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Complaint Investigation

Axiom Healthcare Of West Frankfort

Inspection Date: August 19, 2025
Total Violations 3
Facility ID 145664
Location WEST FRANKFORT, IL
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Inspection Findings

F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Physician to the get the order changed. When asked how long Resident R5 was receiving the Ocuvite instead of the Preservision, V2 stated she didn't know. When asked if the physician order was still Preservision and if the facility nursing staff were signing, they administered Preservsion instead of Ocuvtie, V2 stated she didn't know.On 8/19/25 at 10:57 AM, V14 (ADON) stated V2 wasn't in the facility today but she was familiar with Resident R5 and the Preservision order. V14 stated the pharmacy was providing the Preservision initially and then

they stopped providing it. V14 wasn't sure why but she thought it had something to do with Resident R5 reaching her maximum allowed amount. V14 stated she was made aware on 8/8/25 by Resident R5 that she was receiving Ocuvite and not Preservision as ordered.On 8/19/25 at 11:08 AM, V15 (Pharmacist) stated Resident R5's Preservision was filled on 4/28/25 for a 30-day supply and had not been filled by their pharmacy since then.

V15 stated the Preservision has a different formula than Ocuvite with different concentrations of vitamins and minerals. V15 stated they didn't send any to the facility after 4/28/25 because they didn't have any refills and if the facility would fax over a new prescription for the Preservision they would fill it.The facility Medication Administration through Certain Routes of Administration policy dated 11/15/24 documents, Applicability: Policy 6.7 establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care (LTC) facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Healthcare of West Frankfort

601 North Columbia West Frankfort, IL 62896

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)

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F-Tag F0727

Nursing and Physician Services Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview, and record review the facility failed to ensure they had RN (Registered Nurse) coverage 8 hours/day, 7 days/week. This failure has the potential to affect all 50 residents who reside at the facility. Findings Include:The undated facility Room Roster documents 50 residents currently reside at the facility. On 8/18/25 at 3:20 PM, V2 (Director of Nurses) stated she didn't have a Registered Nurse on staff.

V2 stated she does have agency Registered Nurses that work at the facility at times. The facility schedules dated July 2025 and August 2025 documents the facility did not have RN coverage on 7/18, 7/19, 8/9, 8/10, and 8/23/25. On 8/18/25 at 4:25 PM, V2 confirmed in email the facility did not have RN coverage on the above listed dates.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Healthcare of West Frankfort

601 North Columbia West Frankfort, IL 62896

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)

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F-Tag F0755

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

as ordered.On 8/19/25 at 11:08 AM, V15 (Pharmacist) stated Resident R5's Preservision was filled on 4/28/25 for a 30-day supply and had not been filled by their pharmacy since then. V15 stated the Preservision has a different formula than Ocuvite with different concentrations of vitamins and minerals. V15 stated they didn't send any to the facility after 4/28/25 because they didn't have any refills and if the facility would fax over a new prescription for the Preservision they would fill it.The facility Medication Administration through Certain Routes of Administration policy dated 11/15/24 documents, Applicability: Policy 6.7 establishes guidelines for the safe and effective administration of medications through various routes of administration in a long-term care (LTC) facility. It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations.

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

AXIOM HEALTHCARE OF WEST FRANKFORT in WEST FRANKFORT, IL inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST FRANKFORT, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AXIOM HEALTHCARE OF WEST FRANKFORT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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