Axiom Gardens Nashville: Resident Punched in Face - IL
The certified nursing aide, identified in inspection records as V4, looked at the daily schedule for January 27 and confirmed her own name was on it. She still said she didn't remember the incident. What she did remember was that the resident who threw the punch, identified as R1, had behaviors frequently, and that staff would try to redirect her. Sometimes they'd take her to sing. Sometimes they'd bring her to the keyboard in her room. Whether any of that happened in the weeks or months before R1 punched another resident in the face, the inspection report does not say.
The activities aide, V5, also said she didn't remember if she was working that day. But she remembered the punch. "R1 punched R2 in the face," she told the inspector on April 29. She described R1 as very set in her ways, someone who would become convinced something had happened even when it hadn't, and said staff had to go along with it to redirect her. She said R1 had a lot of behaviors.
The nurse on duty that evening, V7, had more detail than anyone else. She was on the 200 hall passing medications when a CNA witnessed R1 grab R2 in the TV room doorway. R1 called R2 a whore. R2 swung and hit R1 in the face. The CNA stepped between them and separated them. V7 said she went back through her messages to the physician, V8, and found that she had reported R2 had "slight redness to her forehead" from being punched. V7 notified the administrator, the physician, and R2's power of attorney that night.
R2's family member and power of attorney, V2, told inspectors on April 29 that she was told her family member was hit in the face by another resident in January, that it knocked her glasses off, and that was all she knew about it. That was the extent of what reached the family: she was hit, her glasses fell, and that is all.
When inspectors tried to interview R2 herself, she was unable to recall the incident. The report notes her cognitive level as the reason.
The administrator on duty when inspectors arrived, V1, said she had just started working at the facility the month before and had no information about what happened between R1 and R2 in January. The incident was three months old by then. Whatever investigation the facility conducted, whatever steps were taken to prevent R1 from reaching another resident in a doorway and punching her, none of that was accessible through the person now running the building.
The inspection was conducted as a complaint investigation, which means someone contacted authorities about what happened. The report does not identify who made the complaint or when.
What the record does show is a resident with documented, recurring behavioral episodes, staff who described those episodes as frequent and difficult to redirect, and a physical assault that left another resident with visible injury to her face. The progress note entered the same evening, January 27 at 5:56 p.m., described the incident in clinical shorthand: behaviors, redirection, notification of the physician and family. Slight redness to the forehead. Glasses on the floor.
The nursing aide scheduled to work that day looked at her own name on the schedule and said she didn't remember any of it.
That detail sits at the center of this inspection finding. The CMS citation documents actual harm, not potential harm, not a risk of harm. R2 was punched in the face. Her forehead was red. Her glasses were knocked off. The harm was graded as affecting few residents, which is accurate in the narrowest sense, and it is also the kind of accuracy that flattens what actually happened to a specific person in a TV room doorway on a January evening.
R1's behaviors were known. Staff described them to inspectors in the same breath as saying they didn't remember the assault. "R1 had behaviors a lot," V4 said. "They would try to redirect her, but it didn't always work." V5 said R1 "had a lot of behaviors." Both of them used the word lot. Neither of them, in the inspection record, connected that history to any formal plan that might have kept R1 and R2 separated, or placed a staff member between them in a common area, or changed what happened on January 27.
The physician was notified. The power of attorney was notified. A progress note was written. The administrator who received that notification is no longer at the facility, or at least is not the person who showed up to work in March. The administrator who is there now started last month and knows nothing about it.
There is a policy. The facility's own abuse prevention and reporting document, dated January 8, 2026, nineteen days before the assault, states that residents have the right to be free from abuse and mistreatment, and that the facility prohibits both. The policy was nineteen days old when R1 punched R2 in the face in the doorway of the TV room.
Policies do not redirect a resident who is set in her ways. They do not step between two women in a doorway. They do not remember what happened on a Tuesday evening in January.
The CNA who actually stepped between R1 and R2 and separated them, the one the nurse's progress note credits with intervening, was not identified by name in the inspection record. The inspector's notes reference V4 as the CNA interviewed, the one who was on the schedule, the one who didn't remember. Whether V4 was the CNA who intervened or a different person is not resolved in the report.
R2's family member drove to the facility at some point after January 27, or received a phone call, and was told her family member was hit, her glasses came off, and that was all. She told the inspector on April 29 that was all she knew. Three months later. That was the complete picture she had been given of the night another resident grabbed her family member by a doorway, called her a whore, and hit her in the face.
The inspector noted the cognitive status of R2 when attempting to interview her. She could not recall the incident. Whether she was ever told, in terms she could hold onto, that she had been assaulted, that the redness on her forehead had a cause and a person behind it, the report does not say.
What it says is that the harm was actual, that few residents were affected, and that on April 29, 2026, the administrator of Axiom Gardens of Nashville had been on the job for approximately one month and did not know anything about what happened to R2 on January 27.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Axiom Gardens of Nashville from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Axiom Gardens of Nashville in NASHVILLE, IL was cited for violations during a health inspection on April 29, 2026.
The certified nursing aide, identified in inspection records as V4, looked at the daily schedule for January 27 and confirmed her own name was on it.
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.