wound cleanser) or similar, apply Silver Alginate over the wounds, cover with a large gauze pad and secure with tape every night shift for wound care and every 6 hours as needed for wound careR2's Physician's Orders, dated 08/26/25 at 10:52 AM, documented Left buttock - Cleanse area with (wound cleanser) or similar, Pack the depth of the wound with Silver Alginate rope, Apply Silvadene (ointment) over the rest of the open wound, cover with large gauze type pad and secure with tape every night shift for wound healing. R2's Physician's Orders, dated 08/27/25 at 11:38 AM, documented Right Buttock and R posterior thigh- Cleanse areas with (wound cleanser) or similar, apply Silvadene over the wounds, cover with large gauze pad and secure with tape every night shift for wound care and every 6 hours as needed for wound care.R2's Wound Care Report, dated 09/02/25, was reviewed with no new orders noted. Wound #6- Left buttock measures 11.5cm x 11cm x 3.5cm with a moderate amount of drainage noted with odor. Wound #7- Right buttock (separated from thigh on 09/01/25) measures 11cm x 11.5cm x 0.5cm. It has a large amount of drainage noted which has an odor. Wound #8- Right, Posterior leg- thigh separated from buttock 09/01/25 measures 3.5cm x 5cm x 0.1cm. R2's General Surgery Consult, dated 09/02/25 at 12:04 PM, documented R2 was sent by the local wound center for evaluation of decubitus ulcer of her left buttock. It further documented R2 has a decubitus ulcer overlying her left buttock. It had narcotic and fibrinous exudate overlying the wound and the wound center has requested surgical debridement.R2's Surgical Report, dated 09/02/25 at 1:47 PM, documented R2 had debridement of left buttock performed by V43, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 4 of 26 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 12/24/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Physician/Surgeon. R2's Wound Care Report, dated 09/09/25, documented new post debridement wound measurements are as follows: Wound #6- Left buttock 5.7cm x 9.5cm x 4cm, Wound #7- Right buttock measures 9.5cm x 15cm x 0.3, Wound #8- Right posterior leg 9.5cm x 15cm x 0.3cm, and Wound #9- Left, posterior leg, this is a [NAME] Grade 3 diabetic ulcer acquired on 09/07/25 measurements are 1cm x 2.5cm x 0.3cm. Wound treatment to R2's left buttock, left posterior thigh, right buttock, and right posterior thigh. Cleanse wound and peri wound with a non-cytotoxic wound cleanser. Apply half strength dakins moist gauze to wound, cover with large gauze pad, secure with tape, change daily and as needed of soiled or dislodged.R2's Wound Care Report, dated 09/16/25, documented on 09/02/25- Patient returns for follow up visit. She has been referred to V43 for surgical debridement of buttock/thigh wounds. She may be going to surgery this afternoon. The left buttock continues with large amounts of fibrin/slough/necrotic tissue. She has not received her low air loss mattress or heel float boots as of yet. Cover sheet documented Please note dressing changes are daily except for lower right leg. Orders included. Orders for Wound #6 and #7 Left and Right buttock cleanse wound, and peri wound with a non-cytotoxic wound cleanser, pack wound with half strength dakins moist gauze, cover with large gauze pad, secure with tape, change daily and as needed if soiled or dislodged. Wound #8 Right posterior leg (thigh) and wound #9 left posterior leg (thigh)cleanse wound, and peri wound with non-cytotoxic wound cleanser, apply half strength dakins moist gauze to wound, cover with ABD pad, secure with tape, change daily and as needed if soiled or dislodged. Right and left buttock and thigh wounds separated on 09/01/25. Additional orders Off-Loading/Pressure relief- Specialty Bed/Mattress for Pressure Reduction- Low air loss mattress. It also documented the patient's potential to heal is fair. It also documented under the care plan under section 07. Dressing selection: Patient states dressings not being changed per frequency of order. R2's Wound Care prescription, dated 09/19/25 signed at 9:46 AM, documented Cipro (antibiotic medication) 500 milligrams (mg) tablets take one tablet oral twice daily for seven days. On 12/23/25 at 10:38 AM, V13, NP said she started R2 on Cipro due to the culture she had gotten on 09/16/25 from her wound had come back growing she believes pseudomonas.R2's Wound Care Report, dated 09/23/25, documented R2 there for a follow up visit. The left buttock has new areas of breakdown around the current ulcerations with purple areas where the mechanical lift may have pinched the patient's skin. She is on Cipro currently due to culture growing pseudomonas. R2 reports she doesn't like her new mattress as it is hard to turn in it. She reports she has not been sitting in her chair or recliner and she goes to dialysis three times a week. Wound post debridement measurements for this visit are as follows: Wound #6 Left buttock, 6.2cm x 11.5cm x 2.2cm. Wound #7 Right buttock, 6.2cm x 11cm x 2cm. Wound #8 Right posterior leg, 3cm x 4.5cm x 0.3cm. Wound #9 Left posterior leg, 2.6cm x 6.5cm x 1cm. Dressing Orders: Wound #6, #7, #8, and #9. Cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply barrier ointment to protect surrounding skin, apply silver alginate to the wound bed, cover with super absorbent pad and large gauze and, secure with tape, change daily and as needed if soiled or dislodged.R2's TARs for September 2025 were reviewed and had no documentation R2's dressing changes had been done for left buttock, left posterior thigh, right buttock, and right posterior thigh, on 09/01/25, 09/15/25, and R2 refused on 09/22/25. On 09/03/25, 09/05, and 09/24/25, documented #9 other/see progress notes. It also had no documentation a skin assessment was completed on R2 on 09/22/25. R2's Wound Care visit report, dated 09/30/25, documented Wound #6 Left buttock- measures 6.5cm x 12.8cm x 1.3cm, undermining (the skin and tissue under the wound edges have separated, creating a pocket or shelf beneath the surface, making the wound appear smaller than it actually is) has been noted at 9:00 and ends at 2:00 with a maximum distance of 1.4cm. The wound has a moderate amount of drainage with mild odor noted. Wound #7 Right buttock(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 5 of 26 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 12/24/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few measures 7cm x 12cm x 0.2cm. There is a large amount of drainage noted which has no odor. Wound #8 Right Posterior leg- measures 2.8cm x 5cm x 0.2cm. Moderate amount of drainage noted with no odor. Wound #9 Posterior leg- 2.5cm x 5.2cm x 0.3cm with a moderate amount of drainage noted. Wound #10 Proximal buttock (upper)- an acute pressure ulcer acquired on 09/21/25, measuring 4.3cm x 10.1cm with no measurable depth, post debridement measurements for wound #10 are 4.3cm x 10.1cm x 0.3cm. Wound dressings for wound #6, #7, #8, #9, and #10, cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply barrier ointment to protect surrounding skin, apply (brand name) moist gauze to the wound bed, cover with large gauze pad, secure with brief, change daily and as needed if soiled or dislodged.R2's Wound Care visit report, dated 10/14/25, documented Wound #6- Left buttock, measures 6cm x 10.8cm x 1.3cm, undermining noted starting position at 9 o'clock and ending position at 2 o'clock. Wound #7- Right buttocks, measures 6.5cm x 10cm x 0.2cm. Wound #8- Right, posterior leg, measures 2.8cm x 5cm x 0.2. Wound #9- Left, posterior leg, measures 2.3cm x 6cm x 0.5cm, tunneling noted at 9 o'clock. Wound #10- Left, proximal buttock (upper), 4.5cm x 10.5cm x 1.1cm. New wound orders noted for wound #6, 7, 8, 9, and 10 are cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply clobetasol ointment to peri wound skin with every dressing change, apply betadine moist gauze to the wound bed, cover with ABD pad, secure with brief, change daily and as needed if soiled or dislodged.R2's Physician's Orders, dated 10/14/25, documented Low air Loss Bariatric mattress for pressure reduction per wound clinic NP. R2's Wound Care Visit, dated 10/28/25, documented wound measurements after debridement Wound #6- Stage 3 to Left, buttock 6cm x 9cm x 1.3cm undermining noted at 9:00 and ends at 1:00. Wound #7- Stage 3 to Right buttock 6.5cm x 9.5cm x 0.3cm. Wound #8- Stage 3 to Right, posterior leg measures 2.7cm x 5cm x 0.3cm. Wound #9- Stage 3 to Left, Posterior leg measures 6cm x 9cm x 1.1cm with undermining noted at 9:00 and ends at 1:00. Wound #10- Stage 3 to Left, proximal buttock (upper), 6.9cm x 6.5cm x 0.2cm. Dressing orders did not change. R2's TARs for October 2025 were reviewed and had no documentation R2 had dressing changes done on her left proximal buttock and left posterior thigh on 10/03/25 and on her left and right buttock, left proximal buttock, and right posterior buttock and thigh on 10/15/25. There was also no documentation a skin assessment was completed on 10/15/25.R2 was in the local hospital from admission date of 11/05/25 and expected discharge date of 11/14/25. Hospital record was reviewed and documented R2 spent several days in the Intensive Care Unit (ICU). Date of service 11/12/25 at 7:46 AM, documented Patient complains of pain from the wound on her lower back. She has extensive ulcer, status post incisional debridement. Patient was transferred from ICU after being treated for septic shock, anemia and other comorbid conditions.R2's Medicine Progress Note, date of service 11/13/25 at 5:12 PM, documented R2 is receiving a broad-spectrum antibiotic for wound infection, which grew multiple organisms including Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli. It further documented assessment and plan: 1. Extensive decubitus ulcer in lower back/butt, 2. Ulcer on heels and legs -status post (s/p) debridement, - wound culture grew E coli ESBL, Pseudomonas and Enterococcus faecalis, -on Meropenem (IV antibiotic medication), continue on current antibiotic. It also documented 5. Acute medical conditions that resolved/improved *septic shock. Microbiology: Wound cultures: ESBL E coli, Pseudomonas aeruginosa, Enterococcus faecalis, Proteus mirabilis, and MSSA (methicillin-susceptible Staphylococcus aures, a type of staph bacteria. A common type of staph bacteria that lives harmlessly on the skin and in the nose of many people but can cause infections if it enters the body.R2's Wound Care Report, dated 11/25/25, documented Wound #6- Stage 3 to Left, buttock 10.2cm x 11cm x 1cm. Wound #7- Stage 3 to Right buttock 6.7cm x 9cm x 0.3cm. Wound #8- Stage 3 to Right, posterior leg measures 3cm x 6cm x 0.3cm. Wound #9- Stage 3 to Left, Posterior leg measures 2.5cm x 5cm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 6 of 26 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 12/24/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few x 0.2cm. Wound #10- Stage 3 to Left, proximal buttock (upper), 11cm x 8cm x 1cm. New wound orders were cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply silver alginate to the wound bed, cover with super absorbent pad, secure with tape, change three times weekly and as needed if soiled or dislodged for wound #6, 7, 8, 9, and 10. R2's TARs for November 2025 were reviewed and documented the following: Left, proximal buttock upper there is no documentation wound care was completed on 11/03/25 and 11/24/25 and on 11/25/25 and 11/27/25 documented #9 other/see progress notes. Left buttock no documentation wound care was completed on 11/03/25 or 11/24/25 and on 11/25/25, 11/26, and 11/27/25 it documented #9 other/see progress notes and 11/30/25 documented R2 refused. Right thigh no documentation wound care was completed on 11/03/25 and 11/24/25, and on 11/25/25, 11/26, and 11/27/25 documented #9 other/see progress notes. Left Posterior thigh wound had no documentation wound care was completed on 11/03/25 and 11/24/25, on 11/25/25 and 11/26/25 it documented #9, and on 11/30/25 it documented R2 refused. There was no documentation skin assessments were completed on 11/03/25 and 11/24/25, on 11/26/25 and 11/28/25 #9 was documented on the skin assessment. On 11/18/25 at 2:00 PM, Outside of R2's door lying on the floor was a machine (air pump) that went to an old air loss mattress. The control panel was hanging out of the machine by the wires, and it didn't have any hose connected to it.On 12/01/25 at 11:00 AM, V28, LPN and V29, CNA went in to turn R2 so a skin check could be completed. When R2 was turned onto her right side by V28 and V29 the dressings to R2 wounds were dated 11/28/25. The cloth incontinent pad that was under R2 had large rings of drainage from where her wounds had drained. Some of the dressings and tape had drainage on them. V28 and V29 was then assisted onto her left side and the dressings on her right side were dated 11/28/25. There was a strong odor also noted when R2 was assisted in rolling over. On 11/18/25 at 1:50 PM, V8, Certified Nursing Assistant (CNA) said R2's bed had a connection device that had three tubes on it that would connect to the machine, and it would keep coming off. V8 said sometimes when they would just be walking by R2's room and look in they would see that the tube had come disconnected and they would have to go in the room and hook it back up. V8 said the bed R2 has now she just got it three or four days ago.On 11/18/25 at 2:05 PM, V7, Licensed Practical Nurse (LPN) stated R2 should be on an air loss mattress to help prevent wounds. She said the plug had an issue something about the hose would pop off and the plug was loose.On 11/19/25 at 10:41 AM, V9, R2's family member #1 said her biggest issue is with R2's bed. She said R2 is supposed to have an air loss mattress but the one she had was literally held together with duct tape. V9 said they told the Director of Nursing (DON) about it, and she said they had a piece ordered. V9 said R2 would sink in the mattress, and it would make R2's bed sores hurt because the mattress wasn't properly aired up. V9 said they had to change R2's room because the bed she got was bigger than her original bed and it wouldn't fit in her old room. V9 said she has pictures of where the bed was broke, and she would send them to this surveyor. On 11/24/25 at 10:10 AM, R2 said the wound care nurse in nearby local town is the one who recommended switching her to an air loss mattress, but she isn't sure when she did that. She said the mattress she had before she got this one was softer, but they had trouble keeping air in it. R2 said whatever was supposed to be putting air into the bed wasn't working right and it kept coming off. R2 said when the air would go out of the old bed it was just like laying on the floor. She said when the air would go out of the mattress, she couldn't handle it her pain was so bad. She said it was a 10 with 10 being the worst and it was a burning type of pain where her sores are. R2 said she didn't want to be around people because she knew she was a crab-a**, and it hurt too much to sit up in her wheelchair. She said she would just have to grit her teeth and bare it before they got her better pain medication. On 12/02/25 at 10:55 AM, V31, R2's family member #2 said he messaged/sent pictures to the DON about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 7 of 26 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 12/24/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few bed not working. He said he likes to have things in writing when it comes to the facility, so he has proof. He said this didn't start because his mom didn't want to lay down in her bed it was because they put her in a wheelchair that was to small and then sent her to dialysis. He said his mom has always slept in her recliner but now she stays mostly in her bed because of the wounds. V31 said R2 didn't get the low air loss mattress until she came back from the hospital this last time. He said that is why she had to be moved to the 500 halls. V31 said he isn't sure what day R2 got the bed, but it didn't work. The hose that connected to the mattress would keep coming off and they used duct tape to try and keep it in place. V31 said they have changed R2's pain medication also. He said she is in extreme pain due to (d/t) her wounds and so they started her on morphine and after the dressing changes is when she has the most pain.On 11/19/25 at 12:42 PM, This surveyor reviewed pictures provided by V9, R2's family member #1 and they correspond with V31, R2's family member #2, V7, LPN, and V8, CNA interviews that the hose that keeps the bed inflated comes disconnected and causes the mattress to lose air. On 12/04/25 at 2:45 PM, V2, DON stated R2's old bed had an issue with the hose coming off. She said when she was made aware of the situation, she notified maintenance, and they were supposed to order a new part. V2 said they tried to order the part, and they couldn't get it, so they rented R2 a new bed until hers came in. She said whatever day the order is written is the day they got R2 a new bed. V2 said the maintenance man who was working at the facility at the time is no longer with them, they had to let him go due to them having issues with him.On 12/23/25 at 10:20 AM, V15, Anonymous, said she took R2 to the wound clinic a couple of times. She said the one time she took R2 the dressings were dated 9/12 and 9/14. V15 said R2 was supposed to have a special type of boot the NP wanted and V1 went out and just got R2 some cushioned heel protectors. She said she was so embarrassed them thinking the facility is neglecting the residents. V15 said V13 had asked her if she had gotten the mattress, she had wanted R2 to get also. V15 said she asked V13 for copies of the orders so she could give them to the facility. V15 said every time she would take R2 to the appointment when they came back, she would hand over any orders to the DON. V15 said she told the facility R2 was supposed to have a new mattress, but they just don't listen. V15 said she would go down and visit R2 often and she had went into R2's room multiple times and found the mattress flat and R2 lying on the metal bed frame. She said the CNAs would have to get R2 up out of bed because the bed was flat.On 12/01/25 at 10:38 AM, V13, Wound NP said she first seen R2 back in August of this year and on the first visit she wrote an order for R2 to get a low air loss mattress. She said sure it could be painful for R2 if the air loss mattress wouldn't stay inflated and R2 was laying on the hard bed. She said to be 100% truthful she isn't sure if R2's wounds are actually pressure. She said her and her colleagues thought R2 could possibly have what is called Calciphylaxis (a rare, serious disease. It involves a buildup of calcium in small blood vessels of fat tissues and skin. Symptoms include blood clots, lumps under the skin and painful open sores called ulcers. If an ulcer becomes infected, it can be life-threatening.). V13 said she feels like R2 has skin failure related to her renal failure. She said R2's skin is so fragile she is having them use just paper tape on R2. She said R2 has had surgical debridement due to an infection and it can be pretty life threatening and life expectancy is shortened due to the infection. On 12/02/25 at 2:10 PM, V13, Nurse Practitioner (NP) said when R2 first came to see her R2's wound were labeled as pressure ulcers but due to her renal disease, some of her labs, some of the medications (such as Prednisone) not helping the wound in healing, and the progression of the wounds they thought R2 wounds were more related to Calciphylaxis. V13 said she would expect the facility to implement the orders she gives and if a low loss air mattress isn't properly inflating it can cause issues by putting more pressure on R2's wounds and it can cause her pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 8 of 26 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 12/24/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete V13 said she just recently changed R2's dressing orders from daily to three times a week and PRN if soiled or becomes dislodged. V13 said she would expect the nursing staff to follow her orders and if the dressing becomes soiled even if it was changed the day before to change it again. V13 said some of the risk for not changing dressings like they are ordered would be further skin breakdown from the moisture and infection especially because R2's is on her bottom. On 12/23/25 at 10:38 AM, V13, Wound NP said she originally thought R2 had Pyoderma Gangrenousm at first but after trying to treat her wounds with Prednisone and it not working, they decided it was Calciphylaxis and not Pyoderma Gangrenousm. She said sometimes you must try different treatments and other things to try to eliminate what it could be. V13 said she remembers writing for R2 to have a low air loss mattress and cushioned heel boots and she got them around 9/9/25. She said when she came back the following week for her follow up R2 reported to her that her (R2's) new mattress feels like she is laying on the hard frame of the bed. She said she instructed the caregiver who was with R2 to check the mattress for proper inflation every shift. V13 said if they had R2 on a bed that wasn't working properly she would expect the facility to immediately get her a different bed and putting R2 on a different mattress while they were getting her a new bed/mattress. V13 said she started R2 on Cipro on 9/19/25 because she had cultured R2's wound and she believes it was positive for pseudomonas.The facility's policy Pressure Ulcer Prevention, revision date of 1/15/18, documented Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositing measures. May use lotion on dry skin. It further documented 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protection bony prominences as indicated. It also documented 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds.The Immediate Jeopardy began on 08/21/25 was removed on 12/08/25 when the facility took the following actions to remove the immediacy as confirmed by the surveyor during onsite verification: Facility wound care policy was reviewed by [NAME] President of Operations and was found to be in compliance with state and federal regulations. Director of Nursing or designee initiated in-servicing, for all nursing staff, on the wound care policy and procedures on 12/05/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures on 12/05/25. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on 12/5/25 to ensure that all wound orders are carried out and all interventions are in place. Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly times 4 weeks beginning 12/5/25. The Director of Nursing or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand wound care policies and procedures beginning 12/5/25. Maintenance Director checked all Low Air Loss (LAL) mattresses on 12/5/25 to ensure proper functioning. Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning. IDT team on 12/5/25 (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly. R2's mattress was replaced with a new mattress on 11/14/25. Event ID: Facility ID: 146043 If continuation sheet Page 9 of 26 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 12/24/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure new care plan interventions were implemented to prevent new/worsening pressure ulcers. The facility failed to ensure skin assessments were completed, ensure supplies for wound care were available, and complete wound treatments as ordered for 1 of 3 residents (R1) reviewed for wounds in a sample of 10. This failure resulted in R1 developing a stage II pressure ulcer to her right buttock on 11/25/25, a stage III pressure ulcer to her left buttock on 12/02/25, and worsening/decline to the wound on R1's right heel resulting in R1 requiring antibiotic treatment. The Immediate Jeopardy began on 11/25/25 due to the facility's failure to assess, treat, and complete skin assessments to prevent and/or treat pressure wounds for R1. This failure resulted when V47 (Nurse Practitioner) discovered a Stage II pressure wound to R1's right buttock, which the facility was not aware of. Additionally, on 12/2/25, V47 discovered a Stage III pressure wound to R1's left buttock that the facility was not aware of. V1, Administrator and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 12/11/25 at 1:55 PM. Abatement number one and two were not accepted. Abatement number three on 12/12/25 was accepted. The Immediate Jeopardy was removed on 12/12/25, but noncompliance remains at Level Two as additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include:On 12/09/25 at 8:15 AM, R1 was up in the day area in her wheelchair, and she was observed in 15-minute intervals from 8:15 AM to 1:25 PM until she was laid down in bed. During this time R1 did have her float boots on and she was cooperative with care. At 9:45 R1 was leaning forward in her wheelchair. At 10:00 AM the certified nursing assistant (CNA) was going to take R1 and lay her down in bed but due to her having physical therapy they decided to leave her up in her wheelchair. R1 was then taken down to physical therapy at 10:17 AM. After therapy was completed, she was brought back to the day area on the 500 hallways and left in her chair due to it being so close to mealtime. At 11:45 AM, V7, Licensed Practical Nurse (LPN) said R1 eats better when she is up in her wheelchair, so she needed to stay up for lunch. 1:15 PM R1 remained in her wheelchair leaning forward in the day area on the 500 halls. At 1:25 PM V26, CNA and V45, CNA assisted R1 back to bed via mechanical lift. On 12/09/25 at 1:25 PM, Once R1 was placed in bed they removed R1 pants and then unfastened R1's incontinent brief and R1's brief was full of bowel movement (BM), V45 did incontinent care and cleaned R1 up. While R1 was on her left side a red area was noted on R1's right hip. When R1 was rolled over onto her right side there was another reddened area seen on R1's left hip. V26 said the area to R1's right side is where she had an open area at one time, but it has healed up. She said it could also be red because R1 had been sitting up in her chair and it's over a bony area. During incontinent care there was an indention on R1's right labia from sitting on the indwelling catheter and then an indention on back of R1's right leg/thigh from where R1 had been sitting on the indwelling catheter bag tubing. V26 said R1 was gotten up between 7:00 AM and 7:30 AM. She said she likes to make R1 a priority and get her laid down as soon as she can because of her wounds.R1's Face Sheet, print date of 12/11/25, documented diagnoses including type II diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, pressure ulcer of right heel stage II, pressure ulcer of sacral region, stage 4, peripheral vascular disease. R1's Minimum Data Set (MDS), dated [DATE], documented she is moderately cognitively impaired with a BIMS of 09 out of 15 and she requires substantial/maximal assistance with rolling left and right and is dependent on staff for sit to lying and lying to sitting. R1 is always incontinent of bowel and bladder. R1's Care Plan, admission date of 11/20/24, documented Potential for skin breakdown r/t (related to) incontinence, decreased mobility, DM (diabetes mellites), PVD (peripheral vascular Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 10 of 26 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 12/24/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few disease), frequently refuses to lay down, excoriated at times, right foot drop, left great toe amputation, tendon repair left ankle, arterial ulcer right hallux, Refuses vascular studies. R1 will develop no further break down thru next review. Goals include but are not limited to Air mattress, monitor for redness or discoloration to skin, local wound care management consult and tx (treat) weekly, and Weekly skin checks.11/24/25 update: Enhanced Barrier PrecautionsStage 2 Right (R) lateral footStage 3 R heel History (Hx) Methicillin-resistant Staphylococcus aureus (MRSA)Stage 4 Coccyx Revision on: 11/24/25R1's Behavioral Tracking for November 2025 and December 2025 were reviewed and R1 had no behaviors documented refusing to lay down or refusing treatments/care. R1's Wound Management Notes, dated 11/04/25, documented a wound culture was completed to R1's right heel on 10/14/25 and showed pseudomonas aeruginosa. R1's 10/2025 Treatment Administration Record (TAR), documented on 10/27/25#9 other/see progress notes.R1's Progress Notes were reviewed and have no documentation for the day of 10/27/25.R1's Progress Notes, dated 10/28/2025 at 12:41 AM, in part stated Medication Administration Note: Rt. (right) heel on hold; local wound management coming in the morning (AM).R1's Progress Notes, dated 10/28/2025 at 12:42 AM, in part stated Medication Administration Note: Coccyx on hold; local wound management coming in the AM. R1's Progress Notes, dated 10/28/2025 at 07:00 AM, documented R1 was seen by V47, Wound Nurse Practitioner (NP) for wound assessment and treatment. R1's coccyx wound had declined and was measuring 1.5 centimeters (cm) x 0.6cm x 0.4cm. R1's Progress Notes, dated 10/31/2025 at 5:35 PM, documented a new order was received from the local wound management. New order for R1's right heel; cleanse with normal saline (NS) or wound cleanser (wc), apply (antibiotics) Streptomycin 80 milligrams (mg)/Meropenem50mg/Flucytosine 150mg (3 capsules total) mixed with six pumps of (brand name gel) to wound bed, cover with 4x4, wrap with kerlix. Change daily and as needed (PRN) x 30 days. R1's November 2025 TAR was reviewed and documented #9- other/see progress notes on 11/1/25.R1's Progress Notes, dated 11/2/2025 at 05:42 AM, Medication Administration Note in part states medications not available for wound to Rt. heel.R1's TAR, dated 11/03/25 did not have any documentation wound care had been completed for the wounds to R1's Rt. heel and coccyx and there was no documentation a skin check had been completed.R1's Progress Notes, dated 11/04/2025 at 06:00 AM, documented R1 was seen by V47, NP for assessment and treatment. Coccyx wound declined and measures 3cm x 2.5cm x 0.5cm, 70% granulation 30% slough. New order to apply a thin layer of antibiotic to wound bed (WB) (same as Rt heel) and calcium alginate cover with foam silicone bordered dressing to be changed daily and PRN. R1's Skin-Pressure/Diabetic/Venous/Arterial wound report, dated 11/05/25, documented R1 did not have any new wounds. Wound #1 was a stage 3 pressure injury to her right heel measuring 4cm x 6vm x 0.vm2 and was unchanged but did show signs of infection. Wound #2 was a stage 4 pressure injury to R1's coccyx that was first observed on 08/31/25. It measures 3cm x 2.5cm x 0.5cm and the overall impression of wound #2 is it is worsening and is showing signs of infection.R1's Physician's Orders, dated 11/05/25 at 10:00 PM, documented Cleanse open area to coccyx with NS, apply a thin layer of antibiotic; Streptomycin 80mg/Meropenem 50mg/Flucytosine 150mg. Apply calcium Alginate to Wound bed and then cover with silicone bordered dressing. Change daily and PRN until healed every nightshift for skin management.R1's Shower Sheet, dated 11/06/25, had no documentation of her having any abnormal findings. No shower sheets after 11/06/25 were provided to this surveyor.R1's TAR, dated 11/10/25, documented #9- other/see progress notes.R1's Progress notes were reviewed and there is no documentation for 11/10/25 regarding wound care to R1's coccyx.R1's TAR, dated 11/11/25, documented #2- refused her treatment.R1's Progress Notes, dated 11/11/25 at 04:22 AM, documented OrdersAdministration Note in part states Local wound care management coming in the morning AM.R1's Skin-Pressure/Diabetic/Venous/Arterial Wound Report, dated 11/11/25 at 5:13 PM, documented Right heel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 11 of 26 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 12/24/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stage 3 pressure ulcer was measuring 3.5cm x 6cm x 0.2cm. Pressure injury to coccyx was measuring 2.5cm x 2.5cm x 0.4cm. Right Lateral Foot was measuring 1.3cm x 0.5cm x 0cm. R1's TAR, dated 11/14/25, had no documentation R1's wound to her coccyx, to her right heel, and to her right lateral foot had been completed.R1's Progress Notes, dated 11/16/2025 at 04:11 AM, in part states supplies are not available for wound care to R1's Rt. heel. R1's TAR, dated 11/17/25, documented #9 other/see progress notes.R1's Progress Notes, dated 11/17/2025 in part stated local wound care management is coming in the AM for wound care and assessment. R1's TAR, for 11/24/25, had no documentation treatments for R1 were completed to her coccyx and Rt. heel and her skin assessment was not completed. R1's Wound Assessment Report, dated 11/25/25, documented R1 had a new stage II pressure area to her Right buttock measuring 2.0cm x 2.0cm x 0.10cm. New order was put into place.R1's Progress Notes, dated 11/25/2025 at 06:45 AM, documented R1 was seen by V47, NP for wound assessment. New area noted to Rt Buttock 2.0cm x 2.0cm x 0.1cm Stage 2 Pressure injury. New orders to clean Rt buttock with NS, apply collagen sheet and cover with a silicone bordered foam dressing. R1's Skin-Pressure/Diabetic/Venous/Arterial wound report, dated 11/25/25, documented R1 had a new stage 2 pressure injury to her right buttock measuring 2.0cm x2.0cm x 0.1cm and it was first observed on 11/25/25.R1's TAR, dated 11/25/25, documented #9 other/see progress notes.R1's 11/25/25 progress notes were reviewed and no documentation regarding wound care was noted, but her progress notes dated 11/26/2025 at 03:26 AM, documented unable to do treatments as there was a continuous 1 x 1 for this hall that could not be left alone.R1's TAR, dated 11/29/25, had no documentation treatments for R1's coccyx, Rt. buttock and Rt. heel were completed. R1's TAR, dated 12/1/25, documented #9 other/see progress notes for wound to Rt. buttock and coccyx. There was no documentation for the wound to her Rt. heel. R1's Progress Notes, dated 12/1/2025 at 05:36 AM, in part stated there were no supplies for wound care to R1's coccyx.R1's Progress Notes, dated 12/1/2025 at 8:02 PM, documented the local wound management was coming in the AM to assess. R1's Progress Notes, dated 12/2/2025, documented R1 was seen and assessed by V47, Wound NP. Coccyx worsening and measures 3.0x0.5x0.4. Rt heel worsening and measures at 4.0x6.0x0.2. Rt Buttock worsening and measures 2.5x2.0x0.2. New area noted to the Lt buttock, Stage 3 pressure ulcer measuring 3.5x2.5x0.2. New orders received for Lt buttock, Rt buttock, and coccyx: Clean with NS, apply Santyl, cover with silicone bordered foam, change daily and PRN. This nurse along with local wound management assessed air mattress and wheelchair cushion at this time. The current wheelchair cushion was changed out for an Equagel cushion. The current air mattress was inflated at the time of service. Local wound management suggested we order a new mattress. R1's Wound Management Note, dated 12/02/25, documented Wound: 1 right distal heel is worsening. Wound: 2 coccyx is worsening. Wound: 5 right buttock is worsening. Wound: 6 left buttocks newly found on 12/02/25. Impression/Plan: Recommend a low air loss mattress vs. air overlay. Recommended to check roho wheelchair (w/c) to ensure it is working properly. Wound goals: adequate offloading to alleviate pressure for optimal wound healing. Complete adequate wound hygiene with dressing changes to prevent infection.R1's Skin-Pressure/Diabetic/Venous/Arterial wound report, dated 12/02/25, documented R1 had a new stage 3 pressure injury noted to her left buttock. It was first observed on 12/02/25 and measured 3.5 x 2.5 x 0.2. Wound #1 to R1's right heel was worsening and measuring 4.0 x 6.0 x 0.2 with a moderate amount of serosanguinous drainage noted. Wound #2 to R1's coccyx was worsening with measurements of 3.0 x 0.5 x 0.4 and a moderate amount of serosanguinous drainage. Wound #4 to R1's right buttock was worsening and measuring 2.5cm x 2.0cm x 0.2cm with a moderate amount of serosanguinous drainage.R1's Progress Notes, dated 12/3/2025 at 5:00 PM, documented Note Text: New order received to place an indwelling catheter to facilitate wound management and healing by preventing urine contamination to wound areas. Stage 4 wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 12 of 26 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 12/24/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to coccyx and stage 2 to Rt buttock have both declined in the last week. New area, stage 2 to Lt buttock noted this week. Call placed to power of attorney (POA) with no answer, voicemail (VM) left.On 12/23/25 at 10:20 AM, V1, Administrator said she would expect the nurse to follow up and get the treatment changes made right away and document it. She would expect the nurse to do an assessment on any resident who came back from the hospital and to document it. She said if there weren't supplies to complete a treatment, she would expect the nurses to notify the doctor they weren't able to complete the treatment and maybe he would change it until they were able to get the correct supplies in. She would also expect to be notified if the nurses didn't have the proper supplies for wound care and she would get what was needed right away. V1 said she would expect the nurses to continue with the current treatment for the wound until it was time for the new order to start. V1 said she would expect the maintenance department to keep equipment in good working condition. She said V48, Maintenance director is proactive about getting things done and looking for things to make sure they are working properly.On 12/11/2025 at 11:52 AM, V47, Wound Nurse Practitioner (NP) said R1 has a diagnosis of diabetes, and she is not compliant with care. She said the wound to R1's coccyx will open and close, but she has had that wound since being admitted to the facility. V47 said yes, she would expect the facility to have found the new wound on R1's left buttock during routine care. She said she was here making her rounds, and they went to turn R1 over and when they did that's when they found the wound to her Lt. buttock. V47 said the staff should be repositioning residents while they are up in their chairs. She said she would expect to be notified if the facility didn't have the supplies to complete the treatment that was ordered. She said she would expect the nurse to do a full body assessment upon readmission and document any wounds the resident had. V47 said the night shift does the treatments, and they are usually done towards the end of the shift. She said so they usually just wait for her to come in Tuesday morning and complete them. V47 said new interventions should have been put into place after a new wound has been found. She said while she was here doing her rounds, they inspected R1's bed and she was on an air overlay, so she suggested they get R1 a low air loss mattress and she also got a new wheelchair cushion. V47, NP agreed the lack of identifying, treating, and preventing new pressure wounds can for sure cause the wounds to worsen, get infected, and there is always a risk for death.The facility's policy Pressure Ulcer Prevention, revision date of 1/15/18, documented Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositing measures. May use lotion on dry skin. It further documented 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protection bony prominences as indicated. It also documented 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. The Immediate Jeopardy began on 11/25/25 and was removed on 12/16/25 when the facility took the following actions to remove the immediacy: Facility pressure ulcer prevention policy was reviewed by [NAME] President of Operations and was found to be in compliance with state and federal regulations on 12/11/25. R1 was seen by Wound Care Provider on 12/2/25 and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced. Director of Nursing or designee initiated in-servicing, for all facility and Agency nursing staff (agency staff will be in-serviced through shift key portal before they are able to pick up any more shifts) to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures on 12/11/25. In-servicing will be completed by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 13 of 26 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 12/24/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete start of each staff members next shift. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention on 12/11/25. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on 12/11/25 to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly. Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's beginning 12/11/25 on identifying all newly acquired pressure areas timely by completing assessments timely and accurately. All nursing staff will be educated by the beginning of their next shift. Completed on 12/12/25. Director of Nursing or designee will conduct audits of skin assessments weekly beginning 12/11/25 to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process. The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas 12/11/25. Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed completed on 12/12/25. For R1 the skin assessment was missed on readmission on [DATE] and was completed on 10/28/25. The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined. The DON or designee will review all new admissions to ensure that all assessments are completed beginning 12/11/25. The DON or designee educated all facility and agency nurses beginning on 12/11/25 of how and when to complete skin assessments. All facility and agency nurses will be educated by the beginning of their next shift. R1 has had a full skin assessment performed by the ADON on 12/11/25 to ensure all areas of concern have been identified and addressed appropriately. All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee on 12/11/25 that all residents need to be turned and repositioned at least every two hours and as needed. All in-servicing will be completed by the beginning of the staff member's next scheduled shift. IDT team on 12/11/25 (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity. IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review. Event ID: Facility ID: 146043 If continuation sheet Page 14 of 26 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 12/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure R4 was adequately supervised, failed to ensure door alarms were turned on, and respond in a timely manner to alarms to prevent elopement for 2 of 4 residents (R4, R9) reviewed for safety in a sample of 9. These failures resulted in a severely cognitive impaired resident (R4) repeatedly eloping from the facility despite being identified as an elopement risk, and multiple failures of disabling of door alarms and delayed responses contribute to R4's elopements into unknown and unsafe conditions that include walking in middle of road and getting in a strangers vehicle.The Immediate Jeopardy began on 10/16/25 when the facility failed to properly supervise a resident (R4) to prevent an elopement from the facility. V1, Administrator, and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/25/2025 at 12:58 PM. Abatement number one on 11/25/25 was not accepted. Abatement number two was accepted on 11/26/25 at 10:27 AM. The Immediate Jeopardy was removed on 11/26/25, but noncompliance remained at a Level Two at that time as additional time is needed to evaluate the implementation and effectiveness of the in-service training. On 12/01/25 at 12:02 PM, V1 Administrator was made aware the immediacy removal had been rescinded due to additional elopement incidents for R4 and R9. Abatement one through four on 12/01/25 were not accepted. Abatement number five was accepted on 12/01/25. The Immediacy was removed on 12/02/25 but the facility noncompliance remains at level two as additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings Include:The facility's daily census roster dated 11/17/25, documented the facility had 59 total residents.On 11/24/25 at 8:00 AM, when coming into the facility and coming down the 100 hallway the alarm was going off.On 11/24/25 at 8:10 AM, V1, Administrator went down and turned/reset the alarm off at this time.On 11/24/25 at 8:46 AM, R4 was seen walking up the 100 hallway then turned around and came back.On 11/24/25 at 8:50 AM, R4 went up the 100 hallway. She came back down the hallway at 8:55 AM. No staff were seen checking on her. On 11/24/25 at 10:00 AM, the door in the day area at the end of the 100 hallway that led to the outside was cracked a little. This surveyor opened the door up and no alarm sounded when the door was opened.On 11/24/25 at 10:05 AM, R4 was seen being taken by 500 hallway staff back towards the 200 hallway.On 11/24/25 at 11:39 AM, the door to the outside on the 100 hallway remains cracked open and two residents are outside smoking. On 11/24/25 at 1:58 PM, R6 and R7 were seen going out the 200-hallway door to the outside and when they opened the door there was no alarm that sounded. R4's Face Sheet, print date of 12/02/25, documented R4 has diagnoses including Alcohol dependence with alcohol induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, stage3.R4's Minimum Data Set (MDS), dated [DATE], documented R4 is severely cognitively impaired and is independent with ambulation. R4's Progress Notes, dated 10/15/2025 at 5:13 PM, documented Social Services Note Text: Resident admitted via family vehicle. Resident admitted from another facility. Resident is ambulatory and wanders all day/night. Resident is on 15-minute checks as the wander guard will be placed 10/16/2025 depending on how resident does overnight. Resident doesn't wear glasses, denture, or hearing aids. Resident is pleasant, but on the go. Resident arrived approx. 4:55pm.R4's Progress Notes, dated 10/15/2025 at 5:23 PM, documented Social Services Note Text: Code Alert was placed on resident by director of nursing (DON) at approx. 5:20pm.R4's Elopement Risk Assessment, dated 10/16/25 at 9:04 AM, documented R4 was an elopement risk, and the following interventions were to be used: Door Alarm Band, Identification (ID) bracelet on, frequent checks, and redirection.R4's Baseline Care Plan, dated 10/16/25 at 12:10 PM, documented R4 was cognitively impaired, uses a wander guard for safety, and is an elopement risk. It further documented R4 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 15 of 26 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 12/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transferred from another facility. She is alert, ambulates independently and frequently throughout facility, wearing code alert for wandering, closely watched by staff, on 15-minute checks, diagnoses included chronic obstructive pulmonary disease (COPD), alcoholic dementia, and bipolar.R4's Progress Notes, dated 10/16/2025 at 8:15 PM, documented Nurses Note Text: Around 1815 (6:15 PM), resident was found by CNA (Certified Nursing Assistant) outside by the dumpster. Door alarm and wander guard were sounding. CNA heard the alarm and immediately went to check on alarm. Alarm sounded until this nurse turned it off. Doors at the top of 500 hall were closed to help resident stay on the hall while meds were being passed and residents were being put to bed. Another CNA has walked around with resident. Snacks and fluids have been offered, taken well.R4's Elopement Risk Assessment, dated 10/28/25 at 10:29 AM, documented R4 was independent with locomotion on and off the unit, was moderately cognitively impaired, had prior exit seeking behavior, had a change in room, recent hospitalization, has contributing diagnoses of Alzheimer's disease and dementia other than Alzheimer's disease, is an elopement risk with the following interventions to be used: door alarm band, clothing marked with identification, photograph and description readily available, and psych referral. R4's Care Plan, with admission date of 10/15/25, documented on 11/12/25 the following problem, goal, and interventions were initiated: R4 is an elopement risk/wanderer r/t (related to) exit seeking, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities. R4's safety will be maintained through the review date, and interventions include but are not limited to staff to monitor location, redirect R4 away from doors and from going outside of the facility. Report to hall nurse, DON, and administrator if resident leaves facility through a door, and Wander Alert: wander guard on left ankle.R4's Progress Notes, dated 11/17/25 at 5:41 PM, documented R4 was noted to be walking outside of building on 500 patio doors. Noted resident was sitting in visitor van. Resident taken out of van and taken back to room. No injuries noted. Does have code alert on. R4's Progress Notes, dated 11/28/2025 at 04:24 AM, documented Note Text: Resident was walking up and down the hallway was in and out of other's rooms. As this nurse was up the hall passing medications, heard the door to the outside close and when this nurse and CNA looked over resident was out the back door, were able to redirect resident back in without any difficulties. Door alarm did not sound attempted to lock door and lock is broken at this time. CNA on another hall also tried to lock door with no success. DON aware of door.The facility's accident, incident, and fall log for the past two months was reviewed with no documentation noted about R4 getting out of the facility. On 11/18/25 at 2:05 PM, V7, Licensed Practical Nurse (LPN) said R4 is an elopement risk, if there is a way to get out, she will find it. She said she was here when R4 got out. She said there was one day she got out twice. She said she was sitting at the nurse's station on the 500-hallway working and when she looked up from the desk and looked out the window R4 was walking in the back area. V7 said jumped up and went out and got her and brought her back inside. She said R4 was just in her socks. V7 said later in the day she was working at the desk while V3, Registered Nurse (RN) was down on the 500-hallway taking care of a Peripherally inserted central catheter (PICC) line and hanging intravenous (IV) antibiotics for her and she looked out the window again and seen R4 had gotten back outside. V7 said she ran outside again and brought R4 back into the building. V7 said she asked R4 to show her how she was getting outside. V7 said R4 took her (V7) down the 100 hallway and through the set of doors and if you go off to the right there are doors that lead to the 400 hallway and then there is a door that will lead outside and that was where she was getting out. V7 said the alarm was working but it was so far away no one was able to hear it going off. V7 said then there was the time R4 went out the doors right down the hallway. She said she went out with another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 16 of 26 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 12/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident's family, the alarm went off, and so they ran down to get her and by the time they got there R4 had gotten into the visitor's van and V8, CNA had to remove her. V7 said the facility closed the doors on the 100 hallway and 400 hall and she doesn't think R4 has gotten out since. V7 said if you let R4 out of your site for two minutes she's gone.On 11/18/25 at 1:50 PM, V8, CNA said the reason R4 keeps getting out is because she looks like a worker and family members are letting her outside. She said you can't tell her from the workers here at the facility. V8 said one of the other resident's family was going out the door and R4 went out with them. She said the alarm went off and she ran down to get R4 and by the time she got to her R4 had gotten into their van.On 11/25/25 at 10:11 AM, V11, Primary Care Physician (PCP)/Medical Director said he was made aware of R4 getting out of the facility. He said he knew she had gotten out more than once also.On 11/25/25 at 10:50 AM, V3, Registered Nurse (RN) said R4 has gotten out on several occasions. She said one-time R4 had gotten out from the 400 hallway, was seen in between the two buildings, staff went out and got R4 and brought her back in, then they looked out the window again and R4 was back outside so they went back out and got her again and brought R4 back in. She said when R4 finds a way out she will go back to that way to get out again. V3 said each time R4 has had an incident they have made administration aware. V3 said R4 doesn't know what is going on and she worries constantly about R4 especially now with the weather getting cold. V3 said R4 could fall outside where no one can see her and freeze. V3 said it's hard to protect R4 due to not being able to watch R4 continuously. V3 said she has never had this kind of situation because if a resident wonders they will usually put them on the locked unit to keep them safe. V3 said most of the alarms are always on. V3 was questioned about the 200-hallway door alarm being off and she said the smokers go out there and it's been like that for a long time. V3 said when you go out that door and it shuts you can't open that door from the outside it only opens from the inside. On 11/25/25 at 11:05 AM, V15, Anonymous said about two weekends ago she was working and was doing stuff out in the dining room. She said she seen R4 wandering around in the halls, and she could see R4 in a mirror and she was heading toward the 500 hallways. V15 said she didn't see or hear R4 for a minute and she got this feeling, so she got up to check on R4 and found her outside standing in the middle of the street in front of the facility. She said cars sometimes fly by on that street. V15 said she text V1 and told her what was happening and asked if she needed to do anything else and V1 never responded. V15 said if R4 had a wander guard on it didn't go off. V15 said she is concerned about R4, and she absolutely feels R4 is at risk for something to happen to her. On 11/24/25 at 2:35 PM, V14, R4's family member said she was not aware of R4 getting out of the facility and no one ever called her and notified her of this. She said there was one day when her sister was at the facility to visit and asked how R4 was doing, and they told her sister oh by the way she got out of the facility. She said then the next day her sister contacted her and let her know but she is R4's guardian. She said she has never been notified of anything when it comes to R4 not even at her old facility. V14 said she would like to be notified about a lot of things.2. R9's Face Sheet, print date of 12/02/25, documents R9 has diagnoses of but not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, hemiplegia, unspecified affecting right dominant side, chronic kidney disease, stage 3, and cognitive communication deficit.R9's MDS, 09/01/25, documented R9 is moderately cognitively impaired with a BIMS of 12 out of 15 and he requires partial/moderate assistance with transfers and supervision/touching assistance with walking.R9's Care Plan, admission date of 12/12/24, documented R9 is at risk for personal injury and an elopement risk related to lack of regard for own safety, confusion. 11/21/25 resident set off door alarm. Staff followed resident outside of door. No injuries. Goal: R9 will not leave facility without (w/o) assist or obtain injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 17 of 26 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 12/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to self with attempt to leave facility thru next review. Interventions include but are not limited to 11/21/25 elopement attempt. staff educated to redirect resident when he is near doors, wander guard is in place, 15-minute checks, refer to code yellow binder, and if attempts to leave facility, verbally redirect to area away from door.R9‘s Elopement Risk Assessment, dated 06/06/25, documented R9 is a high risk for elopement. R9's Physician's Orders, dated 07/23/25 at 1:36 PM, documented Code Alert check every day shift every Tuesday for safety.R9's Progress Notes, documented the following:On 11/21/2025 at 04:41 AM, Behavior Note Text: Exited out of 500 patio doors with his shirt off. CNA followed behind him and redirected him back inside. Currently sitting in the sitting room, in front of the nurse's station, sleeping in w/c.On 11/21/2025 at 06:33 AM, Behavior Note Text: Alarm went off and CNA followed up with resident. Was found standing outside, in the rain, with shirt off. 2nd CNA assisted with getting the resident to sit in his w/c. Resident was successfully brought back in the facility without injury.On 11/21/2025 at 11:11 AM, Health Status Note Text: Resident is follow up (f/u) from incident last shift. Resident seems to be doing fine with no recollection of leaving facility. V11, Primary Care Physician/Medical Director in this morning and N.N.O (no new orders) at this time. Resident currently in front of nursing station watching tv (television). Care is ongoing.On 11/26/2025 at 03:37 AM, Behavior Note Text: This writer noting that resident has been up all night; resident will not go to bed (unsure if he slept all day or not); resident has gone in to other residents rooms, resident is trying to seek out doors on the unit (has a wander guard on), resident has shown some aggression towards staff, resident has tried to stand from WC, resident has gotten up from WC and walked down hall, resident has required a 1 x 1 for the entirety of the shift; for residents safety, this writer has stayed with resident for 2/3 of the shift and tried to redirect when behaviors were inappropriate; resident is not compliant with redirection and has become very agitated and demanding to go home; resident does not believe wife is here and does not believe he lives here either; resident has been shown personal belongings in room and attempts have been made to toilet resident and offerings of food and drink; resident denies pain and continues to demand that he is going home and he is going home now; this writer noting that for residents safety he has been monitored in the TV room and several attempts have been made to keep resident from standing; resident is unsteady on feet and at this time is very tired; resident will not go to room and does not want to discuss going to bed; will relay to AM shift for continuation of care.On 11/29/2025 at 07:20 AM, Plan of Care Note Text: Unit aid V27 notified this nurse that resident was outside sitting on the ground screaming help. Went outside with aidsV25 and V30 and assessed resident for injuries. Back against chair sitting up. No injuries noted. Aids assisted in getting resident in chair and bringing inside. Vital signs within normal limits. Power of Attorney (POA) notified, V2, DON notified. V11, PCP notified with NNO. Administrator notified. Put resident on one on one with unit aid V27.On 12/01/25 at 12:10 PM, V27, Unit Aide said she was working the day R9 was found outside. She said she was working the 300 hallway, and they asked her to run the food tickets over to the 500 hallway. While she was over on the 500 halls, they asked her for help, so she helped them with what they needed. She said she was on the back part of the hallway going by R2's room and she heard someone yelling help (x's 3) so when she made a left there was a door to the outside and she saw R9 sitting on the ground beside his wheelchair leaning towards the left. V27 said she immediately went and got the nurse so she could assess R9 and then the two CNAs came and got R9 up off the ground and into his wheelchair. V27 said there was snow on the ground, and it was cold outside. She said R9 was dressed in a long-sleeved black shirt, pajama pants, non-skid socks, and house shoes. He didn't have on any jacket or coat. V27 said she did not hear any type of loud alarm going off when she found R9, and she doesn't know how long R9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 18 of 26 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 12/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was outside before she found him. V27 said the first thing she did for R9 when they brought him inside was to get him a blanket so he could warm up.The facility's Code Pink- Missing Resident/Elopement, reviewed date of 11/15/2018, documented the following: Guidelines: 1) All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2) Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should: Attempt to prevent the departure without use of force. Obtain assistance from other staff members in the immediate vicinity, if necessary. Instruct another staff member to inform the Charge Nurse or Director of Nursing services of the resident's attempt to leave the premises. Be courteous in preventing the departure and returning the resident to the facility Notify the attending physician of the resident's attempt to leave the facility Contact legal representative/responsibility party and inform him/her of the incident. Make appropriate notations in the resident's medical record. Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated. The Immediate Jeopardy began on 10/16/25 and was removed on 12/02/25 when the facility took the following actions to remove the immediacy. Facility Elopement Policy was reviewed by Regional Director of Operations on 11/25/25 and was found to be in compliance with state and federal regulations. Facility Administrator or designee initiated in-servicing, for all staff, on the elopement policy and procedures on 11/25/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately on 11/25/25. In-servicing will be completed by the start of each staff members next shift. Maintenance Director or designee will conduct an audit of all facility door alarms on 11/25/25 and to be completed weekly to ensure they are adequately functioning and audible to staff areas. Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance beginning 11/25/25. The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures beginning 11/25/25. IDT team on 11/25/25 (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit. IDT team on 11/25/25 (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement. Completed on 11/25/25. R4 was placed on the locked unit 11/25/25. All facility exit door keys were removed and placed in secured location 12/1/25. Facility Administrator or designee initiated in-servicing for all staff on 12/1/25 to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift. Maintenance Director replaced the door lock to 300 Hall door to courtyard on 12/1/25 and is functioning properly. Event ID: Facility ID: 146043 If continuation sheet Page 19 of 26 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 12/24/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 60 residents residing in the facility. Findings include:The Facility assessment dated [DATE] did not include the following in the plan: identification of current Administrator nor current DON (Director of Nursing), identifying resources to provide necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies; evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans; pertinent information about the resident population the facility serves may include race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy or other factors that affect access to care and health outcomes related to health equity; physical environment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents; evaluations of the facility's training program to ensure any training needs are met for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment did not include an evaluation of applicable policies and procedures, facility based and community-based risk assessment, utilizing an all-hazards approach that evaluates the facility's ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster, and contingency plan for events or an all-hazards approach. On 12/2/25 at 10:52 AM Surveyor asked V1 Administrator if she has additional information on the Facility Assessment as the one provided does not address all required components including facility and community risk assessments and resources. V1 stated the Facility Assessment that was provided is all the information she has. On 12/2/25 at 1:47 PM V1 Administrator stated the facility does not have a policy for the Facility Assessment. The facility's daily census report, dated 12/2/25, documented there are 60 residents residing in the facility. Event ID: Facility ID: 146043 If continuation sheet Page 20 of 26 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 12/24/2025 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 observation, interview and record review the facility failed to ensure infection control standards of practice for hand hygiene, wound dressing disposal, and contaminated linen disposal were followed for 1 (R10) of 3 reviewed for infection control in the sample of 10.Findings Include:R10's admission Record dated [DATE] documented R10's initial admit date to the facility as [DATE]. This same document lists diagnoses for R10 including but not limited to Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status and Chronic Viral Hepatitis B without Delta-Agent.The Weekly Wound Committee Review Pressure Ulcer Cumulative Report dated [DATE] documented R10 admitted to the facility with an unstageable wound to his coccyx with moderate drainage noted.R10's Plan of Care with a revision date of [DATE] documented, R10 is to have Enhanced Barrier Precautions in relation to coccyx pressure ulcer.On [DATE] at 10:39 AM, R10 is observed as residing in a single occupancy room with a sign posted on the door to his room that stated: Stop, Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities.wound care: any skin opening requiring a dressing.On [DATE] at 11:21 AM, V7, Licensed Practical Nurse (LPN) donned a gown, mask and gloves from the 3-drawer cart located outside of R10's room door. Upon entry, R10 was expressing that he needed to have a bowel movement. R10 assisted V7 in rolling to R10's left side and as he did, began to have a bowel movement into the disposable incontinence brief which was under him. R10 was observed as having an undated dressing in place to his coccyx, which was now visibly soiled with feces. After R10 confirmed he had completed his bowel movement, V7 was observed wiping the feces on R10's skin with the disposable brief, folding the feces into the brief and placing it in the trash bag that was located on the floor by R10's room door. V7, then with her still same gloved hands touched the outside of the trash bag to lift the bag to better contain the contents, touched the room door, door handle, door frame and opened the door asking V45 (CNA) to bring in clean bedding supplies for R10. V7 closed the room door and went to the bathroom located within R10's room, touching the bathroom door, bathroom door handle, sink faucet handles and wet a washcloth. Continuous observation was made of V7 in which she remained donned in the same soiled gloves with no hand hygiene completed. V7 returned to R10's bedside and removed the soiled dressing to R10's coccyx and began wiping the skin around the wound as well as the feces smears which were still visible from R10's buttocks area. The coccyx dressing that was removed from R10, was observed as having a moderate amount of blood-tinged drainage present to the dressing as well as a small amount of blood-tinged drainage which ran from the wound onto R10's skin upon the dressing removal. R10 was rolled from his left side, back to his back with the wound coming directly in contact with the bed linens. V7 then doffed her gown, gloves, mask placing them, as well as the soiled coccyx dressing into the clear trash bag located on the floor by the room door, exiting the room, performing no hand hygiene. V7 was then touched the door frame and door handle upon exiting the room. V7 reached into her shirt pocket for the med cart keys, unlocking the med cart, touching the top, sides, as well as opening the drawers of the cart. V7 closed and locked the cart back up, performing no sanitation to the cart and walked down the hall, then utilizing alcohol-based hand sanitizer, midpoint between R10's room and the nurse's station as she was walking. V7 was observed obtaining wound supplies from the wound cart located at the nurses' station. No isolation bins or red / biohazard labeled bins observed being in R10's room or bathroom adjoined to his room. This surveyor was exiting R10's room and asked V45 (Certified Nurse Assistant, CNA) where I should place my cloth isolation gown that I had worn during this observation. V45 stated, put it in the floor by the trash bag & I'll take Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 21 of 26 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 12/24/2025 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 - Few care of it.On [DATE] at 12:02 PM, V7 (LPN) stated that she is familiar with R10. V7 stated that R10 is on enhanced barrier precautions for a coccyx wound. V7 stated that R10 is positive for HIV & Hepatitis B, so enhanced barrier precautions would also be used for contact with his blood and body fluids. V7 stated that anything that is visibly soiled with blood should be placed in a red biohazard bag in the dirty utility room.On [DATE] at 12:20 PM, V46 (ADON/Wound/Infection control Nurse) stated that R10 is on enhanced barrier precautions and has been since his admission to the facility in [DATE], due to having a coccyx wound and previously a g-tube as well as being immunocompromised with HIV and Hep B diagnoses. V46 stated her expectations are for staff to follow facility policy for enhanced barrier precautions.On [DATE] at 11:45 AM, V2 (Director of Nursing) stated that she is familiar with R10. V2 stated that R10 should be on enhanced barrier precautions presently due his wound and has been on enhanced barrier precautions since he was admitted due to being admitted with a wound and an enteral feeding tube. V2 stated she would expect staff to follow the facility policy for Enhanced Barrier precautions and any wound dressings that were observed being contaminated with blood or body fluids should be placed in a red biohazard bag and taken to the dirty utility for proper disposal.Review of the facility policy titled, Enhanced Barrier Precautions with a most recent revision date of [DATE] documents the purpose of this policy is, To reduce risk of transmitting multidrug-resistant organisms (MDRO) and targeted MDRO when contact precautions do not apply for residents identified as higher risk. Guidelines include, Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning of gown and gloves during high- contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: .Chronic Wounds.Review of an article titled, Standard Precautions for Prevention of Transmission of HIV, Hepatitis B Virus, Hepatitis C Virus and Other Bloodborne Pathogens in Health-Care Settings which was not dated and found at https://www.ncbi.nlm.nih.gov/books/NBK305277/ stated, Standard precautions combine the major features of universal precautions (UP) and body substance isolation (BSI), and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection-prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which health care is delivered. These include: hand hygiene; use of gloves, gown, mask, eye protection or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner that prevents transmission of infectious agents (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). The application of standard precautions during patient care is determined by the nature of the health-care worker-patient interaction and extent of anticipated blood, body fluid or pathogen exposure. For some interactions (e.g. performing a venepuncture), only gloves may be needed; during other interactions (e.g. intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Standard precautions are also intended to protect patients by ensuring that health-care personnel do not carry infectious agents to patients on their hands or via equipment used during patient care. A section in the article titled, Hand hygiene stated,1. During the delivery of health care, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.2. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 22 of 26 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 12/24/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete body fluids, wash hands with either a non-antimicrobial or an antimicrobial soap and water.3. If hands are not visibly soiled, or after removing visible material with non-antimicrobial soap and water, decontaminate hands in the clinical situations described in 3.a-f The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub immediately following handwashing with non-antimicrobial soap may increase the frequency of dermatitis. Perform hand hygiene:3.a. Before having direct contact with patients3.b. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings3.c. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure or lifting a patient)3.d. If hands are likely to move from a contaminated body site to a clean body site during patient care3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient3.f. After removing gloves.Wash hands with non-antimicrobial or antimicrobial soap and water if contact with spores (e.g. Clostridium difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors and other antiseptic agents have poor activity against spores.Additionally in the same article, the section titled Gloves stated:Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g. of a patient with incontinence of stool or urine) could occur.Wear gloves with fit and durability appropriate to the task.2.a. Wear disposable medical examination gloves for providing direct patient care.2.b. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using a proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with the transmission of pathogens.2.d. Change gloves during patient care if the hands are likely to move from a contaminated body site (e.g. perineal area) to a clean body site (e.g. face).Review of an article titled, HIV and AIDS, dated [DATE] and found at https://www.who.int/news-room/fact-sheets/detail/hiv-aids documented In 2024, an estimated 630 000 people died from HIV-related causes and an estimated 1.3 million people acquired HIV.Review of an article titled, Why is hepatitis B so dangerous? dated [DATE] and found at https://www.hepb.org/what-is-hepatitis-b/faqs/why-is-hepatitis-so-dangerous/ documented, Hepatitis B is dangerous because it is a silent infection, which means it can infect people without them knowing it. Most people who are infected with hepatitis B are unaware of their infection for many years and can unknowingly spread the virus to others through direct contact with their infected blood and sexually.Review of an article titled, Hepatitis B dated [DATE] and found at https://www.who.int/news-room/fact-sheets/detail/hepatitis-b documented, Hepatitis B can cause a chronic infection and puts people at high risk of death from cirrhosis and liver cancer. Event ID: Facility ID: 146043 If continuation sheet Page 23 of 26 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 12/24/2025 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 0908 Keep all essential equipment working safely. 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 ensure a low air loss mattress was in proper working order for 1 of 3 residents (R2) reviewed for essential equipment, safe operating condition in a sample of 10. This resulted in R2 being in extreme pain due to R2 having multiple pressure ulcers/injuries, the mattress not staying properly inflated, and R2 laying on a hard metal bed frame. Findings Include: R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting.R2's Face Sheet, print date of 12/04/25, documented R2 has diagnoses including pressure ulcer of right buttock, stage 3, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), and chronic combined systolic and diastolic (congestive) heart failure. R2's Care Plan, admission date of 08/18/25, documented Potential for skin breakdown r/t (related to) incontinence, Hx (history) weeping L/E's (lower extremities), ace wraps for edema, morbid obesity, OAB (overactive bladder), resident is at increased risk for unavoidable skin breakdown r/t autoimmune disease pyoderma gangrenosumStage 3 R (right) buttockStage 3 R posterior thighStage 3 L (left) buttockStage 3 L posterior thighStage 3 L proximal buttockR lateral calf skin tearGoal: R2's will have wounds show improvement through next review and interventions include but not limited to Low Air Loss Bariatric Mattress for pressure reduction Per wound clinic/V13, Nurse Practitioner (date initiated 10/15/25), monitor for redness or discoloration to skin, keep skin dry and well lubricated, and weekly skin checks.On 11/18/25 at 1:50 PM, V8, Certified Nursing Assistant (CNA) said R2's bed had a connection device that had three tubes on it that would connect to the machine, and it would keep coming off. V8 said sometimes when they would just be walking by R2's room and look in they would see that the tube had come disconnected and they would have to go in the room and hook it back up. V8 said the bed R2 has now she just got it three or four days ago.On 11/18/25 at 2:00 PM, Outside of R2's door lying on the floor was a machine (air pump) that went to an old air loss mattress. The control panel was hanging out of the machine by the wires, and it didn't have any hose connected to it. On 11/18/25 at 2:05 PM, V7, Licensed Practical Nurse (LPN) stated R2 should be on an air loss mattress to help prevent wounds. She said the plug had an issue something about the hose would pop off and the plug was lose.On 11/19/25 at 10:41 AM, V9, R2's family member #1 said her biggest issue is with R2's bed. She said R2 is supposed to have an air loss mattress but the one she had was literally held together with duct tape. V9 said they told the Director of Nursing (DON) about it, and she said they had a piece ordered. V9 said R2 would sink in the mattress, and it would make R2's bed sores hurt because the mattress wasn't properly inflated. V9 said they had to change R2's room because the bed she got was bigger than her original bed and it wouldn't fit in her old room. V9 said she has pictures of where the bed was broke, and she would send them to this surveyor. On 11/24/25 at 10:10 AM, R2 said the wound care nurse at a local facility is the one who recommended switching her to an air loss mattress, but she isn't sure when she did that. She said the mattress she had before she got this one was softer, but they had trouble keeping air in it. R2 said whatever was supposed to be putting air into the bed wasn't working right and it kept coming off. R2 said when the air would go out of the old bed it was just like laying on the floor. She said when the air would go out of the mattress, she couldn't handle it her pain was so bad. She said it was a 10 with 10 being the worst and it was a burning type of pain where her sores are. R2 said she didn't want to be around people because she knew she was a crab-a**, and it hurt too much to sit up in her wheelchair. She said she would just have to grit her teeth and bare it before they got her better pain medication. On 12/02/25 at 10:55 AM, V31, R2's family Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 24 of 26 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 12/24/2025 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 0908 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete member #2 said he messaged/sent pictures to the DON about the bed not working. He said he likes to have things in writing when it comes to the facility, so he has proof. He said this didn't start because his mom didn't want to lay down in her bed it was because they put her in a wheelchair that was to small and then sent her to dialysis. He said his mom has always slept in her recliner but now she stays mostly in her bed because of the wounds. V31 said R2 didn't get the low air loss mattress until she came back from the hospital this last time. He said that is why she had to be moved to the (specific hall location). V31 said he isn't sure what day R2 got the bed, but it didn't work. The hose that connected to the mattress would keep coming off and they used duct tape to try and keep it in place. V31 said they have changed R2's pain medication also. He said she is in extreme pain due to (d/t) her wounds and so they started her on morphine and after the dressing changes is when she has the most pain.On 11/19/25 at 12:42 PM, This surveyor reviewed pictures provided by V9, R2's family member #1 and they correspond with V31, R2's family member #2, V7, LPN, and V8, CNA interviews that the hose that keeps the bed inflated comes disconnected and causes the mattress to lose air. On 12/04/25 at 2:45 PM, V2, DON stated R2's old bed had an issue with the hose coming off. She said when she was made aware of the situation, she notified maintenance, and they were supposed to order a new part. V2 said they tried to order the part, and they couldn't get it, so they got R2 a new bed. V2 said the maintenance man who was working at the facility at the time is no longer with them, they had to let him go due to them having issues with him.On 12/23/25 at 10:20 AM, V1, Administrator said she would expect the maintenance department to keep equipment in good working condition. She said V48, Maintenance director is proactive about getting things done and looking for things to make sure they are working properly.On 12/01/25 at 10:38 AM, V13, Wound Nurse Practitioner (NP) she first seen R2 back in August of this year and on the first visit she wrote an order for R2 to get a low air loss mattress. She said sure it could be painful for R2 if the air loss mattress wouldn't stay inflated and R2 was laying on the hard bed. She said to be 100% truthful she isn't sure if R2's wounds are pressure. She said her and her colleagues thought R2 could possibly have what is called Calciphylaxis (a rare, serious disease. It involves a buildup of calcium in small blood vessels of fat tissues and skin. Symptoms include blood clots, lumps under the skin and painful open sores called ulcers. If an ulcer becomes infected, it can be life-threatening.).On 12/02/25 at 2:10 PM, V13, Wound NP said she would expect the facility to implement the orders she gives and if a low loss air mattress isn't properly inflating it can cause issues by putting more pressure on R2's wounds and it can cause her pain.The facility's Preventive Maintenance and Inspections policy, not dated, documented In order to provide a safe environment for residents, employes, and visitors, a preventative maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition. Routine inspections and promote safety throughout the facility and aid in keeping fixtures and equipment in good working order and operating in accordance with manufacturer's guidelines. Regular inspection, testing, and replacement or repair of equipment and operational systems contribute to preservation of the facility's assets. Preventive maintenance (PM) is the care and servicing by personnel for the purpose of maintaining fixtures, equipment and facilities in a satisfactory operating condition by providing for systematic inspection, detection, and correction of incipient failures either before they occur or before they develop into major defects. Maintenance includes tests, measurements, adjustments, and parts replacements that are performed specifically to prevent faults from occurring. Event ID: Facility ID: 146043 If continuation sheet Page 25 of 26 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 12/24/2025 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 60 residents residing in the facility. Findings include:The facility's CNA (Certified Nurse Assistant) hire date list documented the following: V32 CNA hire date of 7/26/2011.V33 CNA hire date of 1/21/2002.V34 CNA hire date of 11/12/2018.V35 CNA hire date of 11/4/1999.V36 CNA hire date of 3/18/2019.V37 CNA hire date of 11/19/2019. The facility's in-service records for 2025 documented the following: V32 had 1 hour of education for the past year.V33 had 2 hours of education for the past year. V34 had 1 hour of education for the past year. V35 had 2 hours of education for the past year. V36 had no education documented for the past year.V37 had 2.5 hours of education for the past year. On 12/2/25 at 12:29 AM V1 Administrator stated I have to be honest, that is all we have for the CNA in-services/education for the past year. V1 stated CNAS are supposed to have 10 or 12 hours of continuing education per year. V1 stated the in-services that were provided to the Surveyor were all 30-minute in-services except the wound care in-service did take 1 hour. V1 stated the CNA list has the original hire date and the date the new company took over on 11/1/25. On 12/2/25 at 1:43 PM Surveyor reviewed the CNA education hours with V1 Administrator and V2 DON (Director of Nursing). V1 and V2 both agreed V32, V33, V34, V35, V36, and V37 did not receive the 12 hours of required education in the past year. On 12/2/25 at 2:17 PM V1 Administrator stated she thinks the facility did do dementia training in February of 2025, but she cannot find the attendance records for it. Surveyor asked if the facility provides dementia training within 60 days of hire as documented in the facility Employee Education policy and V1 stated we are not doing that. The facility's Employee Education policy, dated 10/1/22, documented the facility shall provide a Staff Education Plan in accordance with State and Federal regulations. 1. The facility will develop, implement, and maintain a written staff education plan, which ensures a coordinated program for staff education for all facility employees. 2. The staff education plan will be reviewed at least annually by the quality assurance committee and revised as needed. 3. The facility will ensure the staff education plan includes both pre-service and annual requirements. 4. The staff education plan shall ensure that education is conducted annually for all facility employees, at a minimum, in the following areas: a. Prevention and control of infection; b. Fire prevention, emergency procedures-life safety, and disaster preparedness; c. Abuse, neglect, and exploitation; d. Accident, prevention and safety awareness programs; e. Resident's rights to include Advanced Directives; f. OSHA Training - Biomedical Waste Plan and Bloodborne Pathogens; g. Federal law requirement for long term care facilities, which is incorporated by reference, and state rules and regulations; h. Quality Assurance Performance Improvement (QAPI). 5. The facility will ensure, when employed by a nursing home facility for a 12-month period or longer, a nursing assistant, to maintain certification, shall submit to a performance review every 12 months and must receive regular in-service education based on the outcome of such reviews. It continues, 8. The facility will ensure that all employees will have training, as required by the State regarding dementia, both at within 60 days of hire and annually thereafter. The facility's daily census report, dated 12/2/25, documented there are 60 residents residing in the facility. Event ID: Facility ID: 146043 If continuation sheet Page 26 of 26