Axiom Gardens Of Flora

F 0550

dated 11/28/12 documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner.

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

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Flora

701 Shadwell Avenue Flora, IL 62839

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

provided timely, and/or call lights not being answered timely. V1 stated it should all be done in a timely manner. When asked what she would consider timely, V1 stated it would depend on what the CNAs were doing when the call light went off. V1 stated she would expect it to be answered as quickly as possible.The facility Incontinence Care policy dated 11/28/12 documents, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.The facility Call Light policy dated 11/28/12 documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Flora

701 Shadwell Avenue Flora, IL 62839

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

evening shift. V1 clarified they don't run an evening shift, but the traditional evening shift would include the time frames of 6 pm to 10 pm, when the facility is running four CNA's and the calculator, she used to calculate they should be running 5.74 CNAs. V1 then stated the calculator is just a suggestion and they have the staffing numbers to meet the needs of the residents.The Facility Assessment Tool dated 9/5/24 documents under Staffing Plan, 3.2 Based on our resident population and their needs for care and support,

the facility utilizes the minimum staffing calculator to determine staffing needs.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Flora

701 Shadwell Avenue Flora, IL 62839

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

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

them from the pharmacy instead of the over-the-counter ones they normally use, and they weren't available

in the emergency drug kit. This surveyor reviewed Resident R8's MAR and progress notes with V2 and asked if they weren't available on 10/17, 10/18, 10/20, and 10/21 how was it administered on 10/19/25. V2 stated she didn't know and would have to check with the nurse (V16 Agency Registered Nurse) who signed it out. V2 stated Resident R8 was receiving the lidocaine patch for surgical after care/brain surgery. V2 stated Resident R8 admitted to

the facility on [DATE REDACTED] with the order in place at the time of admission. When asked why over a month later

the patch wasn't available, V2 stated, It had to be a pharmacy issue. V2 stated there was no documentation

in Resident R8's record why the medication was not available. V2 stated she didn't know what, if anything, was done to obtain the patches since there was no documentation. V2 stated Resident R8's Lyrica was unavailable for administration on 10/05 and 10/06/25. V2 stated she thought Resident R8 needed a new prescription before the pharmacy would fill it. When asked if it was acceptable practice for Resident R8 to go without the Lyrica and the Lidocaine patch V2 stated, No, it is not. V2 stated she wasn't aware of any negative outcome related to Resident R8 not getting his medications.3. Resident R7's admission Record with a print date of 11/18/25 documents Resident R7 was admitted to the facility on [DATE REDACTED] with diagnoses that include chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension.Resident R7's MDS dated [DATE REDACTED] documents a BIMS score of 15, indicating Resident R7 is cognitively intact.Resident R7's Order Summary Report dated 11/19/25 documents a physician order for Sudafed 30 mg every 12 hours as needed with a start date of 11/05/25.Resident R7's MAR dated 11/1/25 to 11/30/25 documents a physician order for Sudafed 30 mg every 12 hours as needed with a start date of 11/05/25. This same MAR does not document administration of the Sudafed from 11/05/25 to 11/10/25.On 11/16/25 at 6:57 AM, Resident R7 stated he waited 3 to 4 weeks to get the insurance to approve his new sinus medication, but he was getting it now.On 11/18/25 at 10:24 AM, V2 (DON) stated when the physician first wrote the order for Resident R7's Sudafed they didn't put a dosage on the prescription, so they had to get a new order with the dosage and resend it to the pharmacy. V2 stated once they got the new prescription to the pharmacy it came back as an over-the-counter prescription, so the facility had to pay for it. When asked if

she knew why that took five days and if that was an acceptable length of time, V2 stated they were still getting used to the new pharmacy.On 11/16/25 at 12:48 PM, V9 (Registered Nurse) stated they had issues with medications not being available to administer when they switched pharmacies. V9 stated if a resident doesn't get their medication, it should be charted.On 11/18/25 at 10:24 AM, V2 (DON) was unable to locate documentation Resident R1, Resident R7, and/or Resident R8's physicians were notified the medications were not available to see if

they wanted to prescribe a different medication/dosage. V2 stated it was not acceptable practice for residents to not be administered medications as ordered. V2 stated she had in serviced the nursing staff what to do if a medication is unavailable.The Pharmacy policy dated 1/2018 documents under Policy-Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Flora

701 Shadwell Avenue Flora, IL 62839

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 - Few

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

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to ensure the menu met the resident's individual nutritional needs and preferences for 1 of 3 (Resident R8) residents reviewed for dietary services in the sample of 21.Findings include:On 11/16/25 at 12:43 PM, Resident R8 stated he didn't get a meal tray last night at the evening meal (11/15/25). Resident R8 stated he normally eats in his room, and he wasn't sure why they didn't serve him supper. Resident R8 stated at approximately 8:45 pm they made him three peanut butter and jelly sandwiches. Resident R8 stated he would have rather had the chicken and French fries they served for the evening meal.Resident R8's admission

Record with a print date of 11/18/25 documents Resident R8 was admitted to the facility on [DATE REDACTED] with diagnoses that include diffuse traumatic brain injury, traumatic hemorrhage of cerebrum, open wound of head, serotonin syndrome, delirium, and depression.Resident R8's MDS (Minimum Data Set) dated 9/16/25 documents a BIMS (Brief Interview for Mental Status) score of 15 indicating Resident R8 is cognitively intact.Resident R8's current Care Plan documents a Focus area of, I have a nutritional problem or potential problem r/t (related to) TBI (traumatic brain injury), depression Date Initiated: 09/01/2025. This Focus area includes the interventions of, Encourage PO (by mouth) intake of meals and snacks. Date Initiated: 09/17/2025.Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Date Initiated: 09/17/2025.Resident R8's Order Summary Report dated 11/19/25 documents a physician order for a no added salt regular texture diet.The facility Diet Spreadsheet Dated Week 3 25-26 Saturday documents the menu for Dinner as, chicken tenders platter, French fries, ketchup, buttered peas, bread/margarine, banana's with whipped topping, milk/beverage.On 11/16/25 at 1:09 PM, V11(Dietary Aid) stated she worked 11/15/25 and Resident R8's tray was made and sent out the window but somehow didn't get to him. V11 stated they made him peanut butter and jelly sandwiches around 7 pm. When asked if this had ever happened before V11 stated they send the trays out and then the residents say they don't get them. V11 was unable to provide this surveyor with any specific dates and/or residents this had occurred with other than Resident R8.On 11/16/25 at 1:12 PM, V12 (Cook) stated he worked 11/15/25 and wasn't sure what happened with Resident R8's dinner meal tray. V12 stated two tickets may have gotten stuck together. V12 stated an unknown CNA told him Resident R8 didn't get a meal tray, and he made him three peanut butter and jelly sandwiches around 7 pm.On 11/16/25 at 12:48 PM, V9 (Registered Nurse) stated Resident R8's food is always messed up but was unable to provide this surveyor with specific details.On 11/17/25 at 2:39 PM, V10 (Dietary Manager) stated

the nursing staff were aware Resident R8's tray was served to the wrong person who was on the same diet as Resident R8, but they didn't tell the dietary staff Resident R8 needed another tray. On 11/19/25 at 2:20 PM, V10 (Dietary Manager) stated to his knowledge three peanut butter and jelly sandwiches were the only food Resident R8 was served on the night of 11/15/25. V10 stated that was not an acceptable substitution for chicken tenders, French fries, buttered peas, and bananas. V10 stated Resident R8 should have been offered a starch, vegetable, and a dessert.The facility policy titled Dining Options for Meal Service dated 2020 includes, Staff will monitor the resident's food and fluid intake for adequate consumption and offer appropriate meal substitutions to residents when needed.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Flora

701 Shadwell Avenue Flora, IL 62839

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 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review the facility failed to ensure food was served at a palatable temperature. This has the potential to affect 9 of 9 (Resident R1, Resident R10, Resident R14-Resident R20) residents served room trays on the long-term care units reviewed for dining in the sample of 21.Findings Include:On 11/19/25 at 2:55 PM, V1 (Administrator) provided this surveyor with the list of residents who are served meals in their room on the long-term care units. This list documents Resident R1, Resident R10, and Resident R14-20 were served room trays.The facility Concern/Complaint Form dated 10/21/25 documents under Concern/Compliment: this resident (Resident R21 who no longer resides at the facility) states that the vegetables are cold when being delivered on the hall.vegetables are not warm when reaching resident room.Dietary Manager in serviced with staff and educated them to prevent reoccurrence. There are no temperatures of the food documented on this form.On 11/16/25 at 7:27 AM, Resident R4 stated he is served his meals in his room at times and the temperature of

the food sucks.On 11/18/25 at 9:28 AM, V20 (CNA) stated the food is sometimes served cold. V20 was not able to recall a specific resident/time of the complaint but did say she sometimes eats at the facility and the food is cold at times.On 11/18/25 at 9:38 AM, V19 (CNA) stated the food is hot for the residents who eat in

the dining room but the residents who eat in their rooms get colder food.On 11/16/25 at 12:39 PM, this surveyor and V10 (Dietary Manager/DM) followed the uninsulated cart carrying room trays including a test tray to the long-term care units. As the last room tray was being served to the residents, V10 (DM) used the facility thermometer to check the temperature of the food located on the test tray. The temperatures were as follows; pureed ham - 138 degrees Fahrenheit (F), mechanical soft ham 128 degrees F, pureed zucchini 115 degrees F, ham slice 112 degrees F, mashed potatoes 138 degrees F, and zucchini- 125 degrees F.On 11/16/25 at 1:04 PM, V10 (DM) stated the temperature of each of the foods on the food trays delivered to

the residents should be 135 degrees F.On 11/17/25 at 2:39 PM, V10 (DM) stated they split the halls for hall trays up and that fixed the issue with the food not holding temperatures for the hall tray delivery times.The facility Monitoring Food Temperatures for Meal Service dated 2020 documents, Guideline: food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. g. Meals that are served on room trays may be periodically checked at the point of service for palatable temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident. Any complaint regarding food temperatures by residents will be documented on the Food Temperature Log. Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining above 120 degrees F. The investigation is recommended to be completed within 72 hours of the complaint.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet