Axiom Gardens: Duct Tape on Life Support Bed - IL
The resident's specialized low air loss mattress kept losing air because the connecting hose wouldn't stay attached to the bed. Family members photographed the makeshift duct tape repair and messaged pictures to the director of nursing about the malfunctioning equipment.
"She is in extreme pain due to her wounds and so they started her on morphine and after the dressing changes is when she has the most pain," the resident's son told inspectors during the December complaint investigation.
The wound nurse practitioner who first saw the resident in August had immediately ordered the low air loss mattress. She told inspectors that lying on a hard bed when the mattress deflated "sure it could be painful" for someone with the resident's condition.
"If a low loss air mattress isn't properly inflating it can cause issues by putting more pressure on wounds and it can cause her pain," the nurse practitioner said.
The director of nursing acknowledged the bed's problems, saying maintenance tried to order replacement parts but couldn't get them. The facility eventually got a new bed, but only after the resident had endured weeks with the broken equipment.
The administrator said she expected maintenance to keep equipment in good working condition. The facility had to let go the maintenance worker who was there during the bed problems.
The resident's wounds may be related to calciphylaxis, a rare disease involving calcium buildup in blood vessels that causes painful open sores. The nurse practitioner said if the ulcers become infected, the condition can be life-threatening.
The resident now takes morphine for pain management and spends most of her time in bed because of her wounds.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Axiom Gardens of Nashville from 2025-12-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Axiom Gardens of Nashville in NASHVILLE, IL was cited for violations during a health inspection on December 24, 2025.
The resident's specialized low air loss mattress kept losing air because the connecting hose wouldn't stay attached to the bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.