Axiom Gardens Of Flora
Axiom Gardens of Flora in FLORA, IL — inspection on April 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
underwear on R1 when she is up in her wheelchair because she has frequent urinary incontinence. V6
because one pair of padded underwear was in the washer at that time and the other pair weren't
atrial fibrillation, Parkinson's disease, dementia and unsteadiness on feet.R2's MDS dated [DATE] documents R2 has a BIMS score of 3 indicating R2 has impaired cognition and unaware of safety needs.
The same MDS documents R2 is a substantial/maximum assistance for mobility.R2's most recent Care Plan documents R2 has a focus area for R2 being at high risk for falls related to poor cognition, impaired balance and safety awareness dated 3/19/26.
Interventions for this focus area include ensuring resident is wearing appropriate footwear when up and following facility fall protocol both dated 3/19/26.R2's IDT Fall Committee [NAME] Note dated 4/13/26 documents R2 was found in the floor of his room by his bed attempting to ambulate with no assistance.
New intervention documented in the fall investigation was for staff to always leave R2's door open for increased observation.On 4/27/26 at 2:41PM, observed R2's door to his room completely shut.
When this surveyor knocked and opened R2's door, observed R2 lying on his bed. On 4/28/26 at 9:38 AM, observed R2's door again shut to his room.
When this surveyor knocked and opened the door to the room observed R2 sitting on the side of his bed with his feet resting on the floor with his walker within reaching distance. On 4/27/26 at 1:23 PM, V5 (CNA) stated they could not remember any fall interventions for R2 specifically. V5 stated they did remember R2 is to be escorted when he is up ambulating. V5 stated they did know where to find fall interventions for the residents at a binder located at the front hall nurse's desk.On 4/28/26 at 1:51 PM, V2 (Director of Nurses) stated all CNAs can look in the communication book located at the nurse's station of the front hallway for any residents' specific fall precautions. V2 stated fall precautions for all residents can be looked up in CNA's electronic health records they have access to. V2 stated all nursing staff should be aware of resident's fall precautions or at least know where to find them. V2 stated nursing staff are always free to come and talk to them or V1 (Administrator) if they have any questions. V2 stated she does not remember all of R1's fall precautions but does remember R1 has padded underwear to protect her hips if she falls. V2 stated if R1 is out of bed she should have her padded underwear on, but when she is lying down, she doesn't have to wear them. V2 stated R2's fall precautions most recently implemented were for R2's door to remain open so he can be observed frequently.
When asked if there was any reason why R2's door should have been shut those two times this surveyor observed it, V2 stated not unless care was being performed or R2 or his roommate had requested to have the door shut. V2 stated it would be shut upon request of R2 only after re-education had been given as well.The facility Fall Prevention Program policy dated 11/21/17 documents, Safety interventions will be implemented for each resident identified at risk.
All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained.
145624 04/29/2026
Axiom Gardens of Flora 701 Shadwell Avenue Flora, IL 62839
language.The facility's job description for CNA's dated 5/2/17 documents a CNA is responsible for
performing personal hygiene and bathing, and rolling, turning and repositioning in bed and transfers of
Nursing Assistant in accordance with the laws of the state of practice, must be at least [AGE] years of age, be certified in basic life support, and be able to understand, speak, read and write the English language.
The facility's Daily Census 4/26/26 (with a print date of 4/27/26) documents there are a total of 62 residents residing in the facility.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.