Axiom Gardens: Elopement Policy Violations - IL
The facility's Code Pink Missing Resident/Elopement policy, last updated in November 2018, requires all personnel to immediately report any cognitively impaired resident attempting to leave or suspected of missing to the charge nurse. Staff must also prevent departures without using force, obtain assistance from other employees, and ensure the charge nurse or director of nursing services is notified.
When employees observe a cognitively impaired resident leaving or attempting to exit, the policy mandates specific steps: prevent the departure courteously, return the resident to the facility, notify the attending physician, contact the legal representative or responsible party, document the incident in the medical record, complete a new elopement risk assessment, and update the care plan with appropriate interventions.
Inspectors found the facility violated federal regulations requiring timely and effective communication with attending physicians and family members or responsible parties about significant changes in residents' conditions.
The policy emphasizes that all staff are responsible for monitoring residents who might attempt to leave without signing out on pass or notifying personnel. This includes any resident who departed without proper notification procedures.
Federal regulations mandate that nursing homes immediately inform attending physicians and families when residents experience significant changes or incidents that could affect their health and safety. The inspection found these communication requirements were not met in cases involving cognitively impaired residents attempting to leave the facility.
The violation received a minimal harm rating, indicating the deficiency had limited impact on resident safety but represented a failure to follow established protocols designed to protect vulnerable patients.
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 15, 2026 · Our methodology
Axiom Gardens of Nashville in NASHVILLE, IL was cited for violations during a health inspection on December 24, 2025.
The policy emphasizes that all staff are responsible for monitoring residents who might attempt to leave without signing out on pass or notifying personnel.
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.
Frequently Asked Questions
- What happened at Axiom Gardens of Nashville?
- The policy emphasizes that all staff are responsible for monitoring residents who might attempt to leave without signing out on pass or notifying personnel.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in NASHVILLE, IL, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Axiom Gardens of Nashville or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 146043.
- Has this facility had violations before?
- To check Axiom Gardens of Nashville's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.