Axiom Gardens Of Nashville

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.The facility's Code Pink- Missing Resident/Elopement, reviewed date of 11/15/2018, documented the following: Guidelines: 1) All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2) Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should: Attempt to prevent the departure without use of force. Obtain assistance from other staff members in the immediate vicinity, if necessary. Instruct another staff member to inform the Charge Nurse or Director of Nursing services of the resident's attempt to leave

the premises. Be courteous in preventing the departure and returning the resident to the facility Notify the attending physician of the resident's attempt to leave the facility Contact legal representative/responsibility party and inform him/her of the incident. Make appropriate notations in the resident's medical record.

Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

V13 said she just recently changed Resident R2's dressing orders from daily to three times a week and PRN if soiled or becomes dislodged. V13 said she would expect the nursing staff to follow her orders and if the dressing becomes soiled even if it was changed the day before to change it again. V13 said some of the risk for not changing dressings like they are ordered would be further skin breakdown from the moisture and infection especially because Resident R2's is on her bottom. On 12/23/25 at 10:38 AM, V13, Wound NP said she originally thought Resident R2 had Pyoderma Gangrenousm at first but after trying to treat her wounds with Prednisone and it not working, they decided it was Calciphylaxis and not Pyoderma Gangrenousm. She said sometimes you must try different treatments and other things to try to eliminate what it could be. V13 said she remembers writing for Resident R2 to have a low air loss mattress and cushioned heel boots and she got them around 9/9/25.

She said when she came back the following week for her follow up Resident R2 reported to her that her (Resident R2's) new mattress feels like she is laying on the hard frame of the bed. She said she instructed the caregiver who was with Resident R2 to check the mattress for proper inflation every shift. V13 said if they had Resident R2 on a bed that wasn't working properly she would expect the facility to immediately get her a different bed and putting Resident R2

on a different mattress while they were getting her a new bed/mattress. V13 said she started Resident R2 on Cipro

on 9/19/25 because she had cultured Resident R2's wound and she believes it was positive for pseudomonas.The facility's policy Pressure Ulcer Prevention, revision date of 1/15/18, documented Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures.

1. 2. Inspect the skin several times daily during bathing, hygiene, and repositing measures. May use lotion on

dry skin. It further documented 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protection bony prominences as indicated. It also documented 9.

Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds.The Immediate Jeopardy began on 08/21/25 was removed on 12/08/25 when the facility took the following actions to remove the immediacy as confirmed by the surveyor during onsite verification: Facility wound care policy was reviewed by [NAME] President of Operations and was found to be in compliance with state and federal regulations. Director of Nursing or designee initiated in-servicing, for all nursing staff, on the wound care policy and procedures on 12/05/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures on 12/05/25. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on 12/5/25 to ensure that all wound orders are carried out and all interventions are in place. Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly times 4 weeks beginning 12/5/25. The Director of Nursing or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand wound care policies and procedures beginning 12/5/25. Maintenance Director checked all Low Air Loss (LAL) mattresses on 12/5/25 to ensure proper functioning. Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning. IDT team on 12/5/25 (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly. Resident R2's mattress was replaced with a new mattress on 11/14/25.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

start of each staff members next shift. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention on 12/11/25. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on 12/11/25 to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly. Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's beginning 12/11/25 on identifying all newly acquired pressure areas timely by completing assessments timely and accurately. All nursing staff will be educated by the beginning of their next shift. Completed on 12/12/25. Director of Nursing or designee will conduct audits of skin assessments weekly beginning 12/11/25 to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process. The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas 12/11/25. Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed completed on 12/12/25. For Resident R1 the skin assessment was missed on readmission on [DATE REDACTED] and was completed on 10/28/25. The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined. The DON or designee will review all new admissions to ensure that all assessments are completed beginning 12/11/25. The DON or designee educated all facility and agency nurses beginning on 12/11/25 of how and when to complete skin assessments. All facility and agency nurses will be educated by the beginning of their next shift. Resident R1 has had a full skin assessment performed by the ADON on 12/11/25 to ensure all areas of concern have been identified and addressed appropriately. All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee on 12/11/25 that all residents need to be turned and repositioned at least every two hours and as needed. All in-servicing will be completed by the beginning of the staff member's next scheduled shift. IDT team on 12/11/25 (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity. IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

was outside before she found him. V27 said the first thing she did for Resident R9 when they brought him inside was to get him a blanket so he could warm up.The facility's Code Pink- Missing Resident/Elopement, reviewed date of 11/15/2018, documented the following: Guidelines: 1) All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2) Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should: Attempt to prevent the departure without use of force. Obtain assistance from other staff members in the immediate vicinity, if necessary. Instruct another staff member to inform the Charge Nurse or Director of Nursing services of the resident's attempt to leave

the premises. Be courteous in preventing the departure and returning the resident to the facility Notify the attending physician of the resident's attempt to leave the facility Contact legal representative/responsibility party and inform him/her of the incident. Make appropriate notations in the resident's medical record.

Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated. The Immediate Jeopardy began on 10/16/25 and was removed on 12/02/25 when the facility took

the following actions to remove the immediacy. Facility Elopement Policy was reviewed by Regional Director of Operations on 11/25/25 and was found to be in compliance with state and federal regulations. Facility Administrator or designee initiated in-servicing, for all staff, on the elopement policy and procedures on 11/25/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately on 11/25/25. In-servicing will be completed by the start of each staff members next shift. Maintenance Director or designee will conduct an audit of all facility door alarms on 11/25/25 and to be completed weekly to ensure they are adequately functioning and audible to staff areas. Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance beginning 11/25/25. The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures beginning 11/25/25. IDT team on 11/25/25 (Admin, DON, SSD, MDS, DM) has assessed Resident R4 and care plan updated to reflect new interventions for Resident R4 being placed on the locked unit. IDT team on 11/25/25 (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement. Completed on 11/25/25. Resident R4 was placed on the locked unit 11/25/25. All facility exit door keys were removed and placed in secured location 12/1/25. Facility Administrator or designee initiated in-servicing for all staff on 12/1/25 to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift. Maintenance Director replaced the door lock to 300 Hall door to courtyard on 12/1/25 and is functioning properly.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 60 residents residing in the facility. Findings include:The Facility assessment dated [DATE REDACTED] did not include the following in the plan: identification of current Administrator nor current DON (Director of Nursing), identifying resources to provide necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies; evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans; pertinent information about the resident population the facility serves may include race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy or other factors that affect access to care and health outcomes related to health equity; physical environment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents; evaluations of the facility's training program to ensure any training needs are met for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment did not include an evaluation of applicable policies and procedures, facility based and community-based risk assessment, utilizing an all-hazards approach that evaluates the facility's ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster, and contingency plan for events or an all-hazards approach. On 12/2/25 at 10:52 AM Surveyor asked V1 Administrator if she has additional information on the Facility Assessment as

the one provided does not address all required components including facility and community risk assessments and resources. V1 stated the Facility Assessment that was provided is all the information she has. On 12/2/25 at 1:47 PM V1 Administrator stated the facility does not have a policy for the Facility Assessment. The facility's daily census report, dated 12/2/25, documented there are 60 residents residing

in the facility.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

body fluids, wash hands with either a non-antimicrobial or an antimicrobial soap and water.3. If hands are not visibly soiled, or after removing visible material with non-antimicrobial soap and water, decontaminate hands in the clinical situations described in 3.a-f The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water.

Frequent use of alcohol-based hand rub immediately following handwashing with non-antimicrobial soap may increase the frequency of dermatitis. Perform hand hygiene:3.a. Before having direct contact with patients3.b. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings3.c. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure or lifting a patient)3.d. If hands are likely to move from a contaminated body site to a clean body site during patient care3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient3.f. After removing gloves.Wash hands with non-antimicrobial or antimicrobial soap and water if contact with spores (e.g. Clostridium difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors and other antiseptic agents have poor activity against spores.Additionally in the same article, the section titled Gloves stated:Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g. of a patient with incontinence of stool or urine) could occur.Wear gloves with fit and durability appropriate to the task.2.a. Wear disposable medical examination gloves for providing direct patient care.2.b. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using a proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with the transmission of pathogens.2.d. Change gloves during patient care if the hands are likely to move from a contaminated body site (e.g. perineal area) to a clean body site (e.g. face).Review of an article titled, HIV and AIDS, dated [DATE REDACTED] and found at https://www.who.int/news-room/fact-sheets/detail/hiv-aids documented In 2024, an estimated 630 000 people died from HIV-related causes and an estimated 1.3 million people acquired HIV.Review of an article titled, Why is hepatitis B so dangerous? dated [DATE REDACTED] and found at https://www.hepb.org/what-is-hepatitis-b/faqs/why-is-hepatitis-so-dangerous/ documented, Hepatitis B is dangerous because it is a silent infection, which means it can infect people without them knowing it. Most people who are infected with hepatitis B are unaware of their infection for many years and can unknowingly spread the virus to others through direct contact with their infected blood and sexually.Review of an article titled, Hepatitis B dated [DATE REDACTED] and found at https://www.who.int/news-room/fact-sheets/detail/hepatitis-b documented, Hepatitis B can cause a chronic infection and puts people at high risk of death from cirrhosis and liver cancer.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0908 Level of Harm - Actual harm Residents Affected - Few

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

member #2 said he messaged/sent pictures to the DON about the bed not working. He said he likes to have things in writing when it comes to the facility, so he has proof. He said this didn't start because his mom didn't want to lay down in her bed it was because they put her in a wheelchair that was to small and then sent her to dialysis. He said his mom has always slept in her recliner but now she stays mostly in her bed because of the wounds. V31 said Resident R2 didn't get the low air loss mattress until she came back from the hospital this last time. He said that is why she had to be moved to the (specific hall location). V31 said he isn't sure what day Resident R2 got the bed, but it didn't work. The hose that connected to the mattress would keep coming off and they used duct tape to try and keep it in place. V31 said they have changed Resident R2's pain medication also. He said she is in extreme pain due to (d/t) her wounds and so they started her on morphine and after the dressing changes is when she has the most pain.On 11/19/25 at 12:42 PM, This surveyor reviewed pictures provided by V9, Resident R2's family member #1 and they correspond with V31, Resident R2's family member #2, V7, LPN, and V8, CNA interviews that the hose that keeps the bed inflated comes disconnected and causes the mattress to lose air. On 12/04/25 at 2:45 PM, V2, DON stated Resident R2's old bed had an issue with the hose coming off. She said when she was made aware of the situation, she notified maintenance, and they were supposed to order a new part. V2 said they tried to order the part, and they couldn't get it, so they got Resident R2 a new bed. V2 said the maintenance man who was working at the facility at

the time is no longer with them, they had to let him go due to them having issues with him.On 12/23/25 at 10:20 AM, V1, Administrator said she would expect the maintenance department to keep equipment in good working condition. She said V48, Maintenance director is proactive about getting things done and looking for things to make sure they are working properly.On 12/01/25 at 10:38 AM, V13, Wound Nurse Practitioner (NP) she first seen Resident R2 back in August of this year and on the first visit she wrote an order for Resident R2 to get a low air loss mattress. She said sure it could be painful for Resident R2 if the air loss mattress wouldn't stay inflated and Resident R2 was laying on the hard bed. She said to be 100% truthful she isn't sure if Resident R2's wounds are pressure. She said her and her colleagues thought Resident R2 could possibly have what is called Calciphylaxis (a rare, serious disease. It involves a buildup of calcium in small blood vessels of fat tissues and skin.

Symptoms include blood clots, lumps under the skin and painful open sores called ulcers. If an ulcer becomes infected, it can be life-threatening.).On 12/02/25 at 2:10 PM, V13, Wound NP said she would expect the facility to implement the orders she gives and if a low loss air mattress isn't properly inflating it can cause issues by putting more pressure on Resident R2's wounds and it can cause her pain.The facility's Preventive Maintenance and Inspections policy, not dated, documented In order to provide a safe environment for residents, employes, and visitors, a preventative maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition.

Routine inspections and promote safety throughout the facility and aid in keeping fixtures and equipment in good working order and operating in accordance with manufacturer's guidelines. Regular inspection, testing, and replacement or repair of equipment and operational systems contribute to preservation of the facility's assets. Preventive maintenance (PM) is the care and servicing by personnel for the purpose of maintaining fixtures, equipment and facilities in a satisfactory operating condition by providing for systematic inspection, detection, and correction of incipient failures either before they occur or before they develop into major defects. Maintenance includes tests, measurements, adjustments, and parts replacements that are performed specifically to prevent faults from occurring.

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

12/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Axiom Gardens of Nashville

485 South Friendship Drive Nashville, IL 62263

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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Based on interview and record review, the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 60 residents residing in the facility. Findings include:The facility's CNA (Certified Nurse Assistant) hire date list documented the following: V32 CNA hire date of 7/26/2011.V33 CNA hire date of 1/21/2002.V34 CNA hire date of 11/12/2018.V35 CNA hire date of 11/4/1999.V36 CNA hire date of 3/18/2019.V37 CNA hire date of 11/19/2019. The facility's in-service records for 2025 documented the following: V32 had 1 hour of education for the past year.V33 had 2 hours of education for the past year. V34 had 1 hour of education for the past year. V35 had 2 hours of education for the past year. V36 had no education documented for the past year.V37 had 2.5 hours of education for

the past year. On 12/2/25 at 12:29 AM V1 Administrator stated I have to be honest, that is all we have for

the CNA in-services/education for the past year. V1 stated CNAS are supposed to have 10 or 12 hours of continuing education per year. V1 stated the in-services that were provided to the Surveyor were all 30-minute in-services except the wound care in-service did take 1 hour. V1 stated the CNA list has the original hire date and the date the new company took over on 11/1/25. On 12/2/25 at 1:43 PM Surveyor reviewed the CNA education hours with V1 Administrator and V2 DON (Director of Nursing). V1 and V2 both agreed V32, V33, V34, V35, V36, and V37 did not receive the 12 hours of required education in the past year. On 12/2/25 at 2:17 PM V1 Administrator stated she thinks the facility did do dementia training in February of 2025, but she cannot find the attendance records for it. Surveyor asked if the facility provides dementia training within 60 days of hire as documented in the facility Employee Education policy and V1 stated we are not doing that. The facility's Employee Education policy, dated 10/1/22, documented the facility shall provide a Staff Education Plan in accordance with State and Federal regulations. 1. The facility will develop, implement, and maintain a written staff education plan, which ensures a coordinated program for staff education for all facility employees. 2. The staff education plan will be reviewed at least annually by

the quality assurance committee and revised as needed. 3. The facility will ensure the staff education plan includes both pre-service and annual requirements. 4. The staff education plan shall ensure that education is conducted annually for all facility employees, at a minimum, in the following areas: a. Prevention and control of infection; b. Fire prevention, emergency procedures-life safety, and disaster preparedness; c.

Abuse, neglect, and exploitation; d. Accident, prevention and safety awareness programs; e. Resident's rights to include Advanced Directives; f. OSHA Training - Biomedical Waste Plan and Bloodborne Pathogens; g. Federal law requirement for long term care facilities, which is incorporated by reference, and state rules and regulations; h. Quality Assurance Performance Improvement (QAPI). 5. The facility will ensure, when employed by a nursing home facility for a 12-month period or longer, a nursing assistant, to maintain certification, shall submit to a performance review every 12 months and must receive regular in-service education based on the outcome of such reviews. It continues, 8. The facility will ensure that all employees will have training, as required by the State regarding dementia, both at within 60 days of hire and annually thereafter. The facility's daily census report, dated 12/2/25, documented there are 60 residents residing in the facility.

Event ID:

Facility ID:

If continuation sheet