Axiom Healthcare Of West Frankfort

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

On 09/09/25 at 2:50 PM, V29 (Activity Director) stated that she was working as weekend manager one weekend she said she usually works around 4 hours. V29 said that she could hear staff yelling and screaming at each other. V29 said that she went to see who it was she said that it was V32 (CNA) and V18 (CNA). V29 said V18 told her that she was in a resident's room and that V32 came down to that resident room and was jumping all over her about the staff assignment. V29 said V18 told her that V32 was blaming her for upsetting other staff V24 (CNA) and V9. V29 said that she went and talked to V24 and V9 asking them if V18 had done anything to upset them and they stated no. V29 said that V24 was a little upset not at V18 but overall, the drama at the facility. V29 said that V24 left and that is when V39 came into work. V29 said V18 told her that she was going into a room and that she shut the door with her foot because she has just put gloves on and that V39 opened the door and asked her why she slammed the door and V18 told V39 that she did not slam the door and then V39 told V18 she is just weird. V29 said that V1 did know about V18, V32, and V39 yelling at each other and of the way they were acting in the facility.

On 09/03/25 at 4:41 PM, V27 (Agency Licensed Practical Nurse) stated, the second night she worked, the CNAs were yelling and screaming at each other down the halls. V32 (CNA) was following V18 (CNA) down

the hall yelling at her. V32 was starting arguments with V18 because of the things that took place the night before. The CNA (V18) that was getting followed down the hall went home early because she didn't feel comfortable with the situation. V27 stated, she could hear them on the two main halls (the north and south halls). V27 stated, the place had all kinds of drama going, it was crazy.

The timecard reports document on 07/20/25 the CNAs working the 2:00 PM - 10:00 PM shift were V9, V32, V24, and V18 and the only CNA to leave early was V18.

The room roster provided on 08/28/25 documents Resident R2, Resident R23, Resident R4, Resident R18, Resident R11, Resident R33, Resident R24, Resident R29, Resident R10, Resident R6, Resident R13, Resident R38, Resident R39, Resident R35, Resident R32, Resident R1, Resident R19, Resident R15, Resident R40, Resident R41, Resident R25, Resident R8, Resident R30, Resident R26, Resident R42, Resident R27, Resident R43, Resident R5, Resident R44, Resident R45, Resident R21, Resident R12, Resident R16, Resident R17, Resident R7, Resident R31, Resident R46, Resident R47, and Resident R48 live on the north and south halls.

On 09/08/25 at 10:44 AM, V40 (Agency LPN) stated, the time he worked at the facility, he remembers CNA's yelling at each other, you could hear them from the nurse's station on the north and south hall.

Residents wanted to go to the bathroom and they couldn't. V40 stated it was chaos at the facility.

The facility's undated Resident Rights policy documents in part, “Our most important goal is to provide the highest standard of care to our residents in an environment safe, secure, and free of clutter. All employees of (Name of Facility) are expected to treat all residents, their family members, co-workers, and visitors with the utmost respect, kindness, and professionalism at all times… Employees that fail to provide superior care will be subject to corrective action, up to and including termination of employment.”

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

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Facility ID:

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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

09/16/2025

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)

F 0558

reach them.

Level of Harm - Minimal harm or potential for actual harm

On 09/04/25 at 9:54AM, V5 (CNA) stated that they do have a resident who says that her call light is out of reach often it is Resident R4. V5 said that she doesn't know how, but it is at the end of the bed or on the floor sometimes. V5 said that when she works, she tries to connect it to the bed rail or to the resident bed with

the clip. V5 said she knows there are a couple of other residents who complain that their call light is not in reach as well, but she couldn't remember who all it was.

Residents Affected - Some

The Facility policy titled “Call Light” with a revision date of 02/02/2018 which documents the purpose as: to respond to resident' request and needs in a timely and courteous manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside to other reasonable accessible location. Note: In the event

the bed is positioned in a manner that is not within the resident' reach notify maintenance for a call light cord extension.

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

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Facility ID:

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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

09/16/2025

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)

F 0583 Level of Harm - Minimal harm or potential for actual harm

residents. V18 said that some staff didn't care where they were, they would talk about the residents and say their names when they were talking about the resident care.

On 09/09/25 at 2:50PM, V29 (Activities Director) stated that she has heard staff talking about resident care

in common areas such as in the dining room where families and other resident could hear and say names.

Residents Affected - Many

The Facility room roster undated presented on 08/28/25 documents the facility total census is 52.

The facility document titled “Confidentiality Agreement” undated documents in part Under HIPPA policies, employees are prohibited from directly or indirectly divulging, using or permitting the use of any patient confidential information, including medical information, records and invoices, except as required

in the course of employment with the facility. Employees work closely with residents, their doctors, and other staff all information concerning residents, their medical conditions or treatment, their finances, and their families or friends, is to be kept strictly confidential. This confidential information should not be given to other residents, persons outside of this facility, or even other employees unless 1.) withholding the information would hinder the resident's care, health, or safety. 2.) your supervisor or Department Director, or the Administrator, request the information, or 3.) disclosure properly is sought by an investigator/inspector from a government agency. Any employee violation this policy is subject to discharge.

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

Event ID:

Facility ID:

If continuation sheet

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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

09/16/2025

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)

F 0584 Level of Harm - Minimal harm or potential for actual harm

notice. Violation of “The Facility” standards of conduct may lead to corrective action, up to and including immediate termination. Violations of conduct standards that constitute ground for immediate dismissal include in part Violating “The facility” drug/alcohol-free workplace policy and violating “The Facility” non-smoking policy.

Residents Affected - Some

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

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

09/16/2025

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)

F 0585

the facility anymore.

Level of Harm - Minimal harm or potential for actual harm

On 09/03/25 at 3:19PM, V18 (CNA) stated that she has observed V32 (CNA) be rude to several residents.

V18 said V32 would say terrible things to residents. V18 could not remember what all V32 said or to whom

she said it just that she would always have an attitude.

Residents Affected - Many

On 09/09/25 at 2:50PM, V29 (Activity Director) stated that she has heard staff be rude to residents. V29 said that V35 (CNA) she has heard be rude with resident when talking to them. V29 said when she had resident council that some of the residents were complaining about staff being rude. V29 stated that she is sure she wrote up a grievance/concern form about it. V29 stated that she does not know what happened to

the grievance/concern form about staff being rude.

On 09/09/25 at 3:51PM, V1 (Administrator) stated that she was not aware of any complaints about staff being rude to residents.

On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated that she was not aware of residents complaining

in resident council about staff being rude. V2 stated she was not aware of any staff being rude to any residents at all.

The undated room roster presented on 08/28/25 documents 52 residents residing at the facility.

The facility policy dated 09/25/17 titled, Grievances documents: All alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, will be immediately reported to the administrator and as required by State law. All written grievances shall include: the date the grievance was received, a summary statement of the grievance, department assigned to investigate, steps taken to investigate the grievance, summary of the pertinent findings or conclusions regarding the concern(s) 2 statement as to whether the grievance was confirmed or not confirmed, corrective action taken or to be taken by the facility as a result of

the grievance, including measures taken to prevent further potential violations of any resident right while the alleged violation is being investigated, the date the written decision was issued to the resident or the complainant. Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). Under certain circumstances, additional time may be needed to complete an investigation and implement measures to resolve the grievance. In such cases, the resident or complainant should be notified of the extension.

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

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Facility ID:

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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

09/16/2025

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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

not making fun of him. Simply said it was funny and reminded me of that person on that show.The facility policy dated 12/17/21 titled, Abuse Prevention and Reporting - Illinois documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that

the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

Event ID:

Facility ID:

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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

09/16/2025

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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

get over it. V18 said Resident R4 just kept saying it burns and yelling out. V18 said she looked over at V6 who was just standing there rolling her eyes. V18 stated, she reported this to V27 (Agency Licensed Practical Nurse).

V18 stated, Resident R4 also told V27 what happened.On 09/03/25 at 4:41 PM, V27 (Agency Licensed Practical Nurse) stated, the first night she worked, Resident R4 was screaming during the shower she was given, Resident R4 was screaming to the point she walked down to check on them. The CNA's (V9 and V32) giving Resident R4 the shower stated, oh, her (Resident R4) screaming is just her behavior and waved her off. V27 stated, she did not report this to V1 because she did not know the resident's behaviors and the other nurse working V16 (LPN) knew about

the situation. V27 stated, she did not hear Resident R4 yelling at any other time unless she needed something and her call light was not in reach.On 09/09/25 at 3:51PM, V1 (Administrator) stated no one ever told her about

the incident with V32 and Resident R4 in the shower until it was reported to her by IDPH. V1 stated that V18, V27, nor V16 (Licensed Practical Nurse) ever said anything about this incident, and they all have her cell phone number. V1 stated V18 is a disgruntled employee and she never reported anything to her. V1 said she investigated the incident and that V32 did get soap in Resident R4's eyes not on purpose and that they did wipe out her eyes right away. V1 said that Resident R4 does have a behavior of yelling out often. V1 stated that she would not think of V32 to do anything like that to leave soap in Resident R4's eyes.The facility policy titled Abuse Prevention and Reporting with a revision date of 10/24/22 documents in part, Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence.

Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Event ID:

Facility ID:

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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

09/16/2025

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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

also in-service on redirection and interaction with residents. On going in-services will continue with all staff members. The Administrator also was in-serviced by the VP (Vice President) of operations regarding reporting any type of allegation made to the Department of Public health. The Administrator was also in-serviced on the process and procedure of reporting incidents. The two staff members were able to return to work after the full investigation was completed. The facility policy titled Abuse Prevention and Reporting with a revision date of 10/24/22 documents, Internal Investigation, All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to who the accused had regularly provided care, and employees with who the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.

Event ID:

Facility ID:

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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

09/16/2025

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)

F 0689 Level of Harm - Actual harm Residents Affected - Few

On 09/09/25 at 3:45 PM there were six residents outside smoking with nine residents lined up making their way out the door to the smoking area. Resident R10 was in line to go out to the smoking area. Resident R10 would shuffle his feet pushing his walker forward coming within approximately an inch of hitting the resident in front of him and then would move backwards almost stepping into the resident behind him. This action continued until Resident R10 was in the outside area.

The facility policy titled “Fall Prevention Program” with a revision date of 11-21-17 documents

the purpose as: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines include in part: Methods to identify risk factors.

The facility policy titled ‘Safe Smoking and Vaping Policy/Procedure” with a last update date of 09/10/25 documents under policy: The facility works to provide appropriate care for residents, keeping safe and comfort in mind. Residents may have the desire to smoke/vape, and accommodations will be provided as the facility deems appropriate. The facility treats the use of vaping products the same as traditional smoking products. Procedure documents in part: 3. The rules are as followed # 3. Conduct while smoking must promote safety. #4. No negative behaviors related to smoking are permitted. B. The timeframes above are the only times smoking materials may be distributed. Continued disruption of resident care responsibilities over smoking break times constitutes a violation of the “No negative behaviors related to smoking are permitted.”

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

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Facility ID:

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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

09/16/2025

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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

disorders, gastro-esophageal reflux disease without esophagitis, hyperlipidemia, insomnia due to other mental disorder, major depressive disorder, mental disorder, moderate intellectual disabilities, malignant neuroendocrine tumors, schizophrenia, and macular degeneration.Resident R3's MAR documents on [DATE REDACTED] V4 administered cyclobenzaprine HCL (hydrochloride) to Resident R3. On [DATE REDACTED] V4 administered quetiapine fumarate and divalproex sodium to Resident R3. On [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] V4 administered atorvastatin calcium, quetiapine fumarate, divalproex sodium to Resident R3. On [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] V4 administered clonazepam to Resident R3. On [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] V4 administered lamotrigine to Resident R3. On [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] V4 administered divalproex sodium to Resident R3. On [DATE REDACTED] V4 administered cyclobenzaprine HCL to Resident R3. On [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] administered olanzapine to Resident R3.The room roster provided on [DATE REDACTED] documents 52 residents residing at the facility. The job description listing a position title of: Licensed Practical Nurse (Nurse) documents: Qualifications: Licensed Practical Nurse with current unencumbered state licensure.

Event ID:

Facility ID:

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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

09/16/2025

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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

On 09/08/25 at 1:11 PM, V42 (Dietary) stated she has been serving dinner before and it will be getting close to the end so she will put a smaller portion of food on the plate to make sure she has enough food for all the residents, she will then try to go back and put some more food on the plates after she has put food

on all the plates to make sure all the residents get food.

On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated that she was aware of residents complaining they weren't getting seconds, but not of them not getting any food.

The Concern/Compliment Form dated 08/07/25 by Resident R11 documents nature of concern/compliment: not enough snacks at night. Dinner meal time at 5 PM then breakfast at 7 AM is a long time without meals and snacks. Bigger portions would be nice.

The Concern/Compliment Form dated 08/07/25 by Resident R13 documents nature of concern/compliment: bigger portions of food.

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

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

09/16/2025

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)

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

The facility document titled, Inservice Form dated 07/18/25 documents: in-service title snacks & water with

the summary of the in-service stating: pass ice water and snacks (pureed or cooled snacks will be in the milk cooler).

Resident council minutes dated 07/07/25 document under the section titled, Nursing ice water not being passed.

The room roster provided 08/28/25 documents 52 residents residing at the facility.

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

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Facility ID:

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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

09/16/2025

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)

F 0809

mealtime at 5 PM then breakfast at 7 AM is a long time without meals and snacks.

Level of Harm - Minimal harm or potential for actual harm

The Concern/Compliment Form dated 08/30/25 by Resident R2 documents: they don't have enough snacks in the evenings, only thing offered to her is saltine crackers. If they would add peanut butter, that would make them feasible to eat.

Residents Affected - Some Resident council minutes dated 07/07/25 document under the section titled, Nursing ice water not being passed, snacks only offered to smokers at 8:00 PM.

On 09/08/25 at 1:03 PM the picture of the snack basket, which was a plastic tote container, approximately 16 inches by approximately 13 inches. This container appeared to hold approximately: 7 packages of saltines, 7 oatmeal cream pies, 4 packages of cookies, 7 pudding containers, 8 peanut butter and jelly half sandwiches.

On 09/08/25 at 1:03 PM, V41 (Dietary) stated, sometimes she makes the snack basket for the evening snacks. V41 stated, she will put a handful of crackers, a handful of oatmeal cream pies, some fruit cups, and some gelatin cups in the basket. V41 stated, she does not count the snacks in the basket.

On 09/08/25 at 10:44 AM, V40 (Agency LPN) stated, residents did not drinks passed to them, they did not have enough snacks. V40 stated, he felt they did not have enough staff.

The policy dated, 2025 titled, (company name) dietary policies and procedures documents: snacks: the food and nutrition department may provide snacks as requested by residents and HS ([NAME] somni (before bed)) snacks daily, per facility protocol.

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

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